DDU GENERAL 2013 FORSAMLING

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Motivational interviewing in intensive treatment of Type 2
diabetes detected by screening in general practice.
Overall effect of a course in “Motivational interviewing”
PhD thesis
Sune Leisgaard Mørck Rubak
Department and Research Unit of General Practice
Faculty of Health Sciences
University of Aarhus
Denmark
2005
PhD thesis
Motivational interviewing in intensive treatment of Type 2 diabetes in general practice.
Overall effect of a course in “Motivational interviewing”
Sune Rubak
1st edition, 2005
Print: Fællestrykkeriet for Sundhedsvidenskab, University of Aarhus
ISBN
This PhD thesis has been accepted for the defence of the medical PhD by the Faculty of Health
Science, University of Aarhus and was defended on February 22th, 2005.
Supervisors:
Professor, MD, GP, PhD Bo Christensen, Director of Department of General Practice,
University of Aarhus, Denmark
Associate Professor, MD, PhD Annelli Sandbæk, Department of General Practice,
University of Aarhus, Denmark
Professor, MD, GP, DMSc Torsten Lauritzen, Department of General Practice, University
of Aarhus, Denmark
Opponents:
Professor, Consultant, MD, DMSc Povl Munk-Jørgensen, Director of Research Unit of
Psychiatric Department, Aalborg Hospital, University of Aarhus, Denmark (Chair)
Associate Professor, Consultant, MD, DMSc Birger Thorsteinsson, Department of
Medicine F, Hillerød Hospital, Denmark
Professor, MD, GP, DMSc Flemming Bro, Director of Department of General Practice,
University of Southern Denmark, Denmark
Steno Diabetes Center, Gentofte &
Department and Research Unit of General Practice
University of Aarhus
Vennelyst Boulevard 6
DK-8000 Aarhus C
Denmark
Email: sune.rubak@dadlnet.dk or sr@alm.au.dk
www.alm.au.dk
All rights reserved. No parts of this publication may be reproduced, stored in retrieval systems, or
transmitted in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise without indication of source.
Preface
I
Outline of this PhD thesis and the PhD project
This thesis is based on the ADDITION-study, the Anglo-Danish-Ducth study of intensive treatment
in people with screen-detected diabetes in primary care. The ADDITION-study was developed and
implemented in cooperation between the Department of General Practice and the Steno Diabetes
Centre. The ADDITION-study investigates the effects of screening and intensive treatment
including poly-pharmacological treatment and behavioural change, on patients with Type 2
diabetes. The ADDITION-study is an ongoing study encompassing three countries, The
Netherlands, England and Denmark. In Denmark, the study is represented in five counties, Aarhus,
Copenhagen, Ringkoebing, Ribe and South Jutland counties. In this thesis, the effect of
“Motivational interviewing” was evaluated in a cluster-randomised controlled trial carried out in the
counties of Aarhus and Copenhagen, Denmark, 2001. This PhD thesis is a part of the ADDITIONstudy. It specifically explores the effect after one year of “Motivational interviewing” on newly
diagnosed Type 2 diabetes patients detected by screening. This thesis focuses on whether GPs using
“Motivational interviewing” can increase adherence to and effect of intensive treatment of Type 2
diabetes patients risk profile, thus reaching treatment goals.
The concept of “Motivational interviewing” is introduced in Chapter 1, which also offers a
summary of the use of this concept in research and practice and a presentation of the rationale why
“Motivational interviewing” was chosen as the means of intervention. The aim of the PhD study is
presented at the end of Chapter 1. Chapter 2 features a review of previous research on
“Motivational interviewing” and its implications for practice and a meta-analysis on its effect.
In Chapter 3 the effects of a training course in “Motivational interviewing” for general
practitioners (GPs) are presented. The chapter addresses the questions whether the GPs aquired the
methods of “Motivational interviewing” and if they used “Motivational interviewing” in their daily
work. The next step focused on the effect of “Motivational interviewing” on patients lifestyle and
behavioural change. Chapter 4 hence addresses the questions whether the GPs’ use of
“Motivational interviewing” changed the patients’ contemplation of changing behaviour and if they
did, indeed, change lifestyle behaviour. Finally, the effects of “Motivational interviewing” on
patients’ risk profile and adherence to intensive treatment are outlined in Chapter 5.
Chapters 6 to 9 offer a comprehensive and more general discussion of the methods used and the
results presented in the articles, adding perspective to the research questions posed.
Finally, Chapters 10 and 11 present English and Danish summaries. References used
throughout the thesis are listed in citation order. Appendices provide an outline of the study
flowcharts, the educational programme of “Motivational interviewing” and the questionnaires and
case record forms in Danish (Appendix A-D).
II
This PhD thesis is based on the following articles:
I.
Rubak S, Christensen B, Sandbaek A, Lauritzen T. “Motivational interviewing”, a
systematic review and a meta-analysis. British Journal of General Practice. Accepted
2004.
II.
Rubak S, Sandbaek A, Lauritzen T, Borch-Johnsen K, Christensen B. How does an
education and training course in “Motivational interviewing” influence general
practitioner’s professional behaviour. ADDITION Denmark. British Journal of General
Practice. Submitted 2004.
III.
Rubak S, Sandbaek A, Lauritzen T, Borch-Johnsen K, Christensen B. Effect of
“Motivational interviewing” on beliefs and behaviour among patients with Type 2
diabetes detected by screening. ADDITION Denmark. Prepared for publication 2004.
IV.
Rubak S, Sandbaek A, Lauritzen T, Borch-Johnsen K, Christensen B. No effect of
“Motivational interview” on risk profile in patients with Type 2 diabetes detected by
screening. A one-year follow-up of a RCT. ADDITION Denmark. Prepared for
publication 2004.
III
Motivation
After my graduation from the University of Aarhus in 1998, I began my postgraduate career as a
house officer. At this time I came into contact with the Department of General Practice while doing
a small research project. During this project, I felt that the department had pleasant, productive and
appealing atmosphere. However, I started as a senior house officer at the Department of Paediatrics,
Skejby Hospital, where I was much inspired by the clinical work with children. I found myself
standing with “one leg in two worlds”, General Practice or Paediatrics. This dilemma was put into
perspective by my family situation as a husband and father of two children, Johan and Astrid. The
challenge was to combine this wonderful family life with a productive and meaningful, clinical
career and a PhD presented itself as a natural solution. The Department of General Practice
proposed a project on “Motivational interviewing”. I had a meeting with Professor Carl-Erik
Mabeck, my mentor in “Motivational interviewing”, and was intrigued by the possibilities of
“Motivational interviewing” and the lack of research in this field. This was a method which, if it
proved effective, could be used in both General Practice and in Paediatrics. After having caught up
on the subject of “Motivational interviewing”, I decided that this was the right area for me to do
further research in and began my PhD project.
Acknowledgements
The study would never have succeeded had it not been for the tremendous support I have received
from my colleagues, from research funds and from my family.
My colleagues in general practice in the County of Aarhus and the County of Copenhagen have
involved themselves strongly in the project and accepted to be randomized and then undertaken all
the hard work of attending courses, implementing the methods and recruiting the patients to the
project. I am truly grateful for their participation and support for this project. I would also like to
thank the practice staff and all the patients who spent much time filling in the questionnaires and
case record forms.
I am indebted to my supervisors, Professor Bo Christensen for being there all the time during the
study, Associate Professor Annelli Sandbæk for having paid close attention and for having the
“feel” of the project in its different phases, Professor Torsten Lauritzen and Professor Knut BorchJohnsen for their work launching and supporting the ADDITION-study. Finally, I am greatly
indebted to my mentor Professor Carl-Erik Mabeck for sharing his profound knowledge on
“Motivational interviewing”, his guidance and willingness to provide the right amount of
inspiration and motivation when needed.
I owe my sincere thanks to the flourishing research atmosphere at the Department and Research
Unit of General Practice. My research colleagues have been helpful in constructive discussions, in
practical matters of all kinds. I would also like to thank Hans Christian Kjeldsen and Kaare Mai for
good company, our discussions in the office on everything else than research.
The help provided by all the partners in the PhD project, the ADDITION-study, from the County
Health Service, the Department of Health Insurance and all the laboratories on the hospitals has
been exceptional, as has their aid in data retrieval and assistance in sorting out problems
encountered during the study.
The choice and use of statistical methods for data analysis was, of course, an interesting challenge,
and I owe my special thanks to the Department of Biostatistics, Associate Professor, PhD Morten
Frydenberg, who has been most helpful and patient with my queries and questions.
IV
I appreciate all the help that I received from the secretaries, Eva Therkildsen and Helle Hjort
Pedersen at the Department of General Practice, Karen Wolsing, Ynna Margot Nielsen and Inge
Krogh at the ADDITION-study, Elsebeth Schreiber at the Specific Training for General Practice
and Birthe Brauneiser and Eva Højmark Pedersen at the Research Unit of General Practice. I am
greatly thankful for the assistance provided by Bjarne Benner Svendsen, Lars Venge Olesen and
Tonni Juul Hansen in relation to designing questionnaires, handling the retrieval of data and the
database, solving all technical problems at hand and keeping virus, worms and other creatures out
of my computer. I acknowledge the linguistic help of Professor Morten Pilegaard in revising the
text.
I owe a dept of gratitude to the Department of General Practice for housing me and for helping me
administer the project economy. Considerable financial support was essential for the
implementation of the study. The PhD study is funded by The Danish National Research
Foundation for General Practice, the Danish Medical Association Research Fund, the Diabetes
Associations foundation for Scientific Research. Furthermore the PhD study could not have been
carried through without financial support given to the ADDITION study DK by: The National
health service in the counties of Copenhagen, Aarhus, Ringkøbing, Ribe, South Jutland, all in
Denmark. The Danish National Research Foundation for General Practice, Danish Centre for
Evaluation and Health Technology Assessment, The Aarhus University Research Foundation, Novo
Nordic Foundation. Unrestricted grants from Novo Nordic AS, Novo Nordic Scandinavia AS,
ASTRA Denmark, Pfizer Denmark, GlaxoSmithKline Pharma Denmark, SERVIER Denmark A/S,
HemoCue Denmark A/S.
Finally, I am greatly indebted to my family. My father has provided eminent support during the
study. My father has the ability to grasp all aspects of a problem, keep an overview, and yet still
focus on how to solve each of the specific problems. My mother and sister have kept me going with
their loving support and positive attitude. My children give me their unconditioned love and make
me believe everything is possible in this world. My wife, Dorte, has inspired me in many parts of
the project phases and I have enjoyed her ultimate confidence in my capabilities. I can only hope
that I will be able to return this some day.
Sune Rubak
Aarhus, February 2005
V
Abbreviations
BMI
CI
CPR.no
DIRQ
DBP
DSCAQ
F-H
F-M
GP
HbA1c
HCCQ
HDL
C-group
ICC
IHD
IPQ
LDL
I-group
OGTT
OR
PMDIQ
RCT
SD
SBP
Sum-qst
T-Chol
Tgly
TSRQ
T2D
Body Mass Index
Confidence Interval
Civil Personal Registration number
Diabetes Illness Representation Questionnaire
Diastolic Blood Pressure (mmHg)
Diabetes Self-Care Activities Questionnaire
Number of days pr. week with hard physical activity (example: heavy lifting, aerobics,
playing single tennis)
Number of days pr. week with moderate physical activity (example: bicycling in
moderate tempo, playing double in tennis).
General Practitioner
Haemoglobin A 1c (% GHb)
Health Care Climates Questionnaire
High Density Lipoproteins (mmol/l)
Control group in the PhD study of general practitioners receiving no formal education
or training in ”Motivational interviewing” (C-group is used in the chapters 1, 6-10 of
this PhD thesis, otherwise abbreviations for study groups have been specified in each
of the remaining chapters 2-5)
The Intra-Cluster Correlation Coefficient
Ischemic Heart Disease
Illness Perception Questionnaire
Low Density Lipoproteins (mmol/l)
Intervention group in the PhD study of general practitioners trained in ”Motivational
interviewing” (I-group is used in the chapters 1, 6-10 of this PhD thesis, otherwise
abbreviations for study groups have been specified in each of the remaining chapters
2-5)
Oral Glucose Tolerance Test
Odds Ratio
Personal Models of Diabetes Interview Questionnaire
Randomised Controlled Trial
Standard Deviation
Systolic Blood Pressure (mmHg)
Sum scoring from questionnaire
Blood total Cholesterol (mmol/l)
Triglycerid (mmol/l)
Treatment Self-Regulation Questionnaire
Type 2 Diabetes Mellitus
VI
CONTENTS
CHAPTER 1 ..........................................................................................................................................1
GENERAL INTRODUCTION ....................................................................................................................2
THE CONCEPT OF “MOTIVATIONAL INTERVIEWING”......................................................................2
DESCRIPTION OF THE CONCEPT OF “MOTIVATIONAL INTERVIEWING”..........................................2
USE OF “MOTIVATIONAL INTERVIEWING” IN RESEARCH AND PRACTICE .......................................3
THE ADDITION-STUDY.......................................................................................................................4
AIM OF PHD THESIS ...........................................................................................................................4
CHAPTER 2...........................................................................................................................................5
MOTIVATIONAL INTERVIEWING: A SYSTEMATIC REVIEW AND META-ANALYSIS...............................5
ABSTRACT .........................................................................................................................................6
INTRODUCTION .................................................................................................................................7
METHODS ..........................................................................................................................................8
SEARCH STRATEGY ...........................................................................................................................8
SELECTION ....................................................................................................................................10
QUALITATIVE DATA SYNTHESIS ........................................................................................................10
VALIDITY ASSESSMENT, DATA EXTRACTION ......................................................................................11
QUANTITATIVE DATA SYNTHESIS ......................................................................................................11
STUDY CHARACTERISTICS ...............................................................................................................11
RESULTS ..........................................................................................................................................11
TRIAL FLOW ...................................................................................................................................11
VALIDITY ASSESSMENT, DATA EXTRACTION......................................................................................12
QUANTITATIVE DATA SYNTHESIS ......................................................................................................14
QUALITATIVE DATA SYNTHESIS ........................................................................................................17
STUDY CHARACTERISTICS ...............................................................................................................17
DISCUSSION .....................................................................................................................................17
MAIN FINDINGS ..............................................................................................................................17
STRENGTH AND LIMITATIONS ..........................................................................................................18
DETAILED FINDINGS .......................................................................................................................18
IMPLICATIONS FOR FUTURE RESEARCH ...........................................................................................19
IMPLICATIONS FOR PRACTICE .........................................................................................................19
CONCLUSION ...................................................................................................................................19
CHAPTER 3.........................................................................................................................................21
HOW DOES AN EDUCATION AND TRAINING COURSE IN “MOTIVATIONAL INTERVIEWING”
INFLUENCE GENERAL PRACTITIONER’S PROFESSIONAL BEHAVIOUR. ADDITION DENMARK...........21
ABSTRACT .......................................................................................................................................22
INTRODUCTION ...............................................................................................................................23
METHODS ........................................................................................................................................24
STUDY GROUP ................................................................................................................................24
METHOD OF INTERVENTION ............................................................................................................26
MEASUREMENTS .............................................................................................................................26
STATISTICAL METHOD .....................................................................................................................28
RESULTS ..........................................................................................................................................28
STUDY SAMPLE CHARACTERISTICS ...................................................................................................28
VII
STUDY DATA AND ANALYSES ............................................................................................................28
DISCUSSION .....................................................................................................................................31
MAIN FINDINGS ..............................................................................................................................31
CONCLUSION ...................................................................................................................................33
CHAPTER 4.........................................................................................................................................35
EFFECT OF “MOTIVATIONAL INTERVIEWING” ON BELIEFS AND BEHAVIOUR AMONG PATIENTS
WITH TYPE 2 DIABETES DETECTED BY SCREENING. ADDITION DENMARK. ......................................35
ABSTRACT .......................................................................................................................................36
INTRODUCTION ...............................................................................................................................37
METHODS ........................................................................................................................................38
STUDY GROUP ................................................................................................................................38
METHOD OF INTERVENTION ............................................................................................................40
MEASUREMENTS .............................................................................................................................40
STATISTICAL METHOD .....................................................................................................................41
RESULTS ..........................................................................................................................................42
DISCUSSION .....................................................................................................................................45
MAIN FINDINGS ..............................................................................................................................45
CONCLUSION ...................................................................................................................................47
CHAPTER 5.........................................................................................................................................49
NO EFFECT OF “MOTIVATIONAL INTERVIEW” ON RISK PROFILE IN PATIENTS WITH TYPE 2
DIABETES DETECTED BY SCREENING. A ONE YEAR FOLLOW-UP OF A RCT. ADDITION DENMARK. ..49
ABSTRACT .......................................................................................................................................50
INTRODUCTION ...............................................................................................................................51
METHOD ..........................................................................................................................................51
STUDY GROUP ...............................................................................................................................51
METHOD OF INTERVENTION .........................................................................................................53
MEASUREMENTS ...........................................................................................................................53
RISK PROFILE .............................................................................................................................53
HEALTH CARE SERVICES ..............................................................................................................54
SELF-REPORTED DATA ................................................................................................................54
STATISTICAL METHOD ..................................................................................................................54
RESULTS ..........................................................................................................................................54
DISCUSSION .....................................................................................................................................57
MAIN FINDINGS ..............................................................................................................................57
IMPLICATIONS FOR FUTURE RESEARCH AND PRACTICE .....................................................................58
CONCLUSION ...................................................................................................................................59
VIII
CHAPTER 6.........................................................................................................................................61
GENERAL DISCUSSION OF METHODS ..................................................................................................61
INTRODUCTION ...............................................................................................................................62
SETTING OF THE STUDY ..................................................................................................................62
DESIGN ............................................................................................................................................62
CLUSTER RANDOMISED CONTROLLED TRIAL ....................................................................................63
BIAS ..............................................................................................................................................63
BLINDING ......................................................................................................................................63
STUDY EVALUATION .......................................................................................................................64
INTERVENTION ...............................................................................................................................64
MONITORING THE INTERVENTION ....................................................................................................64
ADHERENCE TO “MOTIVATIONAL INTERVIEWING”...........................................................................65
CHANGING AND SUSTAINING LONG-TERM CHANGE OF PROFESSIONAL BEHAVIOUR ............................65
MEASURING METHODS ....................................................................................................................66
GENERAL PRACTITIONER QUESTIONNAIRE ................................................................................66
PATIENT QUESTIONNAIRE ...........................................................................................................66
CASE RECORD FORMS ..................................................................................................................68
BLOOD SAMPLE DATA ..................................................................................................................68
NATIONAL HEALTH SERVICE REGISTRY DATA............................................................................68
STATISTICAL METHODS ..................................................................................................................69
POTENTIAL GENERALISATION OF OUTCOME .................................................................................71
CHAPTER 7.........................................................................................................................................73
GENERAL DISCUSSION OF RESULTS ...................................................................................................73
INTRODUCTION ...............................................................................................................................74
DISCUSSION OF RESULTS.................................................................................................................74
CONDITION FOR OBTAINING AN EFFECT OF THE TRAINING COURSE IN “MOTIVATIONAL INTERVIEWING”
.....................................................................................................................................................74
EFFECT OF ”MOTIVATIONAL INTERVIEWING” ON GENERAL PRACTITIONERS .....................................75
EFFECT OF ”MOTIVATIONAL INTERVIEWING” ON PATIENT BEHAVIOUR CHANGE AND PATIENT RISK
PROFILE ........................................................................................................................................75
CHAPTER 8.........................................................................................................................................77
CONCLUSION ......................................................................................................................................78
CHAPTER 9.........................................................................................................................................79
PERSPECTIVES AND IMPLICATIONS FOR FUTURE RESEARCH AND PRACTICE ...................................80
PERSPECTIVES ................................................................................................................................80
IMPLICATIONS FOR PRACTICE .........................................................................................................80
CHAPTER 10.......................................................................................................................................81
ENGLISH SUMMARY............................................................................................................................82
GENERAL INTRODUCTION .................................................................................................................82
AIM OF PHD THESIS ...........................................................................................................................82
MOTIVATIONAL INTERVIEWING, A SYSTEMATIC REVIEW AND A META-ANALYSIS. (ARTICLE 1)........83
HOW DOES AN EDUCATION AND TRAINING COURSE IN “MOTIVATIONAL INTERVIEWING” INFLUENCE
GENERAL PRACTITIONER’S PROFESSIONAL BEHAVIOUR. (ARTICLE 2)...............................................83
IX
EFFECT OF MOTIVATIONAL INTERVIEWING ON BELIEFS AND BEHAVIOUR AMONG PEOPLE WITH TYPE 2
DIABETES DETECTED BY SCREENING. (ARTICLE 3) ...........................................................................83
NO EFFECT OF THE MOTIVATIONAL INTERVIEW ON RISK PROFILE IN PEOPLE WITH TYPE 2 DIABETES
DETECTED BY SCREENING. A ONE YEAR FOLLOW-UP OF A RCT. (ARTICLE 4).....................................84
GENERAL DISCUSSION OF METHODS. ................................................................................................84
GENERAL DISCUSSION OF RESULTS...................................................................................................84
CONCLUSION....................................................................................................................................84
PERSPECTIVES AND IMPLICATIONS FOR FUTURE RESEARCH AND PRACTICE. .....................................84
CHAPTER 11.......................................................................................................................................85
DANSK RESUMÉ ..................................................................................................................................85
INTRODUKTION ................................................................................................................................86
FORMÅL MED PHD AFHANDLINGEN. .................................................................................................86
DEN MOTIVERENDE SAMTALE, ET SYSTEMATISK REVIEW OG EN META-ANALYSE. (ARTIKEL 1)........87
HVORDAN PÅVIRKER ET KURSUS I ”DEN MOTIVERENDE SAMTALE” PRAKTISERENDE LÆGERS
PROFESSIONELLE ADFÆRD. (ARTIKEL 2) ..........................................................................................87
EFFEKTEN AF “DEN MOTIVERENDE SAMTALE” PÅ SCREENEDE TYPE 2 DIABETES PATIENTERS
OVERBEVISNING OG ADFÆRD. (ARTIKEL 3) ......................................................................................87
INGEN EFFEKT AF ”DEN MOTIVERENDE SAMTALE” PÅ SCREENEDE TYPE 2 DIABETES PATIENTERS’
RISIKO PROFIL. EN 1-ÅRS OPFØLGNING AF ET RANDOMISERET KONTROLLERET FORSØG. (ARTIKEL 4)
........................................................................................................................................................88
GENEREL DISKUSSION AF METODERNE .............................................................................................88
GENEREL DISKUSSION AF RESULTATER ............................................................................................88
KONKLUSION....................................................................................................................................88
PERSPEKTIVER OG STUDIETS KONSEKVENSER FOR FREMTIDIG FORSKNING OG PRAKSIS ...................88
REFERENCES ......................................................................................................................................89
APPENDICES .....................................................................................................................................103
APPENDIX A. FLOWCHART OF THE ADDITION STUDY, OF THE PHD STUDY, AND TABLE 1
APPENDIX B. EDUCATIONAL PROGRAMME OF “MOTIVATIONAL INTERVIEWING”
APPENDIX C. QUESTIONNAIRES IN DANISH USED IN THE STUDY
APPENDIX D. CASE RECORD FORMS IN DANISH USED IN THE STUDY
X
Chapter 1
General introduction
1
The concept of “Motivational interviewing”
In this thesis “Motivational interviewing” as a concept is based on the definition of Miller and
Rollnick presented in their book “Motivational interviewing, preparing people to change addictive
behaviour”, 2002 1;2. Miller and Rollnick defined ”Motivational interviewing” as a “directive,
client-centred counselling style for eliciting behaviour change by helping clients to explore and
resolve ambivalence”.
The concept of “Motivational interviewing” evolved from experience with the treatment of
alcoholism and was described by Miller in 1983 3. This early experience developed into a coherent
theory and detailed description of clinical procedures was provided in Miller and Rollnick (1991) 1,
a work which was recently revised (2002) 2. Miller and Rollnick’s theory also draws inspiration
from Carl Rogers’ work on non-directive counselling and behavioural change theory described in
1951 4.
Previous research and the use of the term or concept “Motivational interviewing” has made it a
more comprehensive concept that also often includes aspects from other psychological models of
behaviour change and different approaches to the patient-doctor relationship. These new conceptual
elements border on “Motivational interviewing”, and some even rest on the same theoretical
foundation. However, in important respects, they are not coherent with the core concept of
“Motivational interviewing” formulated by Miller and Rollnick.
Description of the concept of “Motivational interviewing”
“Motivational interviewing” is based on a characteristic counselling style including different
techniques used in the patient-doctor relationship. The examination and resolution of ambivalence
is the central purpose in non-directive counselling. However, the counsellor is intentionally
directive in pursuing this goal. “Motivational interviewing” is a particularly way of helping clients
recognize problems and change their behaviour accordingly. It is considered particularly useful with
patients who are reluctant to change or ambivalent about changing their behaviour. The strategies of
“Motivational interviewing” are more persuasive than coercive, more supportive than
argumentative, and the overall goal is to increase the client’s intrinsic motivation so that change
arises from within rather than being imposed from without 2. The spirit and characteristics of
“Motivational interviewing” is captured in the following key points 2.
1. Motivation to change is elicited from the client, and not imposed from without. Other
motivational approaches have emphasised coercion, persuasion, constructive confrontation.
Such strategies may have their place in evoking change, but they are quite different in spirit
from “Motivational interviewing” which relies upon identifying and mobilising the client's
intrinsic values and goals to stimulate behaviour change.
2. Ambivalence takes the form of a conflict between two courses of action (e.g. indulgence
versus restraint), each of which has perceived benefits and costs associated with it. The
counsellor's task is to facilitate expression of both sides of the ambivalence impasse, and
guide the client toward an acceptable resolution that triggers change. The specific strategies
of “Motivational interviewing” are designed to elicit, clarify, and resolve ambivalence in a
client-centred and respectful counselling atmosphere.
2
3. The counselling style is generally a quiet and eliciting one. More aggressive strategies,
sometimes guided by a desire to "confront client denial," easily slip into pushing clients to
make changes for which they are not ready, and therefore will not accommodate afterwards.
4. Readiness to change is not a client trait, but a fluctuating product of interpersonal
interaction. Resistance and "denial" are seen not as client traits, but as feedback regarding
counsellor behaviour. Client resistance is often a signal that the counsellor is assuming
greater readiness to change than is the case, and it is a cue that the counsellor needs to
modify motivational strategies.
5. Eliciting and reinforcing the clients in their motivational behaviour towards problem
recognition, concerns, desire, intention, responsibility and ability to change. The client’s
belief in the ability to carry out and succeed achieving a specific goal is essential.
6. The therapeutic relationship is more like a partnership or companionship than
expert/recipient roles. The counsellor respects the client’s autonomy and freedom of choice
and consequences regarding his or her own behaviour.
7. “Motivational interviewing” is not merely a set of techniques that are applied in treatment of
clients. It is an interpersonal style, not restricted to formal counselling settings. It is a subtle
balance of directive and client-centred components shaped by a guiding philosophy and
understanding of what triggers change.
Use of “Motivational interviewing” in research and practice
“Motivational interviewing” is a counselling style and a method that is both rather well documented
and scientifically tested, and it is viewed as a useful intervention strategy for changing behaviour5.
It has been used and evaluated internationally especially in the last decade, in relation to the
following main areas: 1) addiction (alcohol abuse and drug addiction), 2) change in lifestyle
(smoking cessation, weight-loss, physical activity, asthma and diabetes treatment), and 3) adherence
(to treatment and to control, encounters of follow-up, counselling meetings). “Motivational
interviewing” has been deployed by various health care providers, including psychologist, doctors,
nurses, dieticians and midwifes. However, current studies have focused on its effect in hospital
settings with no or little attention to how the methods could be implemented and applied afterward
in the daily clinical work especially in general practice. A few studies have been conducted in a
clinical setting allowing to continue the process of using “Motivational interviewing” in daily
clinical work after project termination 6-10. This thesis explores the effect of “Motivational
interviewing” in general practice.
“Motivational interviewing” has only recently been introduced in Denmark, but its use has been
rising over the past years and it has been deployed in different scientific and clinical settings. Thus,
in 2000 the Danish College of General Practitioners issued an introduction booklet on
“Motivational interviewing” 11, which was mailed to all members of the Danish Medical
Association. Furthermore, a Danish book on the subject written by Professor Carl Erik Mabeck was
issued in more than 10000 copies 12 and more than 30 residential courses in “Motivational
interviewing” have been conducted by Professor Carl Erik Mabeck since. These courses attracted
mainly nurses, however, a number of GPs also attended the courses with a view to use the methods
in general practice. Thus, a significant effort has been made in order to enhance the use of
“Motivational interviewing” in Denmark. However, no research on the effect of this effort has so
far been attempted.
3
The ADDITION-study
The ADDITION-study, Anglo-Danish-Ducth study of intensive treatment in people with screendetected diabetes in primary care was developed and implemented in cooperation between the
Department of General Practice and the Steno Diabetes Centre. The ADDITION-study investigates
the effects of screening and intensive treatment, including poly-pharmacological treatment and
behaviour change, in patients with Type 2 diabetes in general practice (as shown in Figure 1,
Appendix A) 13. The ADDITION-study includes Type 2 diabetes patients detected by screening
treated by a target-driven approach to intensive treatment including behavioural change and it has a
follow-up period of 5 years. It is a large-scale study in general practice of a highly prevalent
disease. The ADDITION-study is an ongoing study encompassing three countries, The Netherlands,
England and Denmark. In Denmark, the study is represented in five counties, Aarhus, Copenhagen,
Ringkoebing, Ribe and South Jutland counties. In this thesis effect of “Motivational interviewing”
was evaluated in a cluster-randomised controlled trial carried out in the counties of Aarhus and
Copenhagen, Denmark, 2001.
This PhD thesis is a part of the ADDITION-study. It specifically explores the effect after one year
of “Motivational interviewing” on newly diagnosed Type 2 diabetes patients detected by screening.
This thesis focuses on whether GPs using “Motivational interviewing” can increase adherence to
and effect of intensive treatment of Type 2 diabetes patients risk profile, thus reaching treatment
goals.
Aim of PhD thesis
The overall aim of this PhD thesis was to evaluate the effect of a course in “Motivational
interviewing” on intensive treatment of Type 2 diabetes patients detected by screening in general
practice. Furthermore, the PhD study aimed at evaluating:
1. The effectiveness of “Motivational Interviewing” as an intervention tool in previous
randomised controlled clinical trials (RCT) and to identify factors shaping outcomes in the
areas reviewed.
2. In which way a 1½-day course in “Motivational interviewing” and subsequent follow-up
meetings influenced the GPs’ professional behaviour.
3. If the GPs having participated in a course in “Motivational interviewing” found the method
applicable and useful in general practice.
4. If “Motivational Interviewing” in general practice can improve patients’ a) contemplation
and readiness to change behaviour, b) their actual change in patient behaviour, and c) their
beliefs about Type 2 diabetes treatment.
5. If a course in “Motivational interviewing” for GPs can improve the risk profile of Type 2
diabetes patients detected by screening.
4
Chapter 2
Motivational interviewing: a systematic review and meta-analysis.
Rubak S, Sandbaek A, Lauritzen T, Christensen B.
British Journal of General Practice. Accepted 2004.
5
Abstract
Background: ”Motivational Interviewing” is a well-known, scientifically tested method of client
counselling developed by Miller and Rollnick and viewed as a useful intervention strategy in
treatment of lifestyle behaviour and disease.
Study design: A systematic review and a meta-analysis of randomized controlled trials (RTCs)
using “Motivational Interviewing” as intervention. The aim is to evaluate the effectiveness of
“Motivational Interviewing” in different areas of disease and to identify factors shaping outcomes.
Methods: A systematic literature search in 16 databases produced after selection criteria 72 RCTs,
the first published in 1991. A quality assessment was made with a validated scale. A meta-analysis
was performed as a generic inverse variance meta-analysis.
Results: Meta-analysis showed significant effect (95% CI) of “Motivational Interviewing” for
combined effect estimates for Body Mass Index (BMI), total serum-cholesterol, systolic blood
pressure, blood alcohol concentration, standard ethanol content, while combined effect estimates for
cigarettes per day and for HbA1c were non-significant. “Motivational Interviewing” had significant
and clinically relevant effect in app. 3 out of 4 studies with equal effect on biological (72%) and
psychological diseases (75%). Psychologists and medical doctors obtained an effect in app. 80% of
the studies, while other health care providers obtained an effect in 46% of the studies. When using
“Motivational Interviewing” in brief encounters of 15 min., 64% of the studies showed effect. More
than one encounter with the patient ensures effect of “Motivational Interviewing”.
Conclusion: We conclude that “Motivational Interviewing” in a scientific setting outperforms
“traditional advice giving” in the treatment of a broad range of behavioural problems and diseases.
We now need large scale studies to prove, that “Motivational Interviewing” can be implemented
into daily clinical work in primary and secondary health care.
6
Introduction
The concept of “Motivational Interviewing” evolved from experience with treatment of alcoholism,
and was first described by Miller in 1983 3. This basic experience was developed into a coherent
theory and detailed description of clinical procedures is provided by Miller and Rollnick (1991) 1,
who defined “Motivational Interviewing” “as a directive, client-centred counselling style for
eliciting behaviour change by helping clients to explore and resolve ambivalence”. Miller and
Rollnick’s theory also draws inspiration from Carl Rogers’ work on non-directive counselling
described in 1953 4. The examination and resolution of ambivalence is the central purpose in nondirective counselling, and the counsellor is intentionally directive in pursuing this goal.
“Motivational Interviewing” is a particular way of helping clients recognize and do something
about their present or potential problems. It is viewed as particularly useful with clients who are
reluctant to change or ambivalent about changing their behaviour. The strategies of “Motivational
Interviewing” are more persuasive than coercive, more supportive than argumentative, and the
overall goal is to increase the client’s intrinsic motivation so that change arises from within rather
than being imposed from without2. The spirit of “Motivational Interviewing” is captured in the key
points in Appendix 1 2.
Appendix 1. Miller & Rollnick: “Characteristics of the motivational interviewing”
1. “Motivational Interviewing” relies upon identifying and mobilizing the client's intrinsic values and
goals to stimulate behaviour change.
2. Motivation to change is elicited from the client and not imposed from without.
3. “Motivational Interviewing” are designed to elicit, clarify, and resolve ambivalence to perceive
benefits and costs associated with it.
4. Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction.
5. Resistance and "denial" is often a signal to modify motivational strategies.
6. Eliciting and reinforcing the client’s belief in ability to carry out and succeed in achieving a specific
goal is essential.
7. The therapeutic relationship is a partnership with respect of client autonomy.
8. “Motivational Interviewing” is both a set of techniques and counselling style.
9. “Motivational Interviewing” is directive and client-centred counselling understanding and eliciting
behaviour change.
“Motivational Interviewing” is broadly applicable in the management of diseases which to some
extent is associated with behaviour 6-77. It has been used and evaluated in relation to alcohol abuse,
addiction to drugs, smoking cessation, weight-loss, adherence to treatment and follow-up, increase
of physical activity, asthma treatment and diabetes treatment, “Motivational Interviewing” has been
deployed by various health care providers, including, among others, psychologist, doctors, nurses
and midwifes6;8;30;38;54;62. This review provides an overview of the areas in which “Motivational
Interviewing” has been applied. The aim of this review is to evaluate the effectiveness of
“Motivational Interviewing” as an intervention tool in randomised controlled clinical trials (RCT)
and to identify factors shaping outcomes in the areas reviewed.
7
Methods
Search strategy
The following electronic libraries were searched according to the Cochrane Collaboration’s search
strategy for randomised controlled trials for each database: the Cochrane Central Register of
Controlled Trials on the Cochrane Library (issue 4, 2002); MEDLINE (1966 to January, 2004);
EMBASE (1974 to January, 2004); and PsychINFO, including PsychLIT (1967 to January, 2004),
Cancerlit (1966 to January, 2004), Science Direct/ISI, including scisearch and social scisearch
(1972 to January, 2004), Sociological abstracts (1963 to January, 2004), social services abstracts
(1980 to January, 2004), EBSCO net research databases (1980 to January, 2004), CSA/Econ lit
index (1969 to January, 2004), Biological science (1982 to January, 2004), Biological abstracts
(1969 to January, 2004), AIDS and cancer research abstracts (1982 to January, 2004), AskERIC
(1966 to January, 2004), BIOSIS PREVIEWS (1969 to January, 2004), ABI-/INFORM (1971 to
January, 2004). The following search terms were used for MEDLINE and adapted for each other
database: “motivational interviewing”, “motivational behaviour”, “behaviour/motivational
interviewing”, “Behaviour change”, “Motivational change” and “Behaviour change/motivational
interviewing”. The proceedings of conferences during 1997 to 2004 on diabetes (American
Diabetes Association, Diabetes UK [formerly British Diabetic Association], European Association
for the Study of Diabetes, International Diabetes Federation) were searched under psychological,
educational, or behavioural headings for reports of any trials using motivational interviewing. The
reference lists of included studies and reviews were searched for additional studies. If an included
trial did not supply sufficient data needed for the meta-analysis, we tried to obtain data approaching
the authors and the same time asking for data from unpublished trials. The search process was
performed by first author. Figure 1 shows the progress of RCTs through the review.
8
Figure 1. Flowchart of progress of RTCs in the review.
Potentially relevant studies based on
key-word search in 16 databases.
N = 15516
Studies excluded because of not being
RCT
N = 15174
RCTs retrieved for more detailed
evaluation. N = 342
Studies excluded because of overlap
of publications between databases.
N = 188
Potentially appropriate RCTs to be
included in the review.
N = 154
Studies excluded because of
intervention not being based on Miller
& Rollnick.
N = 88
RCTs included in the review.
N = 72
RCTs included in the review with
direct effect measures.
N = 42
RCTs included in the review with
direct objective measures and
statistical data entering the
Meta-analysis.
N = 19
9
Selection
In Figure 2, a Funnel plot is presented 82.
RCTs included in the review were using “Motivational Interviewing” defined according to Miller &
Rollnick as intervention 2 regardless of the context of client counselling. Excluded were RCTs in
which there were no or minimal description of the methods of “Motivational Interviewing” and the
modes of delivery. We only included studies where “traditional advice giving” used to help and
advice clients served as control. “Traditional advice giving” is used as an expression for doctorcentred approach, i.e. the GP define the patients’ problem from a biomedical perspective and does
not at all include the patient perspective on the matter, thus giving advice accordingly 12;83.
Figur 2. Funnelplot of RCT´s using motivational interviewing as intervention
1000
800
600
Sample size (n)
400
200
0
-2
-1
0
1
2
3
Log(Effect-estimat)
A Funnel plot is a simple scatter plot of the treatment effects estimated from individual studies (on the x
axis) against some measure of each study’s simple size (on the y axis). A logarithmic scale ensures that
effects of the same magnitude but opposite directions are equidistant. In the absence of bias the Funnel plot
should resemble a symmetrical inverted funnel or a triangle.
Qualitative data synthesis
Quality assessment of each of the resulting 72 RCT was assessed by the first author. Quality
assessment was made with a validated scale 84;85 and individual components known to affect
estimates of intervention efficacy 86. The scale consisted of three items pertaining description of
randomisation, masking, dropouts and withdrawals in the report of an RCT. The scale ranged from
0 to 5, with higher score indicating better reporting. The individual components assessed the
adequacy of reporting of randomisation, allocation concealment and double-blinding. High-quality
trials scored minimum of 2 out of 5 86.
10
Validity assessment, Data extraction
The abstracts of studies identified by electronic searches was assessed by first author and extracted
onto a data extraction form. Confirmation of outcome measures and clinically relevant goals was
assessed by all the authors. All studies were examined to assess the clinical relevance of their goals
and outcome measures to client treatment, for example HbA1c as outcome-measure and study goal
as a 1% reduction in HbA1c. Table 1 (only published in the electronic version of the paper), shows
the studies with objective outcome measures and the assessment of clinical relevance and statistical
significant effect. Furthermore, for a study to be classified as showing effect, the recorded effect
had to be statistically significant. When a study is classified as demonstrating effect, it therefore
enjoys both a statistically significant effect and a clinically relevant effect to client treatment.
Quantitative data synthesis
Statistical data analysis was conducted in SPSS (version 11.0). A descriptive summary of the
information extracted from included trials was made. The meta-analysis was carried out using
Excell 2003 and STATA (version 8). The Meta-analysis conforms to the Cochrane Reviewers
Handbook 82. The meta-analysis is performed as a generic inverse variance meta-analysis, in which
we assume homogeneity between study estimates. The assumption of homogeneity is based on the
confidence intervals for the study estimates having large overlap, which indicates homogeneity 82.
The meta-analysis calculates combined estimates of effect with standard error and 95 % confidence
interval. The meta-analysis is based on the RCTs which included effect measures on patient
outcome and submitted statistical data.
Study characteristics
The following variables were extracted for analysis:
1. Characteristics of the intervention:
- Ways of delivery (in office, out of patient clinic, at home, by telephone, etc.)
- Duration of intervention (time used in one counsellor-client encounter)
- Number of intervention encounters (counselling encounter)
- Practising counsellor (psychologist, doctor, nurse, midwife, etc.)
2. Design of study (study group and follow-up):
- Number of participants
- Follow-up period
- Inclusion criteria (population, selection, etc.)
3. Area of intervention:
- Adherence to treatment of diseases
- Adherence to life style changes
2. Outcome measures:
- Direct indicators (health outcome, e.g. B-glucose, B-cholesterol, utilization of health
care services, e.g. length of hospital stay, etc.)
- Indirect indicators (subjective report, self-assessment, questionnaires)
Results
Trial flow
The systematic review using RCTs progressed as shown in flowchart, Figure 1.
11
Validity assessment, Data extraction
Table 1 (only published in the electronic version of the paper), shows studies with objective
outcome measures, clinical relevance, statistically significance and published statistical data.
Reference
no.
Objective outcome measure
14
B-glc/HbA1c: Interventionsgr.
fall: 11,75-11,02
controlgr. Fall: 10,82-10,78
B-gammaGT mean 190 fall to
30 in groups
HIV pos/neg (do behaviour
correlate to status as HIV
positive og HIV negative)
HIV pos/neg (do behaviour
correlate to status as HIV
positive og HIV negative)
Peak BAC (blood alcohol
concentration) 140 fall to 90
Nicotine test <10 ng/ml
(smoking or not)
B-cholesterol fall = 3,5mg/dL
B-alkohol mg/dL, 168 fall to
149
B-chol fall = 9,5-8,6 mg/dL,
diet-cholesterol fall 183-157
mg/1000kcal
Length of stay, 47 to 21 fall in
hospitalized days for
psychiatric patients
Moderate physical activity =
using a minimum of 57,5kcal/min., BMI fall
U-cocain-test post/neg (drug
addiction or not)
addiction or not)
Number of encounters sustained
with the patient as a measure of
adherence
Nicotine test <10 ng/ml
(smoking or not)
addiction or not)
Number of encounters sustained
with the patient as a measure of
adherence
Fall = BMI:27-26, Total
cholesterol.:7-6, Energy intake
1900kcal/day -1650 kcal/day,
fat intake: 70 g/day-17g/day
15
17
18
19
20
21
22
6
23
24
25
27
29
30
32
34
35
Is the effect of the
outcome measure
evaluated as
clinical relevant
Yes
Do the article
conclude the
effect statistically
significant, 95CI
Yes
Do the article
show sufficient
statistical data i.e.
mean, SD, SE *
Yes
Yes
Yes
No
Yes
Yes
No
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
12
Table 1 (continued)
Reference Objective outcome measure
no.
37
38
41
42
43
45
46
47
48
50
8
51
52
55
57
9
65
70
71
72
77
78
80
81
HbA1c fall = 10,8-9,8, weight
loss 6 kg., BMI fall 34,7-<30
Systolic BP = 140-134,
diastolic BP = 80-75, weight
loss = 2 kg, alcohol intake fall =
170g/day
BAC, SEC
BAC, SEC
BMI: -0,5, weight: -0,5kg,
systolic BP fall -3 units,
HbA1c 9,8-8,8%
Weight loss = -2,5 kg., totalchol-fall = 0,1mM(3,8mg/dL),
LDL fall = 0,1mM, FFA fall =
0,15mM, BMI fall = 1,5 kg/m2
Number of admissions for drug
addicts
SEC
SEC (standard ethanol content)
fall 23-12, Peak BAC (blood
alcohol conc.) fall 75-56
Fall in metadon dosis in mg
addicts
addicts
Weight-loss, BMI
Fall in peak BAC (blood
alcohol conc.)
SEC
Cost-benefit-analysis,
admissions, referrals, out of
clinic patients
HbA1c fall = 7,4-6,9,
BMI fall = -0,5
Compliance towards taking
HIV medication
Drinks per drinking day
CO-test
BAC
Drug addiction symptoms
BAC, SEC
Length of hospital stay,
treatment participation
Is the effect of the
outcome measure
evaluated as
clinical relevant
Yes
Do the article
conclude the
effect statistically
significant, 95CI
Yes
Do the article
show sufficient
statistical data i.e.
mean, SD, SE *
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
(Yes)
Yes
Yes
No
No
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
No
No
No
No
No
Yes
No
13
Quantitative data synthesis
A systematic literature search produced 72 RCT studies, the first published in 1991, assessing the
effectiveness of “Motivational Interviewing” in client counselling. A summary of the results are
shown in Table 2.
Table 2. Study data (N=72).
Effect
Ways of delivery and duration of encounter (Minuts), (N=70)
Individual interview, 10-20
Individual interview, 60
Group
Telephone
Number of encounters, (N=71)
Yes
7
12
26
4
3
0
Yes
No
4
5
6
2
0
1
No
1
2
3
4
5
>5
Counsellor profession, (N=76)
Psychologist
Doctor
Other health care provider (nurse, midwife, dietician)
Intervention period (Month) , (N=71)
<3
3-5
6-11
12
12-24
>24
Measuring method, (N=116)
Direct biological/clinical measures (e.g. HbA1c)
Direct utilization of health care services (e.g. no. of encounters at GP)
Indirect measures e.g. questionnaire
Area of intervention (N=72)
Diabetes /asthma
Smoking cessation
Weight-loss / physical activity
Alcohol abuse
Psychiatrics / Addiction
10
12
5
8
3
13
Yes
33
19
5
Yes
4
8
10
16
5
5
Yes
25
8
53
Yes
2
8
8
23
12
15
0
1
2
0
2
No
9
4
6
No
11
3
3
3
3
0
No
8
3
19
No
1
4
2
5
7
Ways of delivery and duration of intervention. N=70, 2 studies only described the intervention as an individual
interview without describing an accurate length of the interview
Number of counselling encounters. N=71, one study only described the intervention as an individual interview
without describing the number of counselling encounters
Practising counsellor (health care provider, profession). N=76, 5 studies involved encounters with several
counsellors of different educational background, which is why the total number exceeds the total number of studies.
Intervention Follow-up period. N=71, one study did not describe the follow-up period
Measuring method. N=116, In some studies both direct and indirect measures were used, which is why the total
number exceeds the total number of studies.
14
A Funnel-plot, in Figure 2, indicates that publication bias is non-significant 82.
The meta-analysis show significant effect (95% CI) of motivational interviewing for combined
effect estimates for Body Mass Index (BMI), total serum-cholesterol, systolic blood pressure, blood
alcohol concentration, standard ethanol content, while combined effect estimates for cigarettes per
day and for HbA1c are non-significant (Table 3).
Table 3. Meta-analysis, the motivational interviewing effect .
Effect measure
n
Combined effect estimate
P-Value (95 CI)
BMI
1140
0,72*
0,0001 (0,33:1,11)
HbA1c
243
0,43
0,155 (-0,16:1,01)
T-Chol
1358
0,27*
0,0001 (0,20:0,34)
SBT
316
4,22*
0,038 (0,23:8,99)
Cig/day
190
1,32
0,099 (-0,25:2,88)
BAC
278
72,92*
0,0001 (46,80:99,04)
SEC
648
14,64*
0,0001 (13,73:15,55)
* Combined estimate is statistical significant within 95CI.
CI – Confidence interval, SD – Standard deviation, SE – Standard error
BMI - body mass index, HbA1c (% GHb), BAC – blood alcohol concentration (mg%), T-Chol – total serumcholesterol (mmol/l), SEC – standard ethanol content (standard units), Cigg/day (cigarettes per day), SBT –
systolic blood pressure (mmHg)
15
The full version of Table 3 (shown below) was only published in the electronic version of the
journal.
Table 3. Meta-analysis, the effect of motivational interviewing.
Effect Measure/Reference no.
BMI/35
BMI/37
BMI/43
BMI/45
BMI/52
BMI/65
Combined BMI effect
HbA1c /14
HbA1c /37
HbA1c /45
HbA1c /65
Combined HbA1c effect
T-Chol/6
T-Chol/45
T-Chol/35
Combined T-Chol effect
Cig pr. day/20
Cig pr. day/27
Cig pr. day/32
Combined Cig/day effect
SBT/38
SBT/43
Combined SBT effect
BAC/19
BAC/41
BAC/42
BAC/80
BAC/38
BAC/48
Combined BAC effect
SEC/42
SEC/41
SEC/19
SEC/47
SEC/80
SEC/57
SEC/48
Combined SEC effect
n
97
16
147
550
296
34
1140
46
16
147
34
243
334
927
97
1358
40
29
121
190
166
150
316
34
32
28
42
100
42
278
28
32
32
409
42
63
42
648
∆ effect estimat
0,6
4,7
0,48
0,8
0,3
0,46
0,72*
0,69
1,0
0,46
0,15
0,43
0,9
0,12
0,02
0,27*
1,1
1,9
0,1
1,32
4
4,59
4,22*
76,0
41,0
98,8
48,0
164,0
59,9
72,92*
52,3
280,5
20,1
15,1
12,0
3,39
16,6
14,64*
P-value
0,250 (-0,42:1,62)
0,063 (-0,26:9,66)
0,624 (-1,43:2,38)
0,001 (0,32:1,28)
0,602 (-0,83:1,43)
0,836 (-3,9:4,82)
0,0001 (0,33:1,11)
0,394 (-0,90:2,28)
0,370 (-1,19:3,19)
0,300 (-0,41:1,33)
0,771 (-0,86:1,16)
0,155 (-0,16:1,01)
0,000 (0,74:1,06)
0,005 (0,04:0,20)
0,885 (-0,25:0,29)
0,0001 (0,20:0,34)
0,737 (-5,32:7,52)
0,056 (-0,05:3,85)
0,946 (-2,77:2,97)
0,099 (-0,25:2,88)
0,117 (-1,00:9,00)
0,172 (-1,99:11,18)
0,038 (0,23:8,99)
0,001 (32,95:119,1)
0,384 (-51,34:133,3)
0,006 (28,24:169,4)
0,096 (-8,56:104,6)
0,004 (53,5:274,5)
0,086 (-8,46:128,3)
0,0001 (46,8:99,04)
0,001 (22,38:82,22)
0,346 (-302,6:863,6)
0,052 (-0,19:40,4)
0,000 (14,17:16,04)
0,120 (-3,12:27,12)
0,132 (-1,03:7,81)
0,098 (-3,04:36,24)
0,0001 (13,73:15,55)
* Combined estimate is statistical significant within 95% CI.
All ∆ effect estimates are positive. CI – Confidence interval, SD – Standard deviation, SE – Standard error. Sum
weight/sum est*weight are values from the meta-analysis, where the effect estimates are weighed against number of
participants in each study. BMI - Body mass index, HbA1c (% GHb), BAC – Blood alcohol concentration (mg%), TChol – Blood total cholesterol (mmol/l), SEC – Standard ethanol content (standard units), Cigg/day (Cigarettes per
day), SBT – Systolic blood pressure (mmHg).
16
Qualitative data synthesis
Quality assessment was made with a validated scale ranging from 0 to 5, with higher score
indicating better reporting. High-quality trials scored a minimum of 2 out of maximum possible
score of 5. Out of 72 RCTs, 50 were assessed to 3 points, 21 assessed to 2 points and one RCT was
assessed to 1 point.
Study characteristics
An effect of “Motivational Interviewing” was demonstrated in 74% (53/72) of the RCTs. With
regard to adverse effects of motivational interviewing none of the publications reported any adverse
effects nor did they explicitly aim to report this. In no studies have “Motivational Interviewing”
shown to be harmful or having any kind of adverse effects. A total of 94% (68/72) of the RCTs used
individual interview. Of the remaining four studies, three used group therapy; one study used a
telephone interview, but showed no effect. The median duration in all the studies of an individual
counselling encounter was estimated to 60 min. (range: 10-120 min.). Among the studies using
encounters of 60 min., 81% (26/32) showed an effect. Out of eleven studies using less than 20 min.
per encounter 64% (7/11) showed an effect. The likelihood of an effect rose with the number of
encounters. Hence, an effect was demonstrated in 40% (10/25) of studies with one counselling
session, but in 87% (13/15) of studies with more than five encounters. The studies had an estimated
median follow-up period of 12 month (range: 2 months to 4 years). A prolonged follow-up period
increased the percentage of studies showing effect. Thus, 36% (4/11) of studies with a 3-month
follow-up period ascertained an effect compared with 81% (26/32) among studies allowing a 12month or longer follow-up period.
Health care providers as counsellor were: psychologists 55% (42/76), medical doctors 30% (23/76)
and other health care providers (nurses, midwives, dieticians, etc.) 15% (11/76). Medical doctors
obtained an effect of “Motivational Interviewing” in 83% (19/23) of the studies, where
psychologists obtained an effect in 79% (33/42) of the studies. Other health care providers obtained
an effect in 46% (5/11) of the studies.
Intervention targeted alcohol abuse, treatment of clients with psychiatric diagnoses and different
aspects of addiction in 47 of 72 studies, and “Motivational Interviewing” outperformed “traditional
advice giving” in 75% (35/47) of these studies. “Motivational Interviewing” targeted biological
problems, i.e. weight loss, lowering of lipid levels, increasing physical activity, diabetes, asthma
and smoking cessation in 25 of 72 studies and had an effect in 72% (18/25). Smoking cessation
studies alone reported an effect in 67% (8/12), where studies involving treatment of diabetes,
asthma, and weight-related problems reported an effect in 77% (10/13). All studies used indirect
measures, e.g. questionnaires. 46% (33/72) also used direct effect measures (health outcome,
direct/indirect indicators, utilization of health care services). An effect of “Motivational
Interviewing” was obtained in 75% of the studies elicited in terms of direct measures (33/44) and in
74% of the studies elicited in terms of indirect outcome measures (53/72).
Discussion
Main findings
This review documents that “Motivational Interviewing” in a scientific setting effectively helps
clients change behaviour and that it outperforms “traditional advice giving” in approx. 80% of the
studies. No studies have reported “Motivational Interviewing” to be harmful or having any kind of
adverse effects, however no study did explicitly aim to report this.
17
Strength and limitations
Publication bias is often a well known problem. However a Funnel-plot, Figure 2, of all the studies
within the research area of motivational interviewing indicates publication bias to be nonsignificant. Furthermore a methodological quality rating 84-86shows that except one study, all the
RCTs in this review has a high methodological quality. All studies in the meta-analysis demonstrate
a positive effect or tendency although not all studies show a significant effect of “Motivational
Interviewing”. However the meta-analysis was only performed on the 19 studies (out of 42), which
stated effect measures on patient outcome and statistical data needed for the meta-analysis in the
article or delivered these data afterwards on request. Of the remaining 23 studies, 17 concluded
significant effect of “Motivational Interviewing” and 6 showed non-significant effect. These
remaining studies did not deliver the statistical data in the article or afterwards needed for metaanalysis. However, in the light that a vast majority (33 out of 42) of the RCTs with effect measures
on patient outcome, concluded significant effect of “Motivational Interviewing”, we believe a
potential selection bias to be non-significant and the results of the meta-analysis to be valid.
Detailed findings
The meta-analysis shows significant effect of motivational interviewing for combined effect
estimates of Body Mass Index (BMI), total serum-cholesterol, systolic blood pressure, blood
alcohol concentration, standard-ethanol content (Table 3). In particularly the magnitude of the
decrease of BMI, systolic blood pressure, blood alcohol concentration decrease and standard
ethanol content is of clinical relevance and imply that motivational interviewing can and should be
used. The significant decrease for the combined effect estimate of total serum-cholesterol is of less
clinical importance. However viewing an effect as clinical important or not, it is imperative to keep
in mind that “Motivational Interviewing” is based on making the patients themselves aware of
potential “space” for change in behaviour resulting in improved health parameters, which means
that small changes also may be of interest, if they are the beginning of a changing process for the
patient.
The “nature of changes” from the patient is almost always related to both the adherence to
prescribed medication and to what changes the patient make in life style. However effect of
“Motivational Interviewing” in some problem areas e.g. weight loss, smoking cessation, is primarily
mediated through change of own habits, whereas effect on asthma primarily comes from adherence
to prescribed medication. This meta-analysis provides evidence of significant effect of motivational
interviewing on many different areas of intervention. The review has shown that “Motivational
Interviewing” can be effective even in brief encounters of only 15 min and that more than one
encounter with the patient increases the likelihood of effect 6; 7;14;15;24;43;44;45;49;51.
This review sheds new light on the assumption that the effectiveness of “Motivational
Interviewing” depends upon the counsellor’s profession. The effect was not related to the
counsellor’s educational background as medical doctor or psychologist. Hence, there was no
statistical significant difference in the percentage of studies obtaining an effect of “Motivational
Interviewing” whether it was performed by psychologists, psychiatrists, physicians or general
practitioners. Utilization of “Motivational Interviewing” probably depends on other aspects like
duration and number of client-counsellor encounters. However, it would be reasonable to speculate
that aspects like training and experience with “Motivational Interviewing” methods and clientcounsellor relationship also influence the effectiveness, even if this cannot be shown in this review.
Five studies involved other health workers, e.g. nurses, midwifes and dieticians as counsellor, and
18
another six studies partly involved other health workers in the counselling encounter
6;17;18;22;27;30;32;38;62;70;72
. Only five of these eleven studies found “Motivational Interviewing” to be
effective 6;30;38;62;72. This may, to some extent, be explained by the design of these studies as most of
them reported on the effect of only one encounter, had a follow-up period shorter than three months
and began with difficult subjects like HIV-positive addicts changing life style.
Implications for future research
This review underscores the crucial importance of the “Motivational Interviewing” setting and the
study design for obtaining an effect. Thus, a follow-up period shorter than three months increases
the risk of failure counselling, probably due to “lack of intervention” 22; 27;28;32;34;40;65.
Another important aspect was the use of indirect measures versus direct measures. This review
showed that an effect of “Motivational Interviewing” can be demonstrated by indirect measures like
questionnaires but also direct effect measures like blood pressure, blood glucose, weight, length of
hospital-stay, etc. When it is possible to measure effect by epidemiological as well as clinical direct
measures and to capture effect by clinical endpoints, this should be done to ensure the reliability of
the results. The optimal design would match the specificity and reliability of direct measures with
the in-depth qualitative perspective of indirect measures, e.g. questionnaires. Furthermore in the
optimal design, it is imperative that future studies make an effort to describe precisely how
“Motivational Interviewing” education is performed and how we “use” the methods in client
counselling, allowing us all to learn more about how to increase and maximise its effect.
Implications for practice
The review shows that “Motivational Interviewing” has been used in treatment of various life styles
and diseases, psychological as well as biological. The review shows that app. 75% of the studies do
obtain effect no matter biological or psychological disease, which is supported by the meta-analysis.
We may therefore now argue that “Motivational Interviewing” is not limited in any way to
counselling of a small group of selected clients, but can be used in the treatment of a broader area of
diseases which to some extent is influenced by behaviour. When viewed in combination with no
apparent harmful effect and no reported adverse effects of “Motivational Interviewing”, it suggests
a method with an important potential effect, which patients very well may benefit from.
Conclusion
The review and meta-analysis affords the conclusion that “Motivational Interviewing” in a scientific
setting outperforms “traditional advice giving” in the treatment of a broad range of behavioural
problems and diseases. However evaluation of exact methods of “Motivational Interviewing” in a
clinical setting is missing. We now need large scale studies both RCTs and qualitative studies on
how to implement the methods of “Motivational Interviewing”, to prove, that it can be implemented
into daily clinical work for health care providers and yield effect to the benefit of the patients.
19
20
Chapter 3
How does an education and training course in “Motivational
interviewing” influence general practitioner’s professional
behaviour. ADDITION Denmark.
Rubak S, Sandbaek A, Lauritzen T, Borch-Johnsen K, Christensen B.
British Journal of General Practice. Submitted 2004.
21
Abstract
Background: ”Motivational interviewing” has been shown to be broadly usable in the management
of behavioural problems and diseases. However, data concerning implementation and aspects
regarding the use of ”Motivational interviewing” in general practice is missing.
Aim: To evaluate general practitioners (GPs) conception of ”Motivational interviewing” in terms of
methods, adherence to and aspects of its use in general practice after a course.
Study design: The study involved three groups of GPs, two of which comprised a RCT concerning
intensive treatment of newly diagnosed Type 2 diabetes patients detected by screening. These two
groups were randomised to a course in ”Motivational interviewing”. The study also included a third
group of GPs outside the RCT, who had two years previously received a similar course in
”Motivational interviewing”.
Methods: The intervention consisted of a 1½-day residential course in ”Motivational interviewing”
with ½-day follow-ups, twice during the first year. Questionnaire data from GPs were obtained.
Results: We obtained a 100 % response-rate from the GPs in all three groups. The GPs trained in
”Motivational interviewing” adhered statistically significantly more to the methods than did the
control group. More than 95 % of the GPs receiving the course stated that they had used the specific
methods in general practice.
Discussion/Conclusion: A course in ”Motivational interviewing” seems to influence GPs
professional behaviour. Based on self-reported questionnaires, this study shows that the course
provided GPs with skills that raised their confidence in using ”Motivational interviewing” for
patient treatment. GPs found ”Motivational interviewing” to be more effective than “traditional
advice giving”. Furthermore, the experienced GPs found that the method was not more time
consuming than “traditional advice giving”.
22
Introduction
The concept of “Motivational interviewing” evolved from experience with treatment of alcoholics
and was described by Miller in 1983 3. The concept was developed into a coherent theory and a
detailed description of the clinical procedures 1. ”Motivational interviewing” has been shown to be
broadly usable in the management of behavioural problems and diseases 5. Hence, the method has
been used and evaluated internationally especially in the last decade in relation to the following
main areas 1) Addiction (Alcohol abuse and addiction to drugs), 2) Change in lifestyle (Smoking
cessation, weight-loss, physical activity, asthma and diabetes treatment), and 3) Adherence (to
treatment and to control, encounters of follow-up, counselling meetings) 5. The technique has been
deployed by various health care providers, including psychologist, doctors, nurse’s and midwifes.
Controlled trials in general practice have shown that it is an effective strategy in the treatment of
different diseases 21;24;36;38;43;60;64. However, only very few studies have focused on how to
implement and integrate “Motivational interviewing” in professional behaviour in daily work in
general practice 87;88, and they have concluded that this strategy lends itself well to implementation
in general practice. We found a need for evaluating whether the general practitioners (GPs)
educated and trained in ”Motivational interviewing” actually used and adhered to the methods in
their clinical work.
The aim of this study was to evaluate 1) how a 1½-day course in “Motivational interviewing”
including follow-up meetings influenced GPs professional behaviour, 2) whether GPs after a 1½day course found the method to be useful in general practice.
23
Methods
Study group
The study included three groups of GPs:
Two groups participated in the ADDITION study 13, which is a multi-centre randomised controlled
trial of a target-driven approach to intensive treatment of patients with Type 2 diabetes detected by
screening. All practices registered at the County Health Insurance Registry in Aarhus County were
1. January 2001 invited to meetings about participation in the ADDITION-study. In Copenhagen
County only practices located in the north and eastern part (7 municipalities) were invited, because
screening for diabetes had already taken place in the remaining municipalities in the county in
connection with the Inter99 study. In agreement with the County Health Insurance only 60 GPs
were to be included per county at study onset, and primarily practices with more than one GP were
included. No exclusion criteria for the GPs were applied and included GPs in the ADDITION study
were randomised at practice level into a group giving standard care and an intervention group
educated to intensive treatment including lifestyle intervention and poly-pharmacological treatment
aiming for rigorous values of blood glucose, blood pressure and lipids in addition to anticoagulation
treatment.
This study included practices/GPs from the intervention group of the ADDITION study. These
practices/GPs were sub-randomised into:
an internal motivational group (IM-group) comprising GPs receiving a course with education and
training in ”Motivational interviewing” and
an internal control group (IC-group) comprising GPs receiving no formal education or training in
”Motivational interviewing”.
The inclusion of GPs is shown in the flowchart, Figure 1. Randomisation within the ADDITION
study was stratified by county (Copenhagen and Aarhus) and size of practices. GPs received
education and training free of charge.
This study included furthermore an external motivational group (EM-group). This group consisted
of GP, who had attended the course in ”Motivational interviewing” two years before the start of the
ADDITION study (20 GPs). This group was contacted externally to the ADDITION-study and was
asked to answer the same questionnaire as GPs within the ADDITION-study, thus serving as a
group of GPs with long-term knowledge of the use of “Motivational interviewing”. GPs in this
group attended the training and paid all expenses themselves.
24
Figure 1. Flowchart of included general practitioners (GPs) and Type 2 diabetes patients (T2D)
Eligible practices willing to participate
N = 48 (including 65 GPs)
Randomisation
stratified by county (Copenhagen and Aarhus) and size of practice
Control group
IC-group
N = 27 (36 GPs)
Eligible practices/GPs, who
two years previously attended a
residential course in
“Motivational interviewing”.
External Study group
(EM-group)
N = 20 practices (20 GPs)
Intervention group trained in
IM-group, N = 21 (29 GPs)
GPs received residential course in intensive treatment of Type 2 diabetes
GPs received residential course in “Motivational interviewing”
Follow protocol, guidelines, case record forms and patient material
Inclusion of patients according to inclusion-/exclusion criteria
GPs follow up days, ½ day twice during the first year
GPs included with one year follow-up
Control group, IC-group
N = 25 (30 GPs) *
Intervention group, IM-group
N = 21 (29 GPs)
GPs included with three years
follow-up
External group, EM-group
N = 20 (20 GPs)
* 2 practices (6 GPs) dropped out after randomisation
IC-group: Internal control group receiving no formal education or training in ”Motivational interviewing”.
IM-group: Internal motivational group receiving course in “Motivational Interviewing”
EM-group: External motivational group receiving course in “Motivational Interviewing”
25
Method of intervention
The courses in ”Motivational interviewing” for the GPs in the IM and EM groups were conducted
by a single trained teacher, who had conducted several of these courses successfully. The teacher is
the first author of ”Motivational interviewing ”, a manual from the Danish Scientific Society of
General Practitioners (2000) 89 which together with “Motivational interviewing, preparing people to
change addictive behaviour” (1991) 2 constituted the theoretical part of the course curriculum. Each
course included 6-12 GP participants. Each session started with a short introduction to the methods
of “Motivational Interviewing” followed by group discussions and training the methods involving a
high level of participation in workshops and role-plays. The principal rules of “Motivational
Interviewing” in relation to the patient-doctor relationship 2 were trained as was the use of the
specific skills e.g. empowerment 90, use of the ambivalence 2, the decisional balance schedule 2,
visual analogue scale 2 and stage of change 91 and reflective listening 2.
The courses for the GPs in the IM group consisted of a 1½-day training sessions with half a day
follow-up twice during the first year. Two years prior to the start of this study, the GPs in the EM
group had participated in a course similar to that given the IM group. None of the GPs in either
three groups had previously participated in courses in ”Motivational interviewing”.
All GPs in the RCT (IM-/IC group) had participated in the same training courses in intensive
treatment of Type 2 diabetes patients detected by screening. The training course lasted half a day
and follow-up was performed as afternoon meetings twice every year. During these diabetes
training sessions, it was stressed that GPs should act as counsellors for the patients, allowing
treatment decisions to be based on a mutual understanding between the patient and the GP.
Measurements
No validated questionnaire was available for evaluating the courses in ”Motivational interviewing”
and the GP’s conception of the methods, adherence to the technique and their actual use of
”Motivational interviewing”. The construct of the questionnaire was therefore designed based on 1)
the theoretical knowledge about ”Motivational interviewing”, 2) the leading author’s knowledge
from attending the course and 3) knowledge from the teacher and head of the course. The content of
the questionnaire was divided into themes: “GPs reaction in specific patient cases”, “GPs preferred
way of motivating change in patient behaviour” and “practicability of ”Motivational interviewing”
and aspects concerning the GP’s use of the technique in their daily clinical work”. The
questionnaire was evaluated and pilot tested by GPs and lay people within and outside the
Department of General Practice, University of Aarhus. The validation process included ensuring
that questions were not to be misunderstood, that questions in total covered the themes while at the
same time not overlaying each other and that answering categories was sufficient to discriminate
between different answers. In order to evaluate the GP’s use of ”Motivational interviewing”, the
following 4 questions were asked:
Q1: What do you do, when the patient obviously does not follow your advice?
Q2: What do you do, when you sense that the patient does not want to follow your advice?
Q3: What do you do, when the patient’s conception of good health and actual life style are
inconsistent?
Q4: What do you do, when you aim at motivating change in patient behaviour?
For Q1-3 the GPs should respond to 9 different possible reactions (Figure 2) on a 5-item Likert
scale (1=full agreement, 5=total disagreement). With regard to question 4, the GPs should respond
to 8 different possible reactions (Figure 3) on a 5-item Likert scale indicating how often they used
each possibility (1=always, 5=never). The possible reactions for Q1-4 were related to counselling
style, using either ”Motivational interviewing” or “traditional advice giving”.
26
“Traditional advice giving” is used as an expression for doctor-centred approach, i.e. the GP define
the patients’ problem from a biomedical perspective and does not at all include the patient
perspective on the matter, thus giving advice accordingly 12;83.
Figure 2. Questions (Q1-3) to evaluate how GPs used MI.
Q3: What do you do, when the patient’s conception of good health and actual life style are inconsistent?
GP’s had to respond on a 5-item Likert scale to each of the following possible reactions:
Explain the plan of treatment and care once again
Explore further the patients abilities and possibilities for solving the problem
Explain by arguments why it is important to follow the treatment once again
Investigate if the patient believes that the treatment will help
Make the patient tell about advantages and disadvantages of habits in relation to disease
Inform further about the disease and treatment to pursuit the patient to a deal
Tell further about the consequences if the treatment plan is not followed
Make the patient summarize the agreed deal
Ask about the patient’s expectations to what you can do in the actual situation of disease
5-item Likert scale: Fully agree=1, partly agree=2, not agree or disagree=3, partly disagree=4, totally
disagree=5
Figure 3. Questions (Q4) to evaluate how GP’s used MI.
GP’s had to respond on a 5-item Likert scale to each of following possible reactions:
Reflective listening
Preparing the patient of different treatment options before choosing the one
Using accurate arguments for change of life-style to emphasize the consequences of
sustained life-style
Clarifying the treatment strategy in relation to time
Emphasizing the patients resources
Clarify what advantaged and disadvantages the patient sees in relation to disease
and plan of treatment
Showing patient empathy, support and respect
Focusing on the positive sides of the patients habits in relation to the disease
5-item Likert scale: Always=1, Often=2, On occasion=3, Seldom=4, Never=5
27
The sum-scores for questions 1 to 4 were calculated to evaluate whether or not the GPs used the
methods of ”Motivational interviewing” or “traditional advice giving”. “Questions” 1-4 were based
on the responses to each possible reaction in Figure 2 and 3. The responses were first reversed in
order to unify the direction of the response to each possible reaction. Then all the responses to the
possible reactions to each question were added and divided by the number of items, thereby
generating a mean response for each question. The method of sum-scoring questions has been used
and validated in different settings 92-96.
Questions 1-4 were given to all three groups of GPs, whereas the remaining questions regarding the
practicability of ”Motivational interviewing” and aspects concerning the GP’s use of the technique
in their daily clinical work (Tables 1-3) were given to the GPs in the motivational groups (IM-/EMgroup). Questionnaires were mailed to all three groups either one year (IM- and IC-groups) or
threes years (EM-group) after the courses. Reminders were mailed two weeks later.
Statistical method
Statistical analysis of data was conducted in SPSS (version 11.0). All single variables containing
data from a Likert scale were analysed by a non-parametric Mann Whitney test (Tables 2 and 3).
All sum-score variables from questions 1-4 followed a normal distribution and consequently a Ttest was done. Results are either given as median and quartiles, simple percentages or as mean with
95% confidence interval (CI). A statistical significance level of 0.05 (two tailed) was used.
Results
Study sample characteristics
A flowchart for participating practices and GPs is shown in Figure 1. In all, 48 practices (65 GPs)
were included. Twenty-syven practices (36 GPs) were randomised into the IM-group and 21
practices (29 GPs) into the IC-group. Two practices including 6 GPs (all in control group) dropped
out after randomisation. We obtained a 100 % response rate to the questionnaire from the GPs in all
three groups. All GPs in the IM- and EM-group participated in the ”Motivational interviewing”
courses, and less than 10% were absent from the ½-day follow-up meetings. The GPs had an
average age of 53 years, were male in 2 out of 3, and had an average of 1500 patients in their
practice with no significant differences between the study groups.
Study data and analyses
The motivational groups (IM-/EM-group) seemed to adhere more to ”Motivational interviewing”
than the control group (IC-group) as there were no significant differences between these two
groups, as opposed to between the motivational groups and the control group in terms of the GP’s
responses to different doctor-patient situations (Table 1).
28
Table 1. GPs’ counselling according to the methods of “Motivational interviewing”.
Evaluation by mean sum-scores from the possible reactions (Tables 1 and 2) to the following questions:
Q3: What do you do, when the patient’s conception of good health and actual life style are inconsistent?
Q1
IC-group
N=31
Mean sum-score
2.93
IM-gr mean
N=27
Mean sum-score
2.05
ME-gr mean
N=20
Mean sum-score
2.04
Q2
2.92
2.10
2.14
Q3
2.82
2.08
2.23
Q4
1.93
1.69
1.65
P value
(95 CI)
IC vs M
0.001
(0.56;1.21)
0.001
(0.49;1.15)
0.001
(0.40;1.06)
0.005
(0.09;0.44)
P-value
(95 CI)
IC vs EM
0.001
(0.39;1.13)
0.001
(0.41;1.03)
0.022
(0.07;0.74)
0.026
(0.04;0.56)
P-value
(95 CI)
M vs EM
0.59
(-0.21;0.35)
0.94
(-0.31;0.34)
0.40
(-0.48;0.20)
0.88
(-0.23;0.27)
Questionnaire scaling: 1-5, 1 = acting according to the methods of motivational interviewing and 5 = acting
according to “traditional advice giving” (The doctor decides what is best for the patient).
The responses from GPs in the control group to the possibilities raised in Figures 2 and 3 showed
that they used some elements from both strategies, viz.”Motivational interviewing” and using
“traditional advice giving”. A majority (79-100%) of GPs in the motivational groups (IM-/EMgroup) stated that they had used the different elements of ”Motivational interviewing” after the
course (Table 2). The GPs in the IM-group agreed statistically significantly more than the GPs in
EM-group in the usability of the visual analogue scale and the decisional balance schedule, whereas
no differences were seen concerning the usability of the other elements (Table 2).
Table 2. GPs’ use of specific methods of “Motivational Interviewing” one year (IM-group)
and three years (EM-group) after a course in “Motivational Interviewing”.
Group
Method *:
IM-group
(N=27)
GP have used
the specific
method (%)
EM-group
(N=20)
GP have used
the specific
method (%)
IM-group
(N=27)
GP agrees that
method is usable
Median (25%/75%
quartile)
1 (1;2)
1 (1;1)
2 (1;2)
2 (1;2)
1 (1;2)
1 (1;2)
PEARLS @
81%
95%
Reflective listening
100%
100%
Visual analog scale
92%
84%
Stage of change
81%
79%
Balance schedule
100%
90%
Showing and using
85%
79%
the ambivalence
Empowering
96%
100%
1 (1;1)
* Questionnaire scaling: 1-5, 1 = Yes, fully agree and 5 = No, disagree
@ Partnership-Empathy-Accept-Respect-Legitimate-Support (PEARLS)
ns – non-statistical significant difference P < 0.05
29
EM-group
(N=20)
GP agrees that
method is usable
Median (25%/75%
quartile)
2 (1;2)
1 (1;1)
2 (1.75;3)
2 (1;2)
1.5 (1;3)
1 (1;3)
P-value
IM-EM
1 (1;2)
ns
ns
ns
P<0.05
ns
P<0.05
ns
Fourteen questions addressed the GP’s opinion of the course and aspects regarding actual use of the
technique (Table 3). Four statistically significant differences appeared between the IM- and EMgroup. The GPs in IM-group agreed less than GPs in the EM-group to the claim, that it was possible
to change working methods and habits by means of ”Motivational interviewing” (possibility 9,
Table 3). The GPs in EM-group disagreed more than GPs in the IM-group in their awareness to
questions concerning aspects of the use of ”Motivational interviewing” (possibilities 12-14, Table
3).
Table 3. What is your opinion about the methods of “Motivational interviewing”?
Questions
1. Did you get the principal rules of
motivational interviewing from the
residential course?
2. Did you feel trained adequately to use
motivational interviewing in daily work?
3. Are the methods of motivational
interviewing realistic and usable in daily
work?
4. They are very suitable for GP
5. They are suitable to some patients
6. They are more effective than traditional
advice giving
7. I have not yet had patients suitable for the
motivational interview.
8. Motivational interviewing is an
improvement of my working-methods in the
patient-doctor relationship
9. I cannot change my working methods and
habits by using motivational interviewing
10. It is an advantage to change workingmethods to motivational interviewing
11. The methods of motivational interviewing
from the residential course helps me in my
patient care and my patient-doctor
relationship
12. The methods are time-consuming
13. Patients wants the doctor to tell what must
be done
14. It is difficult to change my “ways” in
patient-doctor relationship
IM-group, N=27
Median
(25%;75%
quartiles)
2 (1;2)
EM-group, N=20
Median
(25%;75%
quartiles)
2 (1;2)
IM vs. EM
group
P-value
2 (1;2)
2 (1;2)
ns
1 (1;2)
1 (1;2)
ns
2 (1;2)
3 (2;5)
1 (1;2)
2 (1;2)
4 (2.25;4)
1 (1;2)
ns
ns
ns
5 (4;5)
5 (4;5)
ns
2 (1;2)
1.5 (1;2)
ns
4 (2;4)
5 (4;5)
P<0.05
2 (1;2)
1 (1;2)
ns
1 (1;2)
2 (1;2)
ns
3 (2;4)
3 (2;4)
5 (3.25;5)
5 (4;5)
P<0.05
P<0.05
2 (2;3)
4 (3;5)
P<0.05
1 = Questionnaire scaling: 1-5, 1 = Yes, fully agree and 5 = No, disagree
30
ns
Discussion
Main findings
According to the GPs, a course in ”Motivational interviewing” provide them with skills that gave
them more confidence in using this method for patient treatment. Their professional behaviour in
daily practice seemed to be changed in direction of the ”Motivational interviewing”.
The main strengths of the study are that 1) all GPs responded to the questionnaire, 2) all GPs in the
IM-group attended the ”Motivational interviewing” courses, and 3) less than 10% GPs were absent
from the follow-up meetings. In spite of the relatively small number of GPs in each group (20 to
31), significant findings between groups were found. Previous studies on ”Motivational
interviewing” in general practice have proven an effect 21;24;36;38;43;60;64. However, only few studies
have focused on how to implement ”Motivational interviewing” in the daily clinical work in general
practice in such a way that it is ascertained that the method is used after study closure 87;88. They
concluded that it despite barriers was possible to implement the use “Motivational interviewing” in
general practice 87;88.
We used questionnaires as measuring method on effect of a course in “Motivational interviewing”
of GPs in general practice and obtained statistically significant changes between study groups.
However, the sensitivity of this measuring method is low, when focusing on the GPs actual use and
adherence to ”Motivational interviewing”. In order to enhance sensitivity of these aspects, external
assessment was required, e.g. video-recordings. This was not possible in this study of 48 practices,
and 65 general practitioners in two counties.
The GPs in the internal groups (IM-/IC-group) were randomised into a RCT arm for ”Motivational
interviewing”, whereas GPs in the EM-group had decided by themselves to participate in the
course. Thus the GPs in the latter group were probably more motivated to obtain and use
”Motivational interviewing” than the former groups. However, both motivational groups (IM-/EMgroup) rated ”Motivational interviewing” the same way except that external group agreed more to
the usefulness and the effect of ”Motivational interviewing” in general practice.
The study suffer the limitation that GPs in the control group could have become familiar with
”Motivational interviewing” by personal initiative during the study period. Furthermore, GPs in the
RCT (IM-/IC-group) received training in intensive treatment of Type 2 patients. During these
diabetes training sessions, it was stressed that GPs should act as counsellors giving patients advice
about how to reduce the risk of late diabetic complications and allow treatment decisions to be
based on mutual understanding between the patient and the GP. This may have influenced the GPs
in the control group, who in their response to the possibilities in Figures 2 and 3 indicated that they
neither entirely used ”Motivational interviewing” or the “traditional advice giving”. However, some
of their choices showed a tendency for adhering to ”Motivational interviewing”. These
circumstances tend to reduce the differences between GPs in the IM-group and IC-group. In spite of
this, statistically significant differences were found. This indicates that the course in ”Motivational
interviewing” affected the GPs’ professional behaviour, thus, a relevant change for daily work in
general practice.
The intervention consisted of a course in ”Motivational interviewing” conducted by one person.
Outcome is therefore highly dependent on this person’s teaching methods and capacity to train the
31
GPs. If several teachers had conducted the courses, this problem would have been diminished. The
use of more teachers on different courses, however, might have introduced differences in learning
and training outcome. We chose to use one teacher only because only very few can teach
”Motivational interviewing” in Denmark and the teacher had previously conducted several of these
courses and was the leading author to the course curriculum.
Detailed findings
Of particularly interest was that the EM-group of GPs with three years of experience with
”Motivational interviewing” differed more in their evaluation of the usability of some of the
specific methods than the IM-group of GPs with one year of experience. GPs in the IM-group
evaluated methods like “visual analogue scale” and “decisional balance schedule” to be more usable
in general practice than GPs in the EM-group (both methods being “straight forward” and easy to
use). The GPs in the EM-group showed a tendency of rating “using the ambivalence” and
“empowering” higher than the GPs in the IM-group. These methods demand that the GP is able to
use the principal rules of ”Motivational interviewing” in all aspects. Hence, it seems if GPs in the
EM-group integrated ”Motivational interviewing” in their patient-doctor relationship to a greater
extent than GPs in the IM-group, thus, having obtained more confidence in using its more complex
dimensions.
Even though the GPs in the IM group were recruited by randomisation, their responses mirrored
those of the GPs who participated by own choice (EM group). The results after 3 years in the IMgroup would probably be close to the present results of the EM-group. This is further supported by
the fact that both groups evaluated ”Motivational interviewing” as suitable for general practice.
However, the more experienced GPs in the EM-group expressed that the method was not more time
consuming than “traditional advice giving”. The time-consuming aspect of ”Motivational
interviewing” has previously been investigated by Rollnick et al in relation to smoking cessation
reporting that an average consultation encounter lasted 9-10 min, which was acceptable to the GPs
36
.
Furthermore, the GPs in the EM-group found the method was not difficult to adapt and use in
patient-doctor relationship. The motivational groups found that ”Motivational interviewing”
improved the patient-doctor relationship and that it was more effective than “traditional advice
giving”. Stott et al performed a study on how GPs would react to new technologies and methods
showing that GPs did adopt, accept and use new methods when they facilitated solutions to
problems in patient-doctor relationship 97. The difference between the motivational groups could
indicate that it takes more than one year to integrate ”Motivational interviewing” into daily clinical
practice.
Doherty et al wrote addressed the relevance of developing GPs’ skills through ”Motivational
interviewing” and the importance of acknowledging the difficulties of changing professional
behaviour 98. This study has focused on the first level towards implementing ”Motivational
interviewing”, viz. to change the way GPs are integrating ”Motivational interviewing” into their
daily work. Further research into the precise use of ”Motivational interviewing” by GPs is required
in order to identify which methods are most effective and why.
Another aspect to be addressed is whether and how the use of ”Motivational interviewing” affects
the patient’s attitudes toward changing behaviour, e.g. life style and adherence. Finally future
research should explore the effect on patient risk profile. The ADDITION-study 13is an ongoing
32
study which aims to gather all these issues into a RCT to evaluate whether a course in
”Motivational interviewing” change the professional behaviour of GPs, whether patients change
behaviour and if this improve the risk profile.
Conclusion
A ”Motivational interviewing” course seems to influence GPs’ professional behaviour. GPs find
that the course provide them with skills that afford them greater confidence in using ”Motivational
interviewing” for patient treatment. GPs found that ”Motivational interviewing” was more effective
than “traditional advice giving” and that it improved the patient-doctor relationship. Furthermore,
the experienced GPs used more complex parts of ”Motivational interviewing” and found that the
methods was not more time-consuming than “traditional advice giving”. Whether ”Motivational
interviewing” results in a better prognosis for patients remains to be proved.
33
34
Chapter 4
Effect of “Motivational interviewing” on beliefs and behaviour
among patients with Type 2 diabetes detected by screening.
ADDITION Denmark.
35
Abstract
Background: ”Motivational interviewing” has been shown to be broadly applicable in the
management of behavioural problems and diseases associated with unhealthy lifestyle. Only few
studies have evaluated the effect of ”Motivational interviewing” on the treatment of Type 2 diabetes
and none have explored the effect of “Motivational interviewing” on target-driven intensive
treatment of this disease.
Aim: To evaluate whether “Motivational interviewing” in general practice improves screened Type
2 diabetes patients’ beliefs about Type 2 diabetes and its consequences, and whether it changes their
behaviour.
Study design: Two groups of GPs were randomised to training in ”Motivational interviewing” or
not. Both groups received training in target-driven intensive treatment of Type 2 diabetics.
with ½-day follow-ups twice during the first year. Data from patients was obtained using previously
validated questionnaires.
Results: The study obtained 87% response rate. Patients in the intervention group were statistically
significantly more autonomous and motivated in their inclination to change behaviour compared to
patients from the control group after one year. Patients in intervention group were also statistically
significantly more conscious of the importance of controlling their diabetes and had a significantly
better understanding of the possibility of preventing complications. However the significant
differences between the groups were small.
Discussion/Conclusion: Questionnaires one year showed that “Motivational interviewing” had
improved on patient beliefs of Type 2 diabetes treatment and their contemplation and readiness to
behaviour change. No change was seen in self-reported lifestyle behaviour.
36
Introduction
Type 2 diabetes attracts growing attention because of rising prevalence, its accompanying
disablement due complications and the reduced life expectancy associated with this disease. At the
root of this problem lies inexpedient lifestyle behaviour, failure to adhere to intensive treatment and
prescribed medication 99-102. Most Type 2 patients are being treated in primary care, but the majority
of studies of intensive treatment of patients with Type 2 diabetes have been performed in hospital
settings and without the use of “Motivational interviewing” 99-102. However, there is a growing
interest in methods like “Motivational interviewing”, one of the rather well-known, scientifically
tested method of client counselling developed by Miller and Rollnick 2. It is viewed as a useful
intervention strategy for changing behaviour and it may be instrumental in improving the prognosis
of the disease. “Motivational interviewing” has been used as an intervention strategy in several
contexts, e.g. alcohol abuse, drug addiction, smoking cessation, weight-loss, adherence to treatment
and follow-up, increase of physical activity, asthma treatment and diabetes treatment 5. A previous
study showed a course in “Motivational interviewing” can influence GPs professional behaviour
towards using the method in general practice 103. This study, performed in general practice, aims to
evaluate whether “Motivational interviewing” of Type 2 diabetes patients detected by screening can
improve their self-reported 1) contemplation and readiness to change behaviour, 2) actual change in
patient behaviour, and 3) beliefs regarding Type 2 diabetes.
37
Methods
Study group
This study is a sub-study of the ADDITION study 13, which is a multi-centre randomised controlled
included. No exclusion criteria for the GPs were applied and included GPs were randomised at
practice level into a group giving standard care or an intervention group educated to intensive
treatment including lifestyle intervention and poly-pharmacy aiming for rigorous values of blood
glucose, blood pressure and lipids in addition to anticoagulation treatment.
This study included practices/GPs from the intervention group of the ADDITION study. These
practices/GPs were sub-randomised into
an intervention group (I-group) comprising GPs receiving a course with training in ”Motivational
interviewing” and
a control group (C-group) comprising GPs receiving no formal training in ”Motivational
interviewing”.
Randomisation was stratified by county (Copenhagen and Aarhus) and size of practices. GPs
received training free of charge. The inclusion of GPs and patients is shown in the flowchart, Figure
1. Patients were included in the study by the following inclusion-/exclusion criteria: All newly
diagnosed Type 2 diabetes patients detected by screening aged 40-69 years were eligible unless they
were found to have contraindications or intolerance to study medication; a history of alcoholism,
drug abuse, psychosis or other emotional problems that were likely to invalidate informed consent
or adherence to treatment; malignant disease with a poor prognosis; or were pregnant or lactating.
Patients previously diagnosed with diabetes or treated with blood glucose lowering agents were
excluded.
38
Figure 1. Flowchart of included general practitioners (GPs) and screen-detected Type 2 diabetes patients (T2D)
Randomisation
(stratified by county and size of practice)
Intervention group, trained in
I-group, N = 21 (29 GPs)
Control group, C-group
N = 27 (36 GPs)
GPs received residential course in
“Motivational interviewing”
GPs meeting at follow-up days, ½ day twice during the first year
Intervention group, I-group
N = 21 (29 GPs)
N = 25 (30 GPs) *
Patients included with one year follow-up
N = 137 T2D in I-group
N = 128 T2D in C-group **
Complete questionnaire data after one year follow-up
N = 115 T2D in C-group
** 2 Type 2 diabetes patients dropped out after randomisation
39
The courses in ”Motivational interviewing” for the GPs in the I-group were conducted by a single
trained teacher, who had conducted several of these courses successfully. The teacher is the first
author of ”Motivational interviewing ”, a manual from the Danish Scientific Society of General
Practitioners (2000) 89 which together with “Motivational interviewing, preparing people to change
addictive behaviour” (1991) 2 constituted the theoretical part of the course curriculum. Each course
included 6-8 GP participants. Each session started with a short introduction to the methods of
“Motivational Interviewing” followed by group discussions and training the methods involving a
The courses for the GPs in the I-group consisted of a 1½-day training sessions with a ½-day followup twice during the first year. None of the GPs in I- and C-group had previously participated in a
course in ”Motivational interviewing”.
All GPs in the I- and the C-group had participated in the same training courses in intensive
treatment of Type 2 diabetes patients. This training course lasted half a day and follow up was
performed as afternoon meetings twice every year. During these diabetes training sessions, it was
stressed that GPs should act as counsellors for the patients, allowing treatment decisions to be based
on a mutual understanding between the patient and the GP.
Measurements
The intervention phase began 1. May 2001 and included the 1-year follow-up data.
The questionnaire used for assessment consisted of a collection of previously validated
questionnaires used in primary care and on Type 2 diabetes patients:
-
Health Care Climates Questionnaire (HCCQ) 104-108. It assesses the patient’s perceptions of
patient-doctor relationship and the the degree to which counselling are autonomous supportive
versus controlling. In this study the short 6-item HCCQ was used. It includes 7 items using a
Likert scale with categories from “not at all true” to “very true”.
-
Treatment Self-Regulation Questionnaire (TSRQ) 105;108-110. It assesses the degree to which
behaviour tend to be self-determined. The main scale includes three subscales: the
“autonomous” regulatory style; the “controlled regulatory” style; and “amotivation” style. The
“autonomous style” represents the most self-determined form of motivation and has consistently
been associated with behaviour change and positive health care outcomes 105. TSRQ is a
questionnaire including 21 items. It involves a 7-item Likert scale with categories from “not at
all true” to “very true”.
-
Diabetes Illness Representation Questionnaire (DIRQ), which comprises two questionnaires, the
Illness Perception Questionnaire (IPQ) and the Personal Models of Diabetes Interview
Questionnaire (PMDIQ) 92;93;111.
The DIRQ questionnaire assesses Type 2 diabetes patient’s beliefs and understanding of Type 2
diabetes and involves 5 subscales: Identity (symptoms associated with the illness); cause (the
cause of illness and the factors responsible for illness onset); timeline (patient’s perception of
duration of the illness); threat, impact i.e. consequences (patient’s expected outcome of the
illness); and prevent/control/treatment/effectiveness (patient’s beliefs about the extent to which
40
the illness is amenable to cure, in which way prevention is possible and how good
recommended treatments are at controlling the illness). In this study we only used 4 of the
subscales, excluding “identity” because we obtained this by the GPs’ reports. All questions
involve a 5-item Likert scales with categories from “no importance” to “extremely important”.
The DIRQ included 30 items.
-
Summary of Diabetes Self-Care Activities (SDSCA).95;112-116. It assesses to which extent Type 2
diabetes patients perceive advice on various self-care activities related to Type 2 diabetes. The
questionnaire focuses on which advice from the counsellor has been perceived by the patient in
relation to: general diet and specific diet ; exercise; testing and controlling; adherence to
prescribed medication; foot care; and smoking. The answering categories were either listed on a
dichotomous (yes/no) or a continuous scale (viz. “On how many of the last 7 days did you ...?”).
The SDSCA included 13 items.
-
13 self-constructed and pilot tested questions on self-care activities in relation to smoking,
alcohol and exercise. Answering categories were dichotomised or presented on a continuous
scale.
Sum-scores were calculated for the questionnaires HCCQ, TSRQ and DIRQ. The sum-scores for
questions were calculated to obtain an overall picture of each patient’s views on different subjects
(Table 1 and 5). Questionnaire responses for each subject were first reversed in order to unify the
direction of the response to each question. Then the responses were added and divided by the
number of responses to generating a mean response. The method of sum-scoring questions has been
used and validated in different settings 92;93;95;96;108-111;117.
All the questionnaires were translated by the conventional principal rules of forward-backward
translation. The authors translated from English into Danish and a British subject residing in
England speaking Danish translated backward again in order to ensure mutual agreement of the
translation. After the translation, the final Danish questionnaire was pilot-tested and validated on a
group of 5 GPs and a group of their Type 2 diabetes patients. Questionnaires to all patients in both
groups of GPs were mailed at baseline and 6 and 12 month after inclusion. One reminder was sent
in case of no response within four weeks. The questionnaires were designed in and read by the
computer program Teleform 118, which ensures reliable and valid data 119.
Statistical method
Statistical analysis of data was conducted in SPSS (version 11.0). All single variables containing
data from a Likert scale were analyzed by Non-Parametric Mann Whitney test. All sum-score
variables followed a normal distribution and consequently a T-test was therefore performed. Results
are either given as median and quartiles, simple percentages or as mean and 95% confidence
interval (CI). A statistical significance level of 0.05 (two tailed) has been used. The clustering of
GPs was adjusted for by using a mixed regression model assuming random (normal) variation
between and within GPs.
41
Results
A flowchart for participating practices (GPs) and patients is shown in Figure 1. In all, 48 practices
(65 GPs) were included. Twenty-seven practices (36 GPs) were randomised into the I-group and 21
practices (29 GPs) into the C-group. Two practices (6 GPs) and 2 patients dropped out after
randomisation. All GPs in the I-group participated in the training courses, and less than 10% were
absent from the ½-day follow-up meetings. The study included 265 Type 2 diabetes patients
detected by screening with a one year follow-up; 128 in the C-group and 137 in the I-group. The
response rate to the patient questionnaire was 87% in the I-group and 90% in the C-group. Among
the 265 patients, 59% were males, average age of 62 years, 33% of patients with familiar history of
diabetes, with no significant differences between the study groups. The GPs had an average age of
53 years, were male in 2 out of 3, and had an average of 1500 patients in their practice with no
significant differences between the study groups.
The sum-scores for the HCCQ- and TSRQ-questionnaire are presented in Table 1.
Table 1.
Health Care Climate Questionnairen (HCCQ) and Treatment Self-Regulation
Questionnaire (TSRQ) evaluated after one year.
Sum-score
I-group
mean
5.88
C-group
mean
5.69
0.19 (-0.14;0.52) 0.26
TSRQ control
4.95
4.89
0.06 (-0.31;0.43) 0.75
TSRQ
autonomy
6.46
6.25
0.21 (0.01;0.41) 0.04*
TSRQ
amotivation
2.90
3.43
-0.53 (-0.94;-0.11) 0.014*
TSRQ relative
autonomicontrol index
1.48
1.40
0.08 (-0.08;0.23) 0.34
HCCQ sum
∆; (95 CI); P-value
Interpretation of results
In general, patients in both groups are
satisfied with their relationship with the
GP and the counselling style
In general, patients in both groups tend
to some extent to seek leadership and
controlling counselling
Patients in the I-group were more
autonomous, i.e. more self-determined
and motivated for behavioural change
Patients in the C-group were more
amotivated, i.e. not motivated for
behavioural change
The relative index does not change
statistically significantly between
groups due to the small magnitude of
change in autonomy/control
Sum-scores of sub-questions-answers on a 7-item Likert scale, 1=totally disagree to 7=fully agree
Overall, patients in the C- and I-group reported being satisfied with their GP. With regard to
treatment and self-regulation, both groups wanted “controlling counselling” (TSRQ-control), even
when they stayed “autonomous” in their behaviour decisions (TSRQ-autonomy). Patients from the
I-group were statistically significantly more autonomous in their choice of action towards
behavioural changes than patients from C-group after one year. Patients from the I-group were
statistically significantly more motivated for changing behaviour (less “TSRQ-amotivation”) than
patients in the C-group after one year, but not after 6 month.
42
Table 2 features self-reported advice from GPs regarding diet, exercise and self-control of diabetes
after one year. Patients in the I-group reported having received statistically significantly more
specific advice from their GP regarding diet, exercise and self-control of diabetes than patients in
the C-group after one year. The differences in perceived advice from the GPs became more
statistical significant after 12 month compared to 6 months of study period.
Table 2. Advice giving by the general practitioner to the patient after one year
(Diabetes Self-Care Activities Questionnaire)
Advice given by the GP
Follow a low-fat eating plan
Follow a complex carbonhydrate diet
Reduce the number of calories
Eat lots of food high in dietary fibre
Eat lots (at least 5 servings per day) of
fruits and vegetables
Eat very few sweets. e.g. deserts
You have not been given any advice
about your diet
Get low level exercise (such as
walking) on a daily basis
Exercise continuously for a least 20
minutes at least 3 times a week
Fit exercise into your daily routine
Engage in a specific amount, type,
duration and level of exercise
about exercise
Test your blood glucose (sugar) using a
drop of blood from finger
Test your blood glucose using a
machine to read the results
Test your urine for sugar
about testing for glucose
I-group
% (N=137)
81.8
50.4
70.8
59.9
73.0
C-group
% (N=128)
76.3
33.6
58.8
43.5
61.8
I-gr. vs. C-gr.
P-value
0.025*
0.01*
0.024*
0.002*
0.033*
67.1
2.2
63.4
6.9
0.34
0.79
75.9
74.8
0.66
31.4
20.6
0.029*
64.2
19.0
51.9
6.9
0.02*
0.002*
3.6
8.4
0.61
54.8
38.9
0.034*
45.3
29.0
0.006*
27.1
23.4
11.5
37.4
0.002*
0.029*
43
Self-care activities regarding changing smoking and alcohol habits after one year are shown in
Table 3. A group of patients including 16 patients (1,2%) in the I-group and 22 patients (1,6%) in
the C-group had a level of alcohol consumption above the recommended treatment goals. Overall
there was no significant difference in smoking and alcohol intake suggesting a behavioural change.
Table 3. Patients’ self-care activities regarding smoking and alcohol after one year.
(Diabetes Self-Care Activities Questionnaire)
Question *
I-group
C-group P-value
How many cigarettes do you smoke on average per day?
4.76
3.46
0.35
How many beers do you drink on average per week?
2.19
4.24
0.27
How many glasses of wine do you drink on average per week?
1.84
2.80
0.24
In consideration to your health, do you believe that you should lower
67%
73%
0.27
your alcohol intake? (%;n/N)
(90/137)
(94/128)
At your last doctors visit, did anyone ask about your smoking status?
33%
25%
0.08
(%;n/N)
(47/137)
(32/128)
At your last doctors visit, did anyone council you about stopping
22%
24%
0.79
smoking or refer you to a stop-smoking program? (%;n/N)
(31/137)
(31/128)
How motivated are you at stopping smoking?
2.36
2.48
0.47
(scale: 1= very much, 5= not at all)
* Data regarding smoking was analyzed according only to smokers, whereas data regarding alcohol intake
was analyzed on all patients
The DIRQ questionnaire assessed patients’ self-reported beliefs about the causes of illness,
including the factors responsible for its onset with no significantly differences between groups.
Table 4 shows changes in patients’ beliefs regarding their diabetes. Patients in the C- and I-group
showed no significant differences in terms of their opinion about the threat and the impact diabetes
imposed on their lives and on the time aspects of their disease. Patients in both groups reported
controlling their diabetes and paying attention to preventing factors as important. Patients in the Igroup were statistically significantly more aware of the importance of controlling their diabetes for
specific factors than patients in the C-group and they also had a statistically significantly better
understanding of the probability of how different factors would prevent complication.
Table 4.
Patients’ views on timeline, control, prevention, threat and impact of diabetes
evaluated after one year by the Diabetes Illness Representation Questionnaire
Sum-score
Timeline (patient’s perception of duration of the
illness)
Control (patient’s beliefs about how good
recommended treatments are at controlling the
illness)
Prevention (patient’s beliefs about the extent to
which the illness is amenable to cure and in
which way prevention is possible)
Threat (patient’s expected outcome of the
illness)
Impact (patient’s expected impact on day-today life and in the long term)
I-group
mean
2.41
C-group
mean
2.45
∆; (95 CI); P-value
-0.04 (-0.23;0.15) 0.70
3.90
3.68
0.22 (0.04;0.39) 0.016*
4.16
3.99
0.17 (0.01;0.32) 0.042*
2.61
2.59
0.02 (-0.09;-0.12) 0.67
3.50
3.48
0.02 (-0.12;0.18) 0.70
Sum-scores on a 5-item Likert scale: 1=no importance to 5=extremely important
44
Discussion
Main findings
After one year, patients in the I-group became increasingly more autonomous and motivated for
behavioural changes than patients in the C-group. Furthermore, patients in the I-group were more
knowledgeable and had a better understanding of which factors would help prevent complications
and ensure relevant disease control. The autonomous style represents the most self-determined form
of motivation and has consistently been associated with behavioural change and positive health care
outcomes 105;108-110. A RCT-study showed that changes in perceptions of autonomy predicted
change in glycemic control 108. These findings suggest that “Motivational interviewing” have
moved more patients in the I-group than in the C-group into the contemplation phase and that they
increased their readiness to change behaviour.
We cluster randomised at practice level in order to avoid contamination between the interventionand control group 120. The cluster design does affect the statistical analysis, because in this design
the patients are not independent individuals statistically and the statistical analysis has to be
performed using the number of cluster units, thus reducing the total number in the comparing
groups. 120-122. Cluster randomisation with a small number of units is not likely to show similar
distributions of baseline characteristics among groups 123. However, we included 48 practices in 2
counties, which secured similar distributions in each treatment group. Furthermore, we performed
stratified randomisation of GPs on size of practice and on county. We hence anticipate a high
internal validity, a low degree of selection bias and a random allocation of unpredictable,
immeasurable confounders.
The study showed that the GPs in the different groups included an equal number of Type 2 diabetes
patients, which supports the conclusion that selection bias was limited. The number of GPs and
patients’ (all in C-group) dropped out of the study after randomisation is not expected to bias the
results in consideration of the total number of GPs and patients included in this study.
The study did not include blinding and behavioural changes may therefore be influenced by the
Hawthorne effect 124. However in this PhD project both groups of patients were treated with
intensive treatment and only one group was further exposed to “Motivational interviewing”. In this
way attention to the treatment of Type 2 diabetes including lifestyle changes would increase in both
groups and a potential Hawthorne effect would hence exist in both groups. If the patients’
consciousness about changing lifestyle behaviour was raised because of the Hawthorne effect, this
would tend to reduce the effect of “Motivational interviewing”.
The validity of the study is strengthened by a high response rate to the questionnaire and the use of
sum-scoring, a validated method increasing the power of the statistical analysis. The measuring
methods used to observe patient behaviour change was mainly based on validated questionnaires
which increase the reliability of our results.
The study may suffer from a limitation because training in “Motivational interviewing” was only
performed by one person. This makes outcome highly dependent on this person’s teaching methods
and capacity to train the GPs 103. This person was, however, highly experienced in the methods of
“Motivational interviewing” and in teaching. We evaluated the course and found GPs in the I-group
adhered more to the methods of “Motivational interviewing” than GPs in the C-group 103.
45
In order to ascertain an effect of behavioural intervention, it is necessary to adopt a triple approach
assessing 1) professional behavioural change to “Motivational interviewing” on the part of the
counsellor, 2) patient behavioural change and/or attitudes to entering contemplation phase of
behavioural change, and finally 3) effect on patient outcome measures e.g. risk profile 103. This
paper presents the results of the second stage. The presentation of the effect measures of patient risk
profile of this study awaits publication.
Detailed findings
It was unexpected to find that GPs in I-group gave patients more advice on diet, exercise and selfcontrol of diabetes than GPs in the C-group. In a similar trial investigating the effect of patientcentred care on lifestyle, Kinmonth et al reported that patients became more satisfied by their GP’s
counselling style, however with no effect on perceived advice or the risk profile 125. The authors
suggested that that GPs became too focused on the consultation process at the expense of disease
management 125. Our interpretation of the results in this paper is that GPs in the I-group used
“Motivational interviewing” to increase the patients’ awareness of the need for behavioural changes
in lifestyle and adherence to diabetes treatment, which led the patients to believe that they had
received more advice and thus integrated the behavioural change to a higher degree than patients in
the C-group. However, whether this study shows effect on the patients risk profile remains to be
seen.
GPs in both groups managed to educate the patients to the same level of knowledge about the
causes of Type 2 diabetes, its time-aspects and the consequences of complications. However, in the
I-group GPs counselling had a significant impact on the patients’ understanding of factors
preventing complications and factors controlling the disease compared with the C-group. This
improved understanding or higher levels of awareness can also be interpreted as the patients’
acceptance of the disease and their interest in knowing which opportunities they had for preventing
complications through lifestyle behavioural changes and adherence to medication. Even though the
differences obtained were small, the results do indicate that more patients in the I-group than in the
C-group entered contemplation phase and thereby possibly increased their readiness to change
behaviour. With regard to the lack of change of alcohol intake behaviour, the results revealed that
more than 98% of the patients in both groups were, in fact, within the treatment goals, which left
only little room for demonstrating effect of “Motivational interviewing”. The study showed a
tendency that more GPs in I-group than C-group asked the patients about smoking status and
behaviour (Chapter 4, Table 3, page 44). However, no change was found in smoking behaviour,
which may be caused by the GPs not using the opportunity to focus on smoking behaviour or the
GPs not motivating for smoking behaviour change. The patients’ statements indicated the latter,
thus, that they were not motivated to change smoking behaviour. Whether this was a result of GPs
including many subjects (e.g. smoking behaviour, lifestyle behaviour, Type 2 diabetes self-care
etc.) in the same counselling encounter, or if it was their use of the “Motivational interviewing”, or
the concept of “Motivational interviewing” itself, was difficult to determine for certain.
The study measured no effect on behavioural change, e.g. smoking status or alcohol intake, despite
changes in patient beliefs, contemplation and readiness to change behaviour. Thus, the measuring
methods and the intervention of a study need to be considered. In this study, the method has shown
overall effect on the contemplation of behavioural change. It has previously been shown that a
”Motivational interviewing” course seemed to influence GPs’ professional behaviour and GPs
46
reported that they used ”Motivational interviewing” in their daily practice 103. This supports that
”Motivational interviewing” does have effect, however long-term evaluation is needed in order to
capture effect at both GP-level (changing professional behaviour) and patient level (contemplation
towards change and occurred change).
Conclusion
This study reports a statistically significant effect of ”Motivational interviewing” on patients beliefs
regarding Type 2 diabetes and on their contemplation and readiness to change behaviour. However,
both groups obtained effects, and even though the effect of ”Motivational interviewing” was
statistically significant, it remained a small additional effect. Thus, the importance of this finding in
clinical setting is uncertain. The study showed no significant change in actual change of smoking
and alcohol intake behaviour. Whether better results of ”Motivational interviewing” can be obtained
over a longer period of time has to be investigated.
47
48
Chapter 5
No effect of “Motivational interview” on risk profile in patients
with Type 2 diabetes detected by screening. A one year follow-up of
a RCT. ADDITION Denmark.
49
Abstract
Background: ”Motivational interviewing” has been shown to be broadly applicable in the
management of behavioural problems and diseases associated with unhealthy lifestyle. Only few
studies have evaluated the effect of ”Motivational interviewing” on the treatment of Type 2 diabetes
and none have explored the effect of “Motivational interviewing” on target-driven intensive
treatment of this disease.
Aim: To investigate whether an improved risk profile can be achieved following implementation of
“Motivational interviewing” in general practice.
Study design: Two groups of GPs were randomised to training in ”Motivational interviewing” or
not. Both groups received training in target-driven intensive treatment of patients with Type 2
diabetes.
with ½-day follow-ups twice during the first year. Blood samples, case record forms, national
registry files and validated questionnaires from patients were obtained.
Results: The study showed statistically significant changes in terms of improved metabolic status
and adherence during the intervention period within both randomisation groups. However, there
was no significant difference between the randomisation groups after one year.
Conclusion: Based on a one year follow-up, we found no effect of “Motivational interview” on the
risk profile in patients with Type 2 diabetes detected by screening.
50
Introduction
A large proportion of patients with Type 2 diabetes are treated in primary care. Despite this, most
previous studies on intensive multi-factorial treatment have been conducted in hospital setting 99;102.
A major problem in these studies has been poor patient adherence to healthy life style and poor
adherence to medication 99;102. New approaches to achieve behavioural changes are therefore
required to be introduced. “Motivational interviewing” is one of the rather well-documented,
scientifically tested methods of client counselling developed by Miller and Rollnick and it is viewed
as a useful intervention strategy for changing behaviour and improving disease management 2.
“Motivational interviewing” has been used in very few studies of Type 2 diabetes and the results
have been varying 5;14;43;103. No investigations have evaluated its effect in relation to target-driven
intensive treatment of patients with Type 2 diabetes detected by screening in primary care. The aim
of this study is to show whether a course in “Motivational interviewing” for general practitioners
(GPs) improves patient adherence to intensive treatment based on an evaluation of the risk profile
of patients with Type 2 diabetes detected by screening.
Method
Study group
This study is a sub-study of the ADDITION study 13, which is a multi-centre randomised controlled
included. No exclusion criteria for the GPs were applied and included GPs were randomised at
practice level into a group giving standard care or an intervention group educated to intensive
treatment including lifestyle intervention and poly-pharmacy aiming for rigorous values of blood
glucose, blood pressure and lipids in addition to anticoagulation treatment. This study included
practices/GPs from the intervention group of the ADDITION study. These practices/GPs were subrandomised into
an intervention group (I-group) comprising GPs receiving a course with training in ”Motivational
interviewing” and
a control group (C-group) comprising GPs receiving no formal training in ”Motivational
interviewing”.
Randomisation was stratified by county (Copenhagen and Aarhus) and size of practices. GPs
received training free of charge. The inclusion of GPs and patients is shown in the flowchart, Figure
1. Patients were included in the study by the following inclusion-/exclusion criteria: All newly
diagnosed Type 2 diabetes patients detected by screening aged 40-69 years were eligible unless they
were found to have contraindications or intolerance to study medication; a history of alcoholism,
drug abuse, psychosis or other emotional problems that were likely to invalidate informed consent
or adherence to treatment; malignant disease with a poor prognosis; or were pregnant or lactating.
Patients previously diagnosed with diabetes or treated with blood glucose lowering agents were
excluded. Diagnostic criteria for Type 2 diabetes is defined as fasting capillary whole blood glucose
above 6,1 mM or oral glucose tolerance 2-hour test above 11,1 mM 13.
51
Figure 1. Flowchart of included general practitioners (GPs) and screen-detected Type 2 diabetes patients (T2D)
Randomisation
(stratified by county and size of practice)
Intervention group, trained in
I-group, N = 21 (29 GPs)
N = 27 (36 GPs)
GPs received residential course in
“Motivational interviewing”
GPs meeting at follow up days, ½ a day twice during the first year
Intervention group, I-group
N = 21 (29 GPs)
N = 25 (30 GPs) *
N = 128 T2D in C-group **
View Table 1 to see data rates on all data in I- and C-group
52
The courses in ”Motivational interviewing” for the GPs in the I-group were conducted by a single
trained teacher, who had conducted several of these courses successfully. The teacher is the first
author of ”Motivational interviewing ”, a manual from the Danish Scientific Society of General
Practitioners (2000) 89 which together with “Motivational interviewing, preparing people to change
addictive behaviour” (1991) 2 constituted the theoretical part of the course curriculum. Each course
included 6-8 GP participants. Each session started with a short introduction to the methods of
“Motivational Interviewing” followed by group discussions and training the methods involving a
The courses for the GPs in the I-group consisted of a 1½-day training sessions with a ½-day followup twice during the first year. None of the GPs in I- and C-group had previously participated in a
course in ”Motivational interviewing”.
All GPs in the I- and the C-group had participated in the same training courses in intensive
treatment of Type 2 diabetes patients. This training course lasted half a day and follow up was
performed as afternoon meetings twice every year. During these diabetes training sessions, it was
stressed that GPs should act as counsellors for the patients, allowing treatment decisions to be based
on a mutual understanding between the patient and the GP. In Denmark, GPs’ consultation
encounters average 15 min. and the County Health Insurance has agreed to one longer prophylactic
encounter of 45 min. per patient. In this study the County Health Insurance agreed to allow the GPs
in the I- and C-group to undertake three consultations of 45 min. per patient, in which the I-group
could use “Motivational interviewing”.
Measurements
The choice of effect parameters was based on the recommendations from evidence-based guidelines
for treatment of Type 2 diabetes. In these guidelines treatment goals are controlled by measuring
HbA1c, lipid-profile, blood pressure and body mass index. Furthermore the study aimed at
reporting changes in adherence, which required other measures e.g. health care services, selfreported changes from GPs and patients. The intervention phase began 1. May 2001 and included
the 1-year follow-up data.
The study was based upon the following types of data obtained from all patients:
Risk profile
The use of blood sample data is addressed in Chapter 5. They include HbA1c, total serum
cholesterol, serum LDL, serum HDL and serum triglycerides. Baseline blood samples were
analysed as follows: HbA1c was analysed using a Tosoh blood sample analyzer on venous whole
blood drawn and stored in EDTA aliquots. HbA1c reference interval is 4,1% to 6,1%. Serum
cholesterol, serum HDL-cholesterol and serum triglycerides were analysed using a Hitachi 917
System or an Abbott Aeroset analyzer with an enzymatic colorimetric test as the test principle.
LDL-cholesterol was calculated using Fridewald’s formula. Reference interval for serum
cholesterol is below 6,0mM, for serum HDL above 0,9mM, for serum triglycerides below 2,5mM
and for serum LDL below 4,5mM. All blood samples after baseline were analysed on several
laboratories in the two counties, all subject to the Danish quality assurance for laboratories.
Body mass index (BMI) and systolic- and diastolic blood pressure (measured sitting at rest at the
GP) were obtained from case record forms reported by the GPs.
53
Health care services
Prescribed medication was reported by the GPs on case record forms. The number of prescriptions
cashed in at the pharmacy by the patient was drawn from the National Health Service Registry. The
number of encounters and blood samples was obtained from register data files from the National
Health Service Registry.
Self-reported data
Data on smoking and exercise in leisure time and at work was obtained from patient questionnaires.
- The questions on physical activity had previously been validated in the “International Physical
Activity Questionnaire (IPAQ)” 126.
- The questions on smoking had previously been validated in the “Summary of Diabetes Self-Care
Activities” (SDSCA) questionnaire 95;112;116.
Answering categories for the questions were dichotomised (yes/no) or presented on continuous
scales (“On how many of the last 7 days did you ...?”). The questionnaires were designed in and
read by the computer program Teleform 118, which ensured reliable and valid data 119.
Statistical method
Data was blinded by the use of serial numbers in order to prevent observer bias. Statistical analysis
of data was conducted in SPSS (version 11.0). Results are either given as median and quartiles,
simple percentages or as mean and 95% confidence interval (CI). Paired T test was used to compare
changes from 0 to 12 month. A statistical significance level of 0.05 (two tailed) was used. The
clustering within GP's was adjusted for by using a mixed regression model assuming random
(normal) variation between and within GPs.
Results
A flowchart for participating practices (GPs) and patients can be seen in Figure 1. In all, 48
practices (65 GPs) were included. The 27 practices (36 GPs) were randomised into the I-group and
21 practices (29 GPs) into the C-group. Two practices (6 GPs) and 2 patients dropped out after
randomisation. All GPs in the I-group participated in the educational and training courses, and less
than 10% were absent from the ½-day follow-up meetings. The study included 265 Type 2 diabetes
patients with a 1-year follow-up; 128 in the C-group and 137 in the I-group. The response rate to
the patient questionnaire was 87% in the I-group and 90% in the C-group. According to the case
record forms, 74% patients in the I-group and 79% in the C-group had visited their GP one year
after their inclusion in the study (Table 1). The GPs had an average age of 53 years, were male in 2
out of 3, and had an average of 1500 patients in their practice with no significant differences
between the study groups.
54
Table 1. Data rate collected from patients after one year.
Group
I-group
(N=137)
% data collected from patients
%
T-Chol (total serum-cholesterol (mmol/l))
70%
HDL (high density lipoproteins (mmol/l))
67%
LDL (low density lipoproteins (mmol/l))
61%
Tgly (triglycerid (mmol/l))
64%
HbA1c (% GHb)
91%
Smoking status
88%
Physical activity
86%
Blood pressure
76%
BMI (Body Mass Index)
79%
C-group
(N=128)
%
83%
77%
71%
74%
91%
86%
86%
83%
84%
I-group vs C-group
P-value
P < 0.05
P < 0.05
P < 0.05
P < 0.05
ns
Ns
Ns
Ns
Ns
Among the 265 patients, 59% were males, average age of 62 years, 33% of patients with familiar
history of diabetes, with no significant differences between the groups.
Measures for the risk profile at 0 and 12 months are presented in Table 2. A statistically significant
improvement is seen in both groups from 0 to 12 month with no significance differences between
the I- and the C-group.
Table 2. Risk profile measures at 0 and 12 month follow-up.
Value
Group
Time (Month)
Total values
I-group
C-group
(N = 137)
(N = 128)
0
∆ 0-12
0
∆ 0-12
mean
mean
mean
mean
140.3
-6.4*
139.2
-7.3*
83.8
-4.7*
82.7
-4.4*
5.9
-0.8*
5.7
-0.6*
1.3
0.1*
1.3
0.1*
3.6
-0.7*
3.5
-0.7*
2.4
-0.6*
2.0
-0.3*
7.3
-0.9*
7.2
-0.9*
30.3
-0.9*
31.0
-0.8*
66.1
6.6
71.2
7.8
3.3
0.9
3.5
0.5
Systolic BP
Diastolic BP
T-Chol (total serum-cholesterol (mmol/l))
HbA1c (% GHb)
% Number of non-smokers
F-H (Number of days per week with hard
physical activity (example: aerobics))
F-M (Number of days per week with
4.2
moderate physical activity (example:
bicycling in moderate tempo))
* P < 0.01, ns – non-statistical significant difference
0.6
3.8
0.7
P-value
I- vs. C-group
(N = 137/128)
Time 0-12
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
The number of patients within the treatment targets and BMI < 27 at study entry and after one year
is seen in Table 3. Statistically significantly more patients in the C-group than in the I-group
achieved the treatment goal for blood pressure.
55
Table 3. Patients below treatment target and BMI < 27 after one year
Time
Group
SBT
DBT
Cholesterol
HbA1c
BMI
Achieved treatment goal at time 0 month
I-group (N=137)
C-group (N=128)
% of total N
% of total N
42 %
44 %
57 %
67 %
21 %
23 %
56 %
57 %
26 %
23 %
Achieved treatment goal at time 12 month
P-value
I- vs C-group
Time 0 month
ns
ns
ns
ns
ns
I- vs C-group
Time 12 month
P<0.05
P<0.05
ns
ns
ns
SBT
45 %
57 %
DBT
60 %
74 %
Cholesterol
34 %
39 %
HbA1c
80 %
80 %
BMI
23 %
28 %
ns – non-statistical significant difference P < 0.05. Study treatment targets:
SBT ≤135 (systolic blood pressure (mmHg)), SBT ≤85 (diastolic blood pressure (mmHg))
T-chol ≤ 5.0 (total serum-cholesterol (mmol/l)), HbA1c ≤ 6.4 (% GHb), BMI ≤ 27 (Body mass index)
There were no significant differences between the I-group and the C-group in the number of
encounters or the use of blood tests used in general practice during the 1-year study period (Table4).
Table 4. Patients’ use of health care services in general practice after one year.
Group
I-group (N=137)
No. Ordinary consultation
8.1
No. Prophylactic consultation
1.2
No. Blood samples
3.9
No. Blood glucose
4.2
No. Telephone consultation
5.9
C-group (N=128)
9.8
1.3
4.3
6.8
8.9
P-value
Ns
Ns
Ns
Ns
Ns
The ratios between the proportion of patients reported by GPs to have had a prescription for blood
glucose lowering drugs, BP or lipid lowering drugs and the proportion of patients registered to have
“cashed in” a prescription for each of the three treatments at the pharmacy did not differ statistically
significantly, either within or between the I- or the C-group (Table 5).
Table 5. Adherence to prescribed medication.
Prescriptions ”cashed in” by patients at the pharmacy compared with prescriptions registered
by the GPs after one year (% of patients).
Medicin
I-group (N=137)
C-group (N=128)
I vs C group
% of patients in group
%*
%-ratio
%*
%-ratio
P-value
Anti-hypertensiva
64%/64%
1
63%/63%
1
ns
Lipid-lowering medication
42%/42%
1
47%/47%
1
ns
Anti-trombotica
53%/64%
0.83
56%/63%
0.88
ns
Oral antidiabetica
37%/39%
0.96
36%/36%
1
ns
* X % of patients cashed in a prescription of medication / Y % of patients had registered a prescription of
medication from the GP.
56
Discussion
Main findings
Based on a 1-year follow-up, we found no effect of the motivational interview on the risk profile of
patients with Type 2 diabetes detected by screening. After one year, blood glucose, serum-lipid
profile, blood pressure, physical activity, BMI, drug prescriptions reported by GPs, drug
prescriptions cashed in at the pharmacy and the number of visits to the GP did not differ between
patients being treated by GPs trained in “Motivational interviewing” and those who were treated by
GPs who had received no such training. The study showed significant changes in patient outcome
with improved metabolic status and treatment adherence after one year within both groups.
The validity of the study is strong by virtue of 1) the attendance of all GPs in courses intended for
each group, 2) the absence of less than 10% GPs from the follow-up meetings, 3) a patient response
rate to the questionnaire exceeding 87%, 4) acquisition of 74% of the case record forms from GPs
in the I-group and 79% from GPs in the C-group, and 5) acquisition of a 100% data rate from the
National Health Service Registry. Blood samples during the 1-year follow-up was obtained from
61%-91% of the patients (Table 1). This range may introduce a bias in the interpretation of data at
the 61% end of this continuum. Furthermore, data rates obtained on serum lipid profiles in the Igroup were statistically significantly lower compared to the C-group, which may introduce selection
bias and tend to decrease the difference between the two groups. The number of GPs and patients’
(all in C-group) dropped out of the study after randomisation is not expected to bias the results in
consideration of the total number of GPs and patients included in this study.
The study did not include blinding, in which case behavioural changes may be influenced by the
Hawthorne effect 124. However, in this PhD project both groups of patients were treated with
intensive treatment, and only one group was further exposed to “Motivational interviewing”. In this
way attention to the treatment of Type 2 diabetes including lifestyle changes would increase in both
groups and a potential Hawthorne effect would hence exist in both groups. If the patients’
consciousness about changing lifestyle behaviour was raised because of the Hawthorne effect, this
would tend to reduce the effect of “Motivational interviewing”.
We cluster randomised at practice level in order to avoid contamination between intervention- and
control group 120. The cluster design does affect the statistical analysis, because in this design the
patients are not independent individuals statistically and the statistical analysis has to be performed
using the number of cluster units, thus reducing the total number in the comparing groups. 120-122.
Cluster randomisation with a small number of units is not likely to show similar distributions of
baseline characteristics among groups 123. However, we included 48 practices in 2 counties, which
secured similar distributions in each treatment group. Furthermore, we performed stratified
randomisation of GPs on size of practice and on county. We hence anticipate a high internal
validity, a low degree of selection bias and a random allocation of unpredictable, immeasurable
confounders.
This study may suffer from a limitation because training in “Motivational interviewing” was only
performed by one person. This makes outcome highly dependent on this person’s teaching methods
and capacity to train the GPs 103. This person was, however, highly experienced in the methods of
57
“Motivational interviewing” and in teaching. We evaluated the course and found GPs in the I-group
adhered more to the methods of “Motivational interviewing” than GPs in the C-group 103.
Detailed findings
Adherence to prescribed medication was high compared with previous studies despite intensive
poly-pharmacological treatment, however, there was no significant differences between the groups
127-129
. This may be the result of the intensive training in treatment of Type 2 diabetes, where it was
stressed that GPs should act as counsellors advising the patients how to reduce the risk of late
diabetic complications and allowing treatment decisions to be based on mutual understanding
between the patient and the GP. This is indicated in a previously published paper in this study on
how “Motivational interviewing” influences GPs’ professional behaviour 103. Thus, the effect of
“Motivational interviewing” may have been reduced because of GPs in the C-group had a greater
awareness into all aspects of Type 2 diabetes treatment, including motivating lifestyle changes. The
lacking effect of “Motivational interviewing” may also be ascribed to GPs failure to use all the
potential three motivational consultations made available by the study. GPs in the I- and C-group on
average used only one prophylactic consultation for each patient. Thus, the possibility of an effect
on the risk profile would have been higher if the GPs in I-group had used all three consultations
deploying “Motivational interviewing”.
The results revealed that a large part of the patients in both groups had values (e.g. HbA1c, lipidprofile, blood pressure or BMI) that were, in fact, within the treatment goals from the beginning of
the study. This left only little room for demonstrating an effect of ”Motivational interviewing” due
to the narrowness of the intervention field. However, significantly more patients in the C-group than
in the I-group achieved the treatment goal of blood pressure reduction, but there was no significant
difference in mean blood pressure between the groups. The reason for this may be that the patients
in C-group only had marginal increased blood pressure, and subsequently the patients achieved
treatment goals with only a small decrease in blood pressure. Thus, a difference between the study
groups in patients achieving treatment goals of blood pressure was seen, however, with no
significant difference in mean blood pressure between the study groups. Another reason for more
patients in C-group than I-group achieving treatment goal for blood pressure may be that the GPs
was too focused on the consultation process at the expense of disease management as reported
earlier in a study with a similar design investigating patient-centred care targeting lifestyle changes
125
. The issue of focusing on behaviour change e.g. diet counselling, thus leading to less focus on
other medical treatment e.g. medication is addressed in a newly published paper in the Lancet 130.
Implications for future research and practice
The measuring methods used to observe patients’ behavioural changes included both self-reported
measures, e.g. validated questionnaires and effect measures on patient outcome, e.g. HbA1c. This
ensured valid results regarding the effect of ”Motivational interviewing”. We have previously
outlined that in order to obtain an effect of behavioural intervention, it is important to measure this
effect at several levels, viz. the level of 1) professional behavioural change, 2) patient behavioural
change and/or attitudes to entering the contemplation phase of behavioural change, and 3) effect
measures, e.g. changes in risk profile 103.
Previous studies using ”Motivational interviewing” in general practice have proven an effect of this
approach 21;24;36;38;43;60;64. However, only few studies have focused on how to implement
”Motivational interviewing” in the daily clinical work in general practice in such a way that it is
ascertained that the method is used after study closure 87;88. They concluded that it despite barriers
58
was possible to implement the use “Motivational interviewing” in general practice 87;88. This study
showed that GPs found that implementation of “Motivational interviewing” was not timeconsuming and de facto used the same or fewer consultation encounters than GPs resorting to
“traditional advice giving” 103. Thus, the results decrease the concerns over the time-consuming
aspect of this technique and its concomitant expenses in primary health care services.
The study period lasted one year, a period during which the GPs received training and had to adapt
to the methods of “Motivational interviewing” and to use the technique with a number of patients,
make these patients change lifestyle to the effect that changes could be measured on their risk
profile. This PhD-study has previously shown that 1) a ”Motivational interviewing” course seemed
to influence GPs’ professional behaviour, 2) GPs reported that they used ”Motivational
interviewing” in their daily practice, and 3) that patients’ changed contemplation of behaviour. The
findings of this study support the hypothesis that the non-significant effect of ”Motivational
interviewing” on risk profile may be a result of the study’s attempt to accomplish too much over too
short a period.
Conclusion
Based on a 1-year follow-up, we found no effect of the motivational interview on the risk profile in
patients with Type 2 diabetes detected by screening. Two recent meta-analyses concluded that
psychological therapies improve long-term glycaemic control, and “Motivational interviewing”, as
one of these methods, had an effect on lifestyle factors like food intake, smoking, alcohol
consumption and medication adherence 5;131. These meta-analyses side with the results of the
present study on GPs’ professional behaviour and patient behaviour 103 in supporting the need for
long-term evaluation of the effect of ”Motivational interviewing” on the risk profile.
59
60
Chapter 6
General discussion of methods
61
Introduction
This section offers a comprehensive discussion of the methods used in this study, adding
perspective to the research questions posed. The issues raised are:
1. Setting of the study
2. Design (cluster randomisation, bias, blinding, study evaluation)
3. Intervention (monitoring of intervention, adherence to the method of “Motivational
interviewing”, changing and sustaining long-term change of professional behaviour)
4. Measuring methods (questionnaires to GPs, questionnaires to patients, case record forms,
blood sample data, registry data)
5. Statistical methods
6. Generalisation of outcome
Setting of the study
The clinical setting of this study was Danish general practice in the counties of Copenhagen and
Aarhus. The scientific setting of the study was conducted from the Department of General Practice,
University of Aarhus and the Steno Diabetes Centre, Gentofte. The ADDITION-study aimed at
investigating the effect of early detection of Type 2 diabetes by screening and multi-factorial
intensive treatment, including “Motivational interviewing”. However, the ADDITION-study did not
intend specifically to evaluate if and how the “Motivational interviewing” was used and
implemented in patient-doctor relationship, and if it yielded effect on treatment goals. This PhD
study focuses on the effect of “Motivational interviewing” on GPs professional behaviour, patients
lifestyle behaviour and effect on patient risk profile. The study was conducted in general practice,
because treatment and follow-up of Type 2 diabetes is situated well in general practice.
Furthermore, general practice was preferred to hospital setting because of the GPs’ profound
knowledge with each patient, and thereby the possibility of close follow-up by the GPs. All
practices registered at the County Health Insurance Registry in Aarhus County were 1. January
2001 invited to meetings about participation in the ADDITION-study. In Copenhagen County only
practices located in the north and eastern part (7 municipalities) were invited, because screening for
diabetes had already taken place in the remaining municipalities in the county in connection with
the Inter99 study. In agreement with the County Health Insurance only 60 GPs were to be included
per county at study onset, and primarily practices with more than one GP were included. No
exclusion criteria for the GPs were applied and included GPs were cluster-randomised at practice
level. The PhD study included furthermore a group of GPs who previously had participated in the
course in “Motivational interviewing” (EM-group). This group was contacted externally to the
ADDITION-study and was asked to answer the same questionnaire as GPs within the ADDITIONstudy, thus serving as a group of GPs with long-term knowledge of the use of “Motivational
interviewing”. The GPs in the EM-group did not participate in the ADDITION-study.
Design
The research questions of this PhD thesis (Chapter 1, Aim, page 4), were addressed at the level of
the GP and the patient, using measuring methods on changing behaviour of GPs and patients and on
specific effect, e.g. risk profile, in conformity with previous research advice 132. The study was
conducted as a cluster-randomised controlled trial.
62
Cluster randomised controlled trial
The CONSORT principal rules of classic RCT presuppose the use of a homogeneous population,
blinding and placebo treatment 123;133-135. However, the study design used here involved clusterrandomisation, i.e. it is a pragmatic RCT, which demands special statistical methods to be
considered 122;135-137. Statistical analysis is, for example, affected by the reduced number of units for
randomisation 120;121;138-141, (Statistical methods, Page 69). Cluster-randomisation with a small
number of units is not likely to show similar distributions of baseline characteristics among groups
123
. However, the study included 48 practices in 2 counties, which secured similar distributions in
each randomisation group. Furthermore, there was performed stratified randomisation of GPs on
size of practice and on county. Practices were chosen as randomisation units to prevent confounding
between GPs. Patients were randomised by their practice in order to avoid confounding between the
I- and C- group.
Bias
The study design, RCT, randomly allocates unpredictable, immeasurable confounders and
diminishes selection bias. Patients were included by known inclusion/exclusion criteria (Figure 1,
Appendix A) and afterward randomised, thus diminishing the risk of selection bias. However, the
GP sample may have been biased because the GPs self-entered this study. The GPs volunteering to
courses and using a new intervention method may be a more motivated group of GPs and may thus
be more interested in adopting and implementing new methods in general practice. Furthermore the
GPs attending the course in “Motivational interviewing” may be more focused on including patients
to the study in order to apply the methods of “Motivational interviewing”. However, an equal
number of Type 2 diabetes patients were included in the I- and C-group, which supports our
assumption that selection bias was limited.
Patients’ baseline data (age, gender, marital status, cohabit status, profession, educational
background, family history of myocardial infarction and of diabetes, smoking status, alcohol intake
status, ethnicity, weight, height, waist circumference) did not differ between the randomisation
groups. Inclusion rates did not differ between the randomisations groups either. Inclusion bias due
to skewed inclusion numbers (inclusion rate in intervention group exceeded inclusion rate in control
group) is therefore limited. Two patients and six GPs (all in control group) dropped out of the study
after randomisation. In consideration of the total number of GPs and patients included in this study,
attrition bias is viewed as insignificant 122.
Data rates and response rates are listed in Table 1 (Appendix A). Blood samples during the 1-year
follow-up was obtained from 61%-91% of the patients (Table 1). This range may introduce a bias in
the interpretation of data at the 61% end of this continuum. Furthermore, data rates obtained on
serum lipid profiles in the I-group were statistically significantly lower compared to the C-group,
which may introduce selection bias and tend to decrease the difference between the two groups.
Blinding
The use of an educational programme for intervention in practice prevents blinding. It is, of course,
not impossible to stage a placebo educational programme, but its effect would be doubtful as the
GPs may easily learn from other GPs about their education, and thereby which education was
intervention and which was placebo. Without blinding, behavioural changes may be influenced by
the Hawthorne effect 124. A Hawthorne effect is defined as when an intervention group have a
tendency to change behaviour because they are targeted special attention in a study, regardless of
the specific nature of intervention received 124. However, in this PhD project both groups of patients
63
were given intensive treatment and only one group was subsequently exposed to “Motivational
interviewing”. In this way attention to the treatment of Type 2 diabetes including lifestyle changes
would increase in both groups and a potential Hawthorne effect would hence exist in both groups. If
the patients’ consciousness about changing lifestyle behaviour was raised because of the Hawthorne
effect, this would tend to reduce the effect of “Motivational interviewing”. An increased
consciousness on behaviour may be indicated by the high level of adherence in both groups
compared with previous studies despite intensive poly-pharmacological treatment 127-129;142-144.
Blinding of patients was intended. Patients were obligated to give written informed consent to their
participation in the study, however, they were not informed about whether their GP was allocated to
the I-group or the C-group. It was not checked whether some patients during the study learned
about which treatment group their GP was assigned to. It may have induced an increased motivation
in the patient to know that your GP is in the I-group and vice versus. Furthermore, the study was to
be integrated into daily practice, therefore personal initiatives among both GPs and patients in terms
of self-education was not opposed and have not been accounted for. However, no GPs in this study
had attended a course in “Motivational interviewing” prior to the study.
Study evaluation
Assessment of the implementation of an educational programme into routine care in general
practice requires consideration of all the levels of implementation. It is necessary to evaluate each
level of the process relying on a combination of self-reported measures and effect measures of
behaviour changes among both GPs and patients 145-147. In this study an effort has been made to use
measuring methods evaluating all the levels. The questionnaire data from the GPs focus on how
implementation of a training programme changed the professional behaviour. The questionnaire
data from the patients make it possible to view changes in patient beliefs concerning Type 2
diabetes treatment and their contemplation and readiness to change behaviour. Finally the specific
effect measures make it possible to conclude whether “Motivational interviewing” had an effect on
the patients risk profile.
In this field of intervention, RCTs do not practice follow-up periods exceeding one year 145, and this
PhD study is also limited in the way that the evaluation rest on data obtained at the 1-year followup. However, as a part of the ADDITION-study, the RCT has planned follow-up period of 5 years
to evaluate the long-term effect.
Intervention
The educational programme of “Motivational interviewing” is shown in Appendix B. Intervention
is described in detail in Chapter 3 to 5.
Monitoring the intervention
The effect of “Motivational interviewing” was measured at three levels, i.e. change at GP level,
change at patient level and change in patient risk profile. Assessing the effect at the GP level i.e.
change of professional behaviour required evaluation of whether the course provided the GPs with
skills that afforded them confidence in using ”Motivational interviewing” for patient treatment, and
monitoring of their actual use of the methods in their daily routines. The study aggregated the effect
of both processes, and therefore, it cannot be specified precisely how the different techniques were
used by the GPs after the course. It might have been possible to obtain information about actual use
64
and adherence to “Motivational interviewing” by viewing video recordings of counselling
encounters. This way of evaluation has been used previously in other studies of communication
skills, and it seems to be a feasible method. However, it requires detailed practical planning,
training of the GPs, considerable resources and acceptance from all participating doctors 148-155.
This was not possible within the present study period and the resources were not available to use
this approach in 48 practices and for 65 general practitioners in 2 counties. In this study a
questionnaire survey was conducted one year and three years after the course. Besides this, the
outcome of the training course was evaluated at the next two levels, i.e. changing patient behaviour
and viewing actual change in patient risk profile as described in the section of “Measuring
methods” below.
Adherence to “Motivational interviewing”
It was expected that GPs in the group attending the course in “Motivational interviewing” would
use the method in the patient treatment. However, they were not forced to use the methods, and the
extent to which they actually used the methods or adhered to the concept of “Motivational
interviewing” was not monitored.
Another factor potentially influencing the use and adherence to “Motivational interviewing” is the
GPs’ motivation to participate in the study. In a RCT the GPs cannot decide themselves to which
group and level of intervention and education they are allocated. Therefore it is possible that some
GPs wanted to use “Motivational interviewing”, but were not randomised to this group, and vice
versa. In this way, GPs in the “control group” might have been motivated to do more than just
“traditional advice giving” and GPs in “intervention group” might not have adhered to the method.
This would also tend to reduce the registered effect of “Motivational interviewing”. “Traditional
advice giving” is used as an expression for doctor-centred approach, i.e. the GP define the patients’
problem from a biomedical perspective and does not at all include the patient perspective on the
matter, thus giving advice accordingly 12;83.
Changing and sustaining long-term change of professional behaviour
Changing counsellors’ professional behaviour in the doctor-patient relationship requires a
tremendous effort 156. In this process, it is important to know how and where to influence the GPs
157
. Multiple strategies based on different theories have been applied but very few studies have
explored the long-term effect of training in interviewing skills and treatment 158-162. In order to
obtain professional behaviour change, it is necessary to consider the teaching method carefully
163;164
. GPs changing professional behaviour will often have previous advanced experience, which
requires that adult learning principles is applied in their education 165-170.
If GPs are to be changed, new methods must be scientific based and relevant to general practice
161;162;171
. In medical education passive learning by means of lectures has proven in-effective in
terms of retained participants’ knowledge 172-174. Thus, the permanence and integration of
professional behaviour change among GPs hinge crucially on practical training of the new method
in a clinically relevant case settings, and on how easily the new method can be adopted and used
“the next day” in practice. Furthermore it must be clear for the counsellor, why the alternative
professional behaviour is preferable 157. In the treatment of Type 2 diabetes patients in general
practice, traditional treatment seems neither successful nor effective in terms of changing patient
behaviour. Hence, there seems to be a potential for stimulating change of lifestyle through improved
professional conduct. This improvement has to derive from a new strategy and this is an argument
to retrieve and introduce new methods such as “Motivational interviewing”.
65
Stott et al performed a study on how GPs would react to adopting a new technology and new
methods showing that GPs did, indeed, adopt, accept and use the new methods when they facilitated
solutions to problems in the patient-doctor relationship 97. Only few studies have focused on how to
implement and integrate ”Motivational interviewing” in the daily clinical work in general practice
in such a way that it is ascertained that the method is used after study closure 87;88. They concluded
that it despite barriers was possible to implement the use “Motivational interviewing” in general
practice 87;88.
Measuring methods
The ADDITION-study is an on-going study based on primary and secondary endpoints evaluated
after 5 years, including complete registry data on all included patients 13.
The PhD thesis is based upon the following types of data obtained at the follow up after one year:
- Questionnaires to GPs
- Questionnaires to patients
- Case record forms
- Blood sample data
- Register data files from the National Health Service Registry
General practitioner questionnaire
No validated questionnaire was available for evaluating the courses in ”Motivational interviewing”
and the GPs’ conception of the methods, adherence to the technique and their actual use of
”Motivational interviewing”. A questionnaire was therefore designed drawing on 1) available
theoretical knowledge about ”Motivational interviewing”, 2) the leading author’s knowledge from
attending the course and 3) knowledge from the teacher and head of the course.
The questionnaire was designed in the computer programme Teleform 118. The questionnaire was
self-administered and the processing of the questionnaire data was performed using Teleform. The
questionnaire was blinded by the use of serial numbers in order to prevent observer bias. The
“Teleform method” has been validated by a previous study comparing the use of Teleform and
manual data entry, which found that the Teleform method was the more reliable and that it ensured
valid data 119. Data were afterward automatically transformed into the Statistical Programme for
Social Science (SPSS) version (11.0) for windows 175 and was once more checked for potential
errors. If an error was discovered, the original questionnaire was checked for correct answering and
change was made in the database. The questionnaire content, construction and pilot testing are
addressed in Chapter 3 and the questionnaire is shown in Appendix C. The questionnaire was
relevant and well-constructed, because it was understood by all the GPs and produced a 100%
response rate. The design of questionnaire and pilot testing ensured feasibility and high validity.
Patient questionnaire
The patient questionnaire is addressed in the Chapters 4 to 5, and the questionnaire is shown in
Appendix C.
The questionnaire used for assessment consisted of a collection of previously validated
questionnaires used in primary care and for Type 2 diabetes patients. These questionnaires were
selected in order to measure the following aspects:
66
-
Counselling and patient-doctor relationship
Health Care Climates Questionnaire (HCCQ) 104-108;176;177 was used to assess patients’
perceptions of the GP’s counselling style. This questionnaire has previously shown to be
effective in disclosing the counselling style in many treatment areas 104-108;176;177.
-
Contemplation of behaviour change
Treatment Self-Regulation Questionnaire (TSRQ) 105;108-110;117;176-178 was used to assess the
degree to which behaviour tends to be self-determined. It involves three subscales to the main
scale: the “autonomous” regulatory style; the “controlled regulatory” style; and “amotivation”
(which refers to being unmotivated). The autonomous style represents the most self-determined
form of motivation and has consistently been associated with behaviour change and positive
health care outcomes. These subscales correspond to motivational concepts of selfdetermination theory proposed by William GC and Deci EL 104;106, which are partly based on
concepts of “Motivational interviewing”, Miller and Rollnick 1.
-
Understanding of Type 2 diabetes and its implications on life
Diabetes Illness Representation Questionnaire (DIRQ), which comprises 2 questionnaires:
a.
Illness Perception Questionnaire (IPQ) 92;93;111;179-181
b.
Personal Models of Diabetes Interview Questionnaire (PMDIQ) 92;93;111;180;181
This questionnaire assesses whether “Motivational interviewing” acts to mediate the
relationship between illness representations and emotional well-being in patients with Type 2
diabetes. It assesses patients’ beliefs and understanding of Type 2 diabetes. It involves 5
subscales to the main scale: Identity (symptoms associated with the illness) cause (the cause of
illness and beliefs about the factors responsible for the onset of the illness); timeline (the
patient’s perception of duration of the illness i.e. acute, cyclical or chronic); consequences (the
patient’s expected outcome of the illness in terms of its likely physical, psychological, social
and economic implications, which include impact on day-to-day life and in the long term); and
control/treatment/effectiveness (the patient’s beliefs about the extent to which the illness is
amenable to cure or how good recommended treatments are at controlling the illness). This
study only used four of the subscales: cause, timeline, consequences and
control/treatment/effectiveness. “Identity” was excluded in order to limit the number of
questions in the questionnaire and because all symptoms and objective findings were reported
by the GPs on the case record forms.
-
Advice received on control and self care, and adherence to treatment and self care
Summary of Diabetes Self-Care Activities (SDSCA). This questionnaire assesses to which
extent Type 2 diabetes patients perceived advice on various self-care activities relevant to Type
2 diabetes. It is a brief questionnaire previously validated in many studies and used to measure
diabetes self-management 94;95;112-116;182-184. The questionnaire focuses on which advice from the
counsellor has been perceived by the patient in relation to: general diet and specific diet;
exercise; testing and controlling by blood-glucose measurement and urine-glucose
measurement; medication (which type of medication has been prescribed by the doctor and to
which extent has the patient adhered to the prescription); foot care (self-rated self-care activity
on patient foot care); and smoking (status of smoking habits).
The use of previously validated questionnaires combined with the pilot testing ensured feasibility
and high validity. The final questionnaire also enabled comparison with previous research.
67
Case record forms
The use of case record forms reported by GPs is addressed in Chapter 5, and the case record forms
are shown in Appendix D. Processing of the case record forms was performed by Teleform and
analysis of case record form data by SPSS according to the description in “GP questionnaire
section” above (page 66). The case record forms at baseline and at 3, 6, 9, and 12 months were used
in order to capture potential effects at different points in time. However, no statistically significant
differences were measured with 3 month intervals, and the results are therefore presented as
baseline, 6- and 12-month data. The data response rate (Table 1, Appendix A) was found to be
representative and valid.
Blood sample data
The use of blood sample data is addressed in Chapter 5. They include HbA1c, total serum
cholesterol, serum LDL, serum HDL and serum triglycerides.
Baseline blood samples were analysed as follows: HbA1c was analysed using a Tosoh blood sample
analyser on venous whole blood drawn and stored in EDTA aliquots. Serum cholesterol, serum
HDL-cholesterol and serum triglycerides were analysed using a Hitachi 917 System or an Abbott
Aeroset analyser with an enzymatic colorimetric test as the test principle. LDL-cholesterol was
calculated using Fridewald’s formula. All blood samples after baseline were analysed on several
laboratories in the two counties, all subject to the Danish quality assurance for laboratories.
The blood sample data were fed into a database from case record forms reported by GPs and from
data files obtained from the central laboratories. These data were combined and displayed in one
database by a data-manager to ensure accuracy and eliminate observer bias. Data was blinded by the
use of serial numbers in order to prevent observer bias and to comply with the stipulations
concerning regulation of databases, the Danish Data Protection Agency. Data were afterwards
automatically transformed into the Statistical Program for Social Science (SPSS) version (11.0) for
Windows 175. Blood sample data were obtained at baseline and after 3, 6, 9 and 12 months in order
to capture potential effects at different points in time. However, no statistically significant
differences were measured with the 3-month intervals, and the results are therefore presented as
baseline, 6- and 12-month data. Blood sample data was obtained in order to measure effect on the
patients’ risk profile.
National Health Service Registry data
The use of register data files obtained from the National Health Service Registry are addressed in
Chapter 5. Data extraction was performed by a data-manager and retrieved into database for all
included patients. I used various types of data as measuring method which could have created
problems during the data processing and analysis stages. However, the support of a data-manager
secured proper data-entry into the database and data could be analysed in SPSS.
68
Statistical methods
The intervention, “Motivational interviewing”, targeted the GPs and was supposed to be
implemented into the daily clinical work in general practice. Practices were randomisation units.
Thereby the included patients were cluster-randomised, meaning that they were allocated into
clusters receiving different intervention depending on the grouping of their GP. Statistically, the
patients were therefore not independent individuals and the statistical analysis was performed at the
level of the practice/GPs. Variability between and within the clusters could arise if the sample
included a small number of clusters, because of the individuality of GPs and/or their practices. If
variability between the clusters was present and ignored, the confidence intervals would become too
narrow 120;122;137;139;185;186. However, when a study includes a large number of cluster units,
variability is reduced to an insignificant level and balanced comparison is possible. Random
(normal) variation between and within the GPs was assumed on basis of the number of
practices/GPs randomised in the study. Statistical analysis was adjusted for the clustering within
GPs by using a mixed regression model.
Before launch of the ADDITION-study and this PhD study, power analysis was performed. At that
time the study assumed inclusion of approximately 650 patients in the intervention arm of the RCT
in the ADDITION-study. These 650 patients would be cluster-randomised to GPs trained in using
“Motivational interviewing” or not. At that time approximately 60 GPs within approximately 40
practices were expected to be cluster-randomised and that an average of 16 Type 2 diabetes patients
would be included per practice. In general practice, the intra-cluster correlation coefficient on
outcome is approximately 0.03 to 0.05 121;187. However, Kerry et al investigated cholesterol in
general practice and concluded that the intra-cluster correlation coefficient was 0.0036 138. In the
power analysis, the intra-cluster correlation coefficient was conservatively estimated to be 0.05 on
the remaining primary outcome measures.
When sample size in power analysis is to be corrected for cluster-sampling, the following equation
was used: N=n/(1+((m-1)xICC))
N=Total number (corrected of cluster-sampling)
n=Total number (total number before cluster-sampling correction)
m=Average cluster size
ICC= Intra-cluster Correlation Coefficient
This equation was used in order to reach the corrected number (N), which could be used in the
power analysis for the outcome measures below:
- HbA1c: N=650/(1+((16-1)x0.05)) =371.
- Total cholesterol: N=650/(1+((16-1)x0.0036)) =617.
- Adherence to prescribed medication: N=650/(1+((16-1)x0.05)) =371.
- Smoking cessation: N=430/(1+((16-1)x0.05)) =245. (It was assumed that approximately 2/3 of
650 patients within the intervention arm of the ADDITION-study were smokers, which makes
N=430).
69
In the power analysis SPSS Sample Power Two Sample Proportion was used. After correction of
cluster-sampling it was concluded at that time, that the study would show effect (95%CI) of
“Motivational interviewing, if:
- Min. 19% patients reached normal HbA1c (HbA1c below 6,4)
- Min. 15% patients achieved a 10% reduction of total cholesterol
- Min. 22% patients achieved smoking cessation
- Min. 19% patients adhered to prescribed medication (adherence defined as 90% respecting the
prescribed medication)
The study did achieve the inclusion of 65 GPs from the beginning of the study. However, it did not
reach the goals of including 650 patients within the intervention arm of the ADDITION-study. At
the data deadline of the PhD study, only 265 Type 2 diabetes patients with a 1-year follow-up had
been included. Thereby it was not possible to fulfil the expectations of measured effect of the study.
This is supported by using “post” power analysis on the goals, as an example HbA1c:
In power analysis 650 patients was used as “N”, which after correction for clustering allowed us by
means of power analysis to conclude that “Motivational interviewing” would show effect if a min.
of 19% patients reached normal HbA1c (HbA1c below 6.4). If the included number was used,
N=265, then the power analysis after correction for clustering concludes that “Motivational
interviewing” would show effect if a min. of 28% patients reached normal HbA1c (HbA1c below
6.4). Finally, a large proportion (56%) of the included patients had HbA1c within treatment goal
from the onset of the study, which meant that these patients could not show any change due to
“Motivational interviewing”. If the number of included Type 2 diabetes patients who actually had
an HbA1c level above the treatment target at baseline (44% of all included patients, N=117) was
used, (Chapter 5, Table 3, page 56), then the number would decrease further and power analysis
would, after correction for clustered sampling, conclude that “Motivational interviewing” would
show effect if a min. of 39% patients reached normal HbA1c (HbA1c below 6.4). Thus, a lower
number of included Type 2 diabetes patients decreased the probability of achieving positive effect
on patient risk profile.
Considering the “form” of intervention (“Motivational interviewing”), the 1-year follow-up period,
the patient population (newly diagnosed Type 2 diabetes patients detected by screening), the actual
number of included patients, and the large proportion of patients within treatment goal from onset
of study, it is questionable whether the study goals could have been reached. Retrospectively, the
total number of expected patients should have been reduced in the power analysis in order to take
into account that a proportion of the patients might have been within the treatment goal from the
study onset. However, the size of this proportion of patients was unexpected. Furthermore, the study
goals were deemed clinically relevant and realistic at the study onset which was important if the
study should reach a conclusion recommending the implementation of “Motivational interviewing”
in general practice in Denmark.
70
Potential generalisation of outcome
This study had no exclusion criteria for the GPs, which secured external data validity. The study
managed to diminish potential selection bias at GP level by including a large number of GPs from
which only 6 GPs dropped out (all in the control group) after randomisation (Figure 1, Appendix
A). Patient exclusion criteria were limited to patients previously diagnosed with diabetes, which
should not influence the potential generalisation of outcome to the general population.
This study includes GPs randomised to a training programme in “Motivational interviewing”, which
was flexible in relation to the GPs’ daily work and training in the practical use of specific methods
was focused and targeted Type 2 diabetes patients. Therefore it may be possible to generalise to
GPs in Denmark as to how “Motivational interviewing” was implemented, how the method was
used in the daily work in general practice, and which effect the methods had. Furthermore, the use
of “Motivational interviewing” is not limited to certain types of counsellors, i.e. GPs, psychologists
etc., as shown in Chapter 2. Thereby, the effect of “Motivational interviewing” may be generalised
to a hospital setting, however keeping in mind, that the method requires training and a continuum in
the patient-doctor relationship. Thus, generalisation is probably limited to consultants because of
their possibility of meeting the same patient in a treatment continuum. Furthermore, motivating and
changing behaviour in patients with Type 2 diabetes allows for generalisation to other disease areas.
71
72
Chapter 7
General discussion of results
73
Introduction
Analysis of the data obtained in the PhD study has addressed the research questions put forward in
the aim of the PhD study stated in the general introduction (Chapter 1, page 2). The results and the
analysis have been discussed in detail in the Chapters 3 to 5. This chapter will review the results
and offer an overall discussion in relation to current literature.
Discussion of results
Condition for obtaining an effect of the training course in “Motivational interviewing”
The training in “Motivational interviewing” was to be learned through active participation in a
residential course. This course gave introductions to the different techniques of “Motivational
interviewing” and it presupposed a high level of participation in subsequent groups, workshops and
role-plays. Thus, it may be a difficult process as a teacher to choose the way to present and train a
concept including a specific method and technique at the course 132;157;163;169;188. Thus, different
demands have to be evaluated and accommodated to design the course in the best way possible. In
this process, subjects like teaching resources, incentives helping the GPs to set aside time for the
courses and the contents of the course are crucial elements. Residential courses in “Motivational
interviewing” had previously been conducted several times by Professor Carl Erik Mabeck, and
GPs had attended these courses. Course evaluations had been positive but the courses had not been
validated or been a part of a research study. In this study it was chosen to train the GPs by using the
same course, course curriculum and Professor Carl Erik Mabeck as teacher (Chapter 3, page 26)
2;89
.
The strategy of these courses, combining various multifaceted approaches (cognitive, behavioural
and affective components) and training the methods of “Motivational interviewing” had been
described in previous studies 189-191. Multiple theories and strategies have been proposed on how to
achieve behaviour change and obtain adherence to methods 1;2;4;90;104;106;128;129;142;144;192-210. All these
theories and strategies, including the “Motivational interviewing”, have similarities, e.g. that
behavioural change and adherence is achieved only by reaching a plan accepted by both the patient
and the GP, allowing treatment decisions to be based on mutual understanding between the patient
and the GP 98;189-191;211-218.
It was deemed necessary for the intervention to obtain effect and have a sustained effect not only to
conduct the course with a view to launching a process of professional behaviour change, but also to
maintain the potential effect through follow-up meetings supervised by Professor Carl Erik Mabeck.
All GPs scheduled for the course during the study participated and with only few exceptions all GPs
attended the follow-up days. However, GPs were not supplied with further support in maintaining
the use of “Motivational interviewing” or tools for self-evaluation in order to prevent lack of
adherence to the method. Besides this, the teaching style may also influence the implementation and
use of the methods. Thus, an ineffective teaching style (in terms of teachers’ pedagogical abilities,
contents and teaching method, size of teaching group) may also decrease the use of “Motivational
interviewing” and thereby influence the effect on the patients’ risk profile. However, the GPs found
that the course had provided them with skills that afforded them great confidence in using
”Motivational interviewing” for patient treatment. It may, of course, be possible that availability of
continuous supervision groups and self-evaluation methods would have increased the
implementation and the use of “Motivational interviewing” even further.
74
Effect of ”Motivational interviewing” on general practitioners
When focusing on the first level of change upon introducing “Motivational interviewing”, i.e.
change of professional behaviour among the GPs, this study showed that a ”Motivational
interviewing” course influence GPs’ professional behaviour, thus providing the GPs with skills that
afford them greater confidence in using ”Motivational interviewing” for patient treatment. In
addition to this, GPs found that ”Motivational interviewing” was more effective than “traditional
advice giving” and that it improved the patient-doctor relationship. Furthermore, the experienced
GPs used the more complex parts of ”Motivational interviewing”. The GPs using ”Motivational
interviewing” found that the methods was not more time-consuming and that they de facto used the
same or fewer consultation encounters than GPs resorting to “traditional advice giving” 103. than
“traditional advice giving”. This has also been found in previous studies 88;98;219;220. However, the
study provided no specific measuring of the actual use of “Motivational interviewing” or the extent
to which the GPs adhered to the methods. Therefore, it cannot be determined, on basis of the GPs’
self-rated use of “Motivational interviewing”, whether the poor effect on the patient risk profile was
due to the concept of “Motivational interviewing” or to poor implementation of the method by the
GPs. In order to conclude on the specific use of “Motivational interviewing” and adherence to the
methods, direct measuring method is required, e.g. video recordings of counselling encounters, as
discussed in Chapter 6, Intervention, page 64. However, as described above, the study showed that
GPs self-rated an effect of a course in “Motivational interviewing” on their professional behaviour
and on their use of the method. Thus, no effect on the patient risk profile may be caused by the
limited observation period of change in patient behaviour as discussed below.
Besides this, the lacking effect on patient risk profile may reflect our choice of GPs in the I- and Cgroup. The study control group comprised GPs who were trained in intensive treatment of Type 2
diabetes, including giving advice on behaviour change. Thus, GPs in C-group were not supposed to
use “Motivational interviewing”, but they were urged to act as counsellors for the patients, giving
them advice on how to reduce the risk of late diabetic complications and letting the treatment
decisions to be based on mutual understanding between the patient and the GP (Chapter 3, page 26).
Thus, some of these GPs may have used elements from “Motivational interviewing”, which may
have reduced the effect of “Motivational interviewing”. The lacking effect of “Motivational
interviewing” may also be ascribed to GPs failure to use all the potential three motivational
consultations made available by the study. GPs in the I- and C-group on average used only one
prophylactic consultation for each patient. This may be an indicator for poor implementation of
“Motivational interviewing” and use of the method by the GPs. Thus, the possibility of an effect on
the risk profile would have been greater if the GPs in I-group had used all three consultations
deploying “Motivational interviewing”.
Effect of ”Motivational interviewing” on patient behaviour change and patient risk profile
The effect of “Motivational interviewing” at the second level, i.e. change at the level of patient
behaviour (e.g. lifestyle behaviour, adherence to prescribed medication), was monitored in terms of
self-rated change (e.g. smoking and alcohol status) and effect measures external to the patient (e.g.
use of prescribed medication) (Chapters 4 and 5). This enabled us to evaluate the patient’s
contemplation and readiness to change behaviour and the changes in behaviour that actual occurred.
The study showed significant an effect of “Motivational interviewing” on self-rated patient
behaviour with patients becoming more motivated for change and for sustaining behavioural
change. The study obtained a statistically significant effect of ”Motivational Interviewing” on
patients’ beliefs regarding Type 2 diabetes and on patients’ contemplation and readiness to
behaviour change. However, even though the effect was statistically significant, it was small, and
75
the importance of this finding in the clinical setting remains uncertain.
The study showed no effect on actual changes in smoking and alcohol intake behaviour. In relation
to change of alcohol intake behaviour, this may be caused by the fact that more than 98% of the
patient population were within treatment goals from study onset which left only little room for
demonstrating effect of “Motivational interviewing”. The study showed a tendency that more GPs
in I-group than C-group asked the patients about smoking status and behaviour (Chapter 4, Table 3,
page 44). However, no change was found in smoking behaviour, which may be caused by the GPs
not using the opportunity to focus on smoking behaviour or the GPs not motivating for smoking
behaviour change. The patients’ statements indicated the latter, thus, that they were not motivated to
change smoking behaviour. Whether this was a result of GPs including many subjects (e.g. smoking
behaviour, lifestyle behaviour, Type 2 diabetes self-care etc.) in the same counselling encounter, or
if it was their use of the “Motivational interviewing”, or the concept of “Motivational interviewing”
itself, was difficult to determine for certain. However, overall the patients found themselves to be
more motivated for changing behaviour, thus it seems as “Motivational interviewing” has effect on
the patients contemplation of behaviour change. Whether “Motivational interviewing” will induce
measurable change in patient behaviour needs to be evaluated on a long-term follow-up period as
planned in the ADDITION-study.
At the third level, changes were evaluated in terms of specific measures of the patient’ risk profile,
in which no effect of “Motivational interviewing” were found. It cannot be established for certain
whether this is a result of lacking effect of “Motivational interviewing”, lacking use or adherence to
“Motivational interviewing” from the GPs or if it is due to the limitations of the study design, e.g.
the limited observation period of 1-year follow-up as previously discussed (Design, Page 62). The
review and the meta-analysis showed that a number of studies with a 1-year follow-up period had
an effect on patient outcome measures (Chapter 2). However, neither of these studies intervened on
diabetes, but were related primarily to alcohol treatment performed by trained psychologists
familiar with the methods of “Motivational interviewing” before study onset 15;16;23;31;33;4749;54;62;66;67;72;74
. Only a few studies with a 1-year follow-up period and GPs as counsellor have been
21;45;46;51
. These studies showed effect, however, none of these focused on diabetes, but
conducted
on other different subjects 21;45;46;51. In all of these studies, the GPs were trained and familiar with
the methods of “Motivational interviewing” before onset of the study, and they were thus focusing
from study onset on patient behaviour change and patient outcome 21;45;46;51. It is possible that an
effect on the patients’ risk profile might have been obtained within the 1-year study period if GPs
had been trained and had been familiar with “Motivational interviewing” before the study was
launched. The lack of effect on outcome may also have been shaped by the the patient population
(newly diagnosed Type 2 diabetes patients detected by screening), the actual number of included
patients, and the large proportion of patients within treatment goal from onset of study. As
discussed in the section “Statistical methods” (page 69), this left little room for demonstrating an
effect of ”Motivational interviewing”.
The study showed effect of “Motivational interviewing on the first level, the GPs professional
behaviour and use of the method, and on the second level on the patients contemplation of
behaviour change. The uncertainty on what caused no effect on patient risk profile may simply
reflect how much effect the “Motivational interviewing” method accomplished in the process of
change within the follow-up period the first year.
76
Chapter 8
Conclusion
77
Conclusion
Chapters 6 and 7 have discussed the methods and results of the PhD thesis. Chapter 8 presents the
overall conclusion of the PhD thesis
The review shows that “Motivational interviewing” has been used in treatment of various lifestyles
and diseases, and 3 out of 4 studies obtained an effect no matter biological or psychological disease
as shown in the meta-analysis (Chapter 2, page 17). “Motivational interviewing” has an effect not
only according to questionnaires, but also measured in terms of epidemiological and clinical
measures and endpoints. “Motivational interviewing” can be effective even in brief encounters of
15 min. and the likelihood of an effect rises with the number of counselling encounters.
“Motivational interviewing” can be utilized with equal effect by physicians, GPs, psychiatrists and
psychologists.
The PhD study shows that a ”Motivational interviewing” course seems to influence GPs’
professional behaviour. GPs found that the course provided them with skills that afforded them
greater confidence in using ”Motivational interviewing” for patient treatment. GPs also found that
”Motivational interviewing” was more effective than “traditional advice giving” and that it
improved the patient-doctor relationship. Furthermore, the experienced GPs found that the method
was not more time-consuming than “traditional advice giving”. The study obtained a statistically
significant effect of ”Motivational Interviewing” on patients’ beliefs regarding Type 2 diabetes and
on patients’ contemplation and readiness to behaviour change. However, even though the effect was
statistically significant, it was small, and the importance of this finding in the clinical setting
remains uncertain. The study did not show an effect of “Motivational interviewing” on actual
lifestyle behaviour or on the risk profile in patients with Type 2 diabetes detected by screening.
The process of behaviour change in general practice is elicited and supported by different methods,
e.g. “Motivational interviewing” 143;221-224. “Motivational interviewing” is a promising approach for
changing and sustaining altered patient behaviour 88;220. A meta-analysis concludes that
psychological therapies like “Motivational interviewing” can improve long-term glycaemic control
131
. Previous studies have also pointed to the need for more research on innovative approaches like
“Motivational interviewing” to assist patient behaviour change and sustain adherence, and on
methods for integration of such approaches into clinical settings, clinical guidelines and into the
health care system 127;225-227. Thus, previous studies side with the results of the present study on
GPs’ professional behaviour and patient behaviour (Chapters 2 and 3) in supporting the need for
long-term evaluation of the effect of ”Motivational interviewing” on the risk profile.
78
Chapter 9
Perspectives and implications for future
research and practice
79
Perspectives
Previous research and use of “Motivational interviewing” has increasingly embraced aspects from
other psychological models of behaviour change and different approaches for managing the patientdoctor relationship. In order for future research to be able to recommend guidelines on how to use
“Motivational interviewing” in practice, it is imperative that it makes an effort to describe exactly
how the counsellor is educated and trained, which methods are used and in what ways
“Motivational interviewing” have been applied in the counselling. This would improve the
knowledge on “what proved effective” and it would allow us to recommend to future counsellors
“what to do in your present encounter with a patient in need for change”. In the process of analysing
how and “where” “Motivational interviewing” will be effect, future research would benefit from a
detailed discussion of models for implementation of “the method” in clinical setting, and the extent
of generalisation from the project to other clinical settings.
Implications for practice
“Motivational interviewing” is not limited to counselling of a small group of selected clients or use
by certain types of counsellors. Given the assumption that future research is able to provide more
specific recommendations on how to use “Motivational interviewing”, it becomes important to
clarify what is needed in order to initiate the process by changing professional behaviour. This
study showed that the use of a training programme requires an effort to sustain the spirit,
enthusiasm and motivation of the professionals. Immediately after the course, it is “fun” to adapt
and apply new methods. However, as time passes, it becomes increasingly difficult to sustain a
professional behaviour change, if the professional does not have visual “sight” of the advantages of
using the method. This may be assured by 1) listing progress in patient treatment, 2) using
standardised methods of self-evaluation, e.g. video-recordings, 3) establishing supervision groups,
and 4) by changing the organisational level in order to facilitate the process.
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Chapter 10
English summary
81
This PhD thesis is a part of the ADDITION-study, Anglo-Danish-Ducth study of intensive
treatment in people with screen-detected diabetes in primary care, which was developed and
implemented in cooperation between the Department of General Practice and the Steno Diabetes
Centre. This PhD thesis includes a 1-year follow-up of the effect of “Motivational interviewing” on
newly diagnosed Type 2 diabetes patients detected by screening undergoing intensive polypharmacological treatment. This thesis focuses on whether GPs using “Motivational interviewing”
can increase adherence to and effect of intensive treatment of Type 2 diabetes patients risk profile,
thus reaching treatment goals. The PhD study was enrolled in 2001 and this thesis was submitted in
2004.
General introduction
The PhD thesis consist of a general introduction, four articles, a discussion of methods and results
and a conclusion with perspectives and presentation of future implications for research and practice.
Chapter 1 introduces the concept and methods of “Motivational interviewing”. This PhD thesis is
based on the definition of “Motivational interviewing” by Miller & Rollnick, described in 1991 and
elaborated in 2002. It has been used and evaluated internationally, especially during the last decade
in relation to the following main areas 1) addiction (alcohol abuse and addiction to drugs), 2)
change in lifestyle (smoking cessation, weight-loss, physical activity, asthma and diabetes
treatment), and 3) adherence (to treatment and to control, encounters of follow-up, counselling
meetings).
“Motivational interviewing” has been deployed by various health care providers, including
psychologist, doctors, nurses, dieticians and midwifes. However, current studies have focused on
the effect of “Motivational interviewing” in a hospital setting with no or little attention to how the
methods could be implemented and applied afterward in daily clinical work. This thesis focuses on
the effect of “Motivational interviewing” in general practice.
“Motivational interviewing” has only recently been introduced in Denmark, but its use has been
rising over the past years and it has been deployed in different scientific and clinical settings. Thus,
in 2000 the Danish College of General Practitioners issued an introduction booklet on
“Motivational interviewing” 11, which was mailed to all members of the Danish Medical
Association. Furthermore, a Danish book on the subject was issued in more than 10000 copies 12
and more than 30 residential courses in “Motivational interviewing” have been conducted by
Professor Carl Erik Mabeck since. These courses attracted mainly nurses, however, a number of
GPs also attended the courses with a view to use the methods in general practice. Thus, a significant
effort has been made in order to enhance the use of “Motivational interviewing” in Denmark.
However, no research on the effect of this effort has so far been attempted.
Aim of PhD thesis
The overall aim of this PhD thesis was to evaluate the effect of a course in “Motivational
interviewing” on intensive treatment of Type 2 diabetes patients detected by screening in general
practice. Furthermore, the PhD study aimed at evaluating:
1. The effectiveness of “Motivational Interviewing” as an intervention tool in previous
randomised controlled clinical trials (RCT) and to identify factors shaping outcomes in the
areas reviewed.
2. In which way a 1½-day course in “Motivational interviewing” and subsequent follow-up
meetings influenced the GPs’ professional behaviour.
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3. If the GPs having participated in a course in “Motivational interviewing” found the method
applicable and useful in general practice.
4. If “Motivational Interviewing” in general practice can improve patients’ a) contemplation
and readiness to change behaviour, b) their actual change in patient behaviour, and c) their
beliefs about Type 2 diabetes treatment.
5. If a course in “Motivational interviewing” for GPs can improve the risk profile of Type 2
diabetes patients detected by screening.
Motivational interviewing, a systematic review and a meta-analysis. (Article 1)
Chapter 2 describes the background of “Motivational interviewing”, reviews the literature and
performs a meta-analysis on previous studies. Its aim is to evaluate the effectiveness of
“Motivational interviewing” in different disease areas and to identify factors shaping outcomes. The
meta-analysis showed a significant effect of “Motivational interviewing” for combined effect
estimates for BMI, total serum-cholesterol, systolic blood pressure, blood alcohol concentration,
standard ethanol content, while combined effect estimates for cigarettes per day and for HbA1c
were non-significant. “Motivational interviewing” had a significant and clinically relevant effect in
approximately 3 out of 4 studies with equal effect on biological (72%) and psychological diseases
(75%). Psychologists and medical doctors obtained an effect in approximately 80% of the studies,
while other health care providers obtained an effect in 46% of the studies.
How does an education and training course in “Motivational interviewing” influence general
practitioner’s professional behaviour. (Article 2)
Chapter 3 examines the first level in the process of measuring the effect of “Motivational
interviewing”. It presents the results of how a 1½-day course in “Motivational interviewing”
including follow-up meetings influenced GPs’ professional behaviour and GPs’ evaluation of the
usefulness of the course in general practice. The study showed that a ”Motivational interviewing”
course influenced GPs’ professional behaviour. GPs found that the course provided them with skills
that afforded them greater confidence in using ”Motivational interviewing” for patient treatment.
GPs found that ”Motivational interviewing” was more effective than “traditional advice giving” and
that it improved the patient-doctor relationship. Furthermore, the experienced GPs used more
complex parts of ”Motivational interviewing” and found that the methods was not more timeconsuming than “traditional advice giving”.
Effect of motivational interviewing on beliefs and behaviour among people with Type 2
diabetes detected by screening. (Article 3)
Chapter 4 analyses the second level in the process of measuring the effect of “Motivational
interviewing”. It brings the results of screen-detected Type 2 diabetes patients’ evaluation of the
effect of “Motivational interviewing” in terms of the patients’ self-reported 1) contemplation and
readiness to change behaviour, 2) their actual behaviour change, and 3) their beliefs regarding Type
2 diabetes. The study showed a statistically significant effect of ”Motivational Interviewing” on
patients’ beliefs regarding Type 2 diabetes and on their contemplation and readiness to behaviour
change. However, both groups obtained effects, and even though effect of ”Motivational
Interviewing” was statistically significant, it was a small additional effect. Thus, the importance of
this finding in the clinical setting is uncertain. The study did not show any significant changes in
lifestyle behaviour.
83
No effect of the motivational interview on risk profile in people with Type 2 diabetes detected
by screening. A one year follow-up of a RCT. (Article 4)
Chapter 5 presents the third level in the process of measuring the effect of “Motivational
interviewing”. It analyses whether a course in “Motivational interviewing” for GPs improved
adherence to intensive treatment based on evaluation of risk profile in patients with Type 2 diabetes
detected by screening. The study showed no effect of the motivational interview on the risk profile
of patients with Type 2 diabetes detected by screening at the 1-year follow-up. Previous studies side
with the results of the present study on GPs’ professional behaviour and patient behaviour in
supporting the need for long-term evaluation of the effect of ”Motivational interviewing” on the risk
profile.
General discussion of methods.
Chapter 6 provides an overall discussion of the methods of the study applied at the various levels
of the process. These methods are also discussed separately in the four articles (Chapters 2 to 5).
The discussion is divided into headings: Setting, Design, Intervention, Measuring methods,
Statistical methods and Generalisation. The difficulties of evaluating a training programme are
discussed.
General discussion of results.
Chapter 7 comprises a discussion of all the results of the study obtained at the different levels of
the study process: results which are presented separately in the four articles (Chapter 2 to 5). The
results are discussed in relation to current literature and accomplishments are detailed. The
discussion is structured into headings: 1) condition for obtaining an effect of the training course in
“Motivational interviewing”, 2) effect of “Motivational interviewing” on general practitioners, and
3) effect of “Motivational interviewing” on patient behaviour change and patient risk profile.
Conclusion.
Chapter 8 presents the overall conclusions of this PhD study. “Motivational interviewing” has been
used in treatment of various lifestyles and diseases, and 3 out of 4 studies obtained an effect no
matter biological or psychological disease as shown in the meta-analysis. The PhD study shows that
a ”Motivational interviewing” course seems to influence GPs’ professional behaviour. Furthermore,
the study obtained a statistically significant effect of ”Motivational Interviewing” on patients’
beliefs regarding Type 2 diabetes and on patients’ contemplation and readiness to behaviour
change. However, the study did not show an effect of “Motivational interviewing” on the risk
profile
Perspectives and implications for future research and practice.
Chapter 9 draw the methods, results and conclusions of this PhD study into perspective and
underscore the implications and recommendations for the future, divided into issues for research
and practice.
84
Chapter 11
Dansk resumé
85
PhD afhandlingen er en del af ADDITION-studiet og baseret på projektet “Effekten af den
motiverende samtale i intensive behandling af Type 2 diabetes”. Studiet blev afviklet i 2 amter,
København og Aarhus, Danmark. Studiet blev startet og styret i samarbejde mellem Institut og
Forskningsenhed for Almen Medicin, Aarhus Universitet og Steno Diabetes Center, Gentofte. PhD
studiet inkluderer en 1-års opfølgning på effekten af ”den motiverende samtale” på screenede
nydiagnosticerede Type 2 diabetes patienter intensivt behandlet. PhD studiet fokuserer på effekten
af ”den motiverende samtale på adherence og effekten af intensiv medicinsk behandling af Type 2
diabetes patienternes risiko profil. PhD studiet blev indskrevet og optaget i 2001 og PhD
afhandlingen blev indleveret i 2004.
Introduktion
PhD afhandlingen består af en generel introduktion, 4 artikler, en generel diskussion af metode og
resultater med konklusion, samt perspektivering med anbefalinger i forhold til fremtidig forskning
og fremtidig lægepraksis.
Kapitel 1 introducerer til de grundlæggende elementer af ”den motiverende samtale”. Denne PhD
afhandling er baseret på Miller & Rollnicks definition af ”den motiverende samtale”, beskrevet i
1991 og uddybet i 2002. ”Den motiverende samtale har været brugt og blevet evalueret
internationalt i den seneste årrække i relation til 1) misbrug (alkohol misbrug og stof misbrug), 2)
livsstilsadfærd (rygning, overvægt, manglende fysisk aktivitet, astma og diabetes behandling), og 3)
adherence (til behandling og kontrolforløb).
”Den motiverende samtale” er blevet anvendt af mange forskellige behandlere, blandt andet
psykologer, læger, sygeplejersker, diætister og jordmødre. Tidligere studier har udelukkende
arbejdet med effekten af ”den motiverende samtale” i hospitalssystemet uden at være opmærksom
på hvordan denne metode kunne implementeres og anvendes i hverdagens kliniske arbejde
efterfølgende.
I Danmark er anvendelsen af ”den motiverende samtale” som metode relativt ny, dog er den over de
seneste 5 år blevet mere udbredt. I år 2000 udgav Dansk Selskab for Almen Medicin en
klaringsrapport med vejledning i anvendelsen af ”den motiverende samtale”, som blev udsendt til
samtlige medlemmer af den Danske Lægeforening. Desuden blev der udgivet en dansk bog på
området, som blev solgt i mere end 10.000 eksemplarer og endelig er der afholdt mere end 30
internats kurser i ”den motiverende samtale” af Professor Carl Erik Mabeck. Disse kurser har været
målrettet til fag personer indenfor sundhedssektoren, men hoveddelen af deltagerne har været
sygeplejersker. Enkelte kurser er blevet afholdt primært målrettet mod praktiserende læger. Der er
således brugt store ressourcer på at indføre og forstærke brugen af ”den motiverende samtale” i
Danmark. Indtil nu er der ikke udført forskning på effekten af ”den motiverende samtale” i
Danmark.
Formål med PhD afhandlingen.
Det overordnede formål med PhD afhandlingen var at evaluere effekten af et kursus i ”den
motiverende samtale” på intensiv behandling af screenede nydiagnosticerede Type 2 diabetes
patienter i almen praksis. Derudover havde PhD studiet til formål at evaluere om:
1. Effekten af ”den motiverende samtale” som intervention i tidligere randomiserede
kontrollerede forsøg, samt hvilke faktorer som påvirker effekten af ”den motiverende
samtale”.
86
2. Hvordan et 1½-dags kursus i ”den motiverende samtale” påvirker praktiserende lægers
professionelle adfærd.
3. De praktiserende læger efter et kursus i ”den motiverende samtale” finder disse metoder
anvendelige og mulige at integrere i deres kliniske arbejde i almen praksis.
4. “Den motiverende samtale” i almen praksis forbedrer Type 2 diabetes patienters a)
parathed til at ændre livsstil, b) deres aktuelle ændringer i livsstil og adfærd, samt c) deres
overbevisning og forståelse af Type 2 diabetes sygdommen.
5. Et kursus i “den motiverende samtale” til praktiserende læger forbedrer Type 2 diabetes
patienters risiko profil.
Den motiverende samtale, et systematisk review og en meta-analyse. (Artikel 1)
Kapitel 2 beskriver baggrunden for ”den motiverende samtale” med en kritisk gennemgang af
litteraturen, samt præsenterer en meta-analyse baseret på de tilgængelige data. Målet var at evaluere
effekten af ”den motiverende samtale” set i forhold til forskellige sygdomsområder og desuden at
identificere de mulige faktorer, som påvirker effekten. Meta-analysen påviste signifikant effekt
(95%CI) af ”den motiverende samtale” for det kombinerede effekt estimat for body mass index
(BMI), blod total-cholesterol, systolisk blodtryk, blod alkohol koncentration, standard ethanol
indhold, imens kombinerede effekt estimat for cigaretter pr. dag og HbA1c var non-signifikant.
”Den motiverende samtale” vist signifikant og klinisk relevant effekt i omtrent 3 ud af 4 studier
uafhængigt af om det drejede sig om biologiske/somatiske (72%) eller psykologiske/
psykosomatiske (74%) sygdomme. Psykologer og læger opnåede ens effekt (80%) i studierne,
hvorimod andre sundheds faggrupper opnåede mindre effekt (46%) i studierne.
Hvordan påvirker et kursus i ”den motiverende samtale” praktiserende lægers professionelle
adfærd. (Artikel 2)
Kapitel 3 undersøger det første niveau i processen af at måle effekt af ”den motiverende samtale”.
Her vises resultaterne af hvordan et 1½-dags internats kursus i ”den motiverende samtale påvirkede
de praktiserende lægers professionelle adfærd, samt deres evaluering af metodernes anvendelighed
et år efter kurset. Studiet viste, at ”den motiverende samtale” påvirker praktiserende lægers
professionelle adfærd. De praktiserende læger fandt, at kurset medførte kompetence til at anvende
metoden i patientbehandlingen. Desuden fandt de praktiserende læger at metoden ”den motiverende
samtale” var mere effektiv end deres vanlige rådgivning/samtaleteknik og at det forbedrede patientlæge forholdet. Endelig angav de praktiserende læger, at anvendelse af ”den motiverende samtale”
ikke var mere tidskrævende end deres vanlige samtaler
Effekten af “den motiverende samtale” på screenede Type 2 diabetes patienters overbevisning
og adfærd. (Artikel 3)
Kapitel 4 undersøger det andet niveau i processen af at måle effekt af ”den motiverende samtale”.
Her bringes resultater af de screenede nydiagnosticerede Type 2 diabetes patienters evaluering af
effekten af ”den motiverende samtale” på patienternes 1) holdning og parathed til at ændre adfærd,
2) på deres aktuelle ændringer i livsstil, og 3) på deres overbevisning og forståelse for Type 2
diabetes sygdommen. Studiet dokumenterede statistisk signifikant effekt af ”den motiverende
samtale” på patienternes overbevisning og forståelse af sygdommen og dens konsekvenser, samt
deres overvejelser og parathed til at ændre adfærd. PhD studiet påviste dog effekt i begge grupper,
og den signifikante effekt af ”den motiverende samtale” var ”lille”, hvilket medfører, at den kliniske
betydning af dette fund er usikker. Studiet påviste ingen ændringer i livsstilsadfærd i form af fx
rygestop.
87
Ingen effekt af ”den motiverende samtale” på screenede Type 2 diabetes patienters’ risiko
profil. En 1-års opfølgning af et randomiseret kontrolleret forsøg. (Artikel 4)
Kapitel 5 undersøger det tredje niveau i processen af at måle effekt af ”den motiverende samtale”.
Her angives i hvilket omfang ”den motiverende samtale” gennem ændring af ”faglig adfærd” og
herefter patient adfærd medførte effekt på patienternes risiko profil. Studiet kunne ikke påvise
ændring i risiko profil efter 1 år på screenede nydiagnosticerede Type 2 diabetes patienter. Tidligere
studier støtter sammen med resultaterne fra dette PhD studie, at det er nødvendigt at foretage lang
tids evaluering af ”den motiverende samtales’” effekt på risiko profil.
Generel diskussion af metoderne
Kapitel 6 diskuterer de metoder studiet har anvendt til at evaluere processen på de forskellige
niveauer, hver især publiceret i de 4 artikler (Kapitel 2 til 5). Afsnittet tillader en mere detaljeret
diskussion, som indgående omhandler alle aspekter set i forhold til diskussionsafsnittet af hver
enkelt artikel. Diskussionen er inddelt i overskrifterne: setting, design, intervention, måle metoder,
statistiske metoder og generalisering. Problemstillinger i forbindelse med evaluering af et
uddannelsesprogram diskuteres, samt hvordan studiet har forsøgt at løse disse problemer og på
hvilken måde metoderne opfyldte kravene til evaluering af alle niveauer i denne proces.
Generel diskussion af resultater
Kapitel 7 indeholder en diskussion af studiets resultater på de forskellige niveauer i processen, som
alle er publiceret i de 4 artikler (Kapitel 2 til 5). Resultaterne diskuteres i forhold til litteraturen på
området. Diskussionen er struktureret i overskrifterne: 1) forhold som påvirker muligheden for at
opnå effekt af et kursus i ”den motiverende samtale”, 2) effekten af ”den motiverende samtale” på
praktiserende læger, og 3) effekten af ”den motiverende samtale” på patienternes ændring i adfærd,
samt ændring i deres risiko profil.
Konklusion
Kapitel 8 præsenterer et resumé af konklusionerne fra diskussionen af metoder og resultater i PhD
studiet, samt desuden en overordnet diskussion.
”Den motiverende samtale” har været anvendt i behandlingen af mange forskellige adfærdsområder
og har vist signifikant og klinisk relevant effekt i omtrent 3 ud af 4 studier uafhængigt af om det
drejede sig om biologiske/somatiske eller psykologiske/psykosomatiske sygdomme. Derudover
viste PhD studiet, at et kursus i ”den motiverende samtale” påvirkede de praktiserende lægers
professionelle adfærd til at anvende metoden. Desuden dokumenterede studiet statistisk signifikant
effekt af ”den motiverende samtale” på patienternes overbevisning og forståelse af sygdommen og
deres overvejelser og parathed til at ændre adfærd. Endelig påviste studiet ikke en ændring i risiko
profil efter 1 år på screenede nydiagnosticerede Type 2 diabetes patienter.
Perspektiver og studiets konsekvenser for fremtidig forskning og praksis
Kapitel 9 sammenholder PhD studiets metoder, resultater og konklusioner i et fremtidig perspektiv
og uddrager konsekvenser og anbefalinger for fremtidens forskning og klinisk praksis.
88
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89
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102
Appendices
103
Appendix A
Figure 1. Flowchart of the ADDITION-study
Eligible practices/General practitioners willing to participate in
United Kingdom, The Netherlands and Denmark
Randomisation stratified by county and size of practice
Intervention group
Educated and trained in intensive multifactorial treatment of
Type 2 diabetes including lifestyle advice, prescription of aspirin
and ACE-inhibitors, in addition to protocol-driven tight control
of blood glucose, blood pressure and cholesterol.
In addition to intensive treatment,
GPs are educated and trained in
centre-specific interventions to
motivate adherence to lifestyle
changes and medication e.g.
“Motivational Interviewing”
Control group
Following conventional
treatment according to
current national guidelines
Intensive treatment
with no further
intervention
Inclusion of app. 3000 patients with Type 2 diabetes following inclusion-/exclusion criteria:
All newly diagnosed Type 2 diabetes patients detected by screening, aged 40-69 years, were eligible
unless they were found to have: contraindications or intolerance to study medication; a history of
alcoholism, drug abuse, psychosis or other emotional problems that were likely to invalidate informed
consent or adherence to treatment; malignant disease with a poor prognosis; or were pregnant or lactating.
Patients previously diagnosed with diabetes were excluded.
Follow up is planned for 5 years.
Endpoints will include mortality, macro-vascular and micro-vascular complications, patient health status
and satisfaction, process-of-care indicators and costs.
Figure 2. Flowchart of included general practitioners (GPs) and Type 2 diabetes patients (T2D)
Randomisation
stratified by county (Copenhagen and Aarhus) and size of practice
Control group
IC-group
N = 27 (36 GPs)
Eligible practices/GPs, who
two years previously attended a
residential course in
External Study group
(EM-group)
N = 20 practices (20 GPs)
Intervention group trained in
IM-group, N = 21 (29 GPs)
GPs received residential course in “Motivational interviewing”
GPs follow up days, ½ day twice during the first year
Control group, IC-group
N = 25 (30 GPs) *
Intervention group, IM-group
N = 21 (29 GPs)
GPs included with three
years follow-up
External group, EM-group
N = 20 (20 GPs)
N = 128 T2D in IC-group **
N = 137 T2D in IM-group
View Table 1 to see data rates on all data in IM- and IC-group
IC-group: Internal control group receiving no formal education or training in ”Motivational interviewing”.
IM-group: Internal motivational group receiving course in “Motivational Interviewing”
EM-group: External motivational group receiving course in “Motivational Interviewing”
Table 1. Data rate collected from patients after one year.
C-group: Control group of GPs (N=128)
I-group: Intervention group of GPs trained in”Motivational interviewing” (N=137)
Group
% data collected from patients
T-Chol (blood total cholesterol (mmol/l))
HbA1c (% GHb)
Smoking status
Physical activity
Blood pressure
ns – non-statistical significant difference P < 0,05
I-group
(N=137)
%
70%
67%
61%
64%
91%
88%
86%
76%
79%
C-group
(N=128)
%
83%
77%
71%
74%
91%
86%
86%
83%
84%
I-group vs C-group
P-value
P < 0,05
P < 0,05
P < 0,05
P < 0,05
ns
ns
ns
ns
ns
Appendix B
Noter til
Den motiverende samtale
- et uundværligt redskab
Carl Erik Mabeck
Overordnet mål.
Øge deltagernes muligheder for at motivere patienter til adfærdsændringer, der er nødvendige
for at realisere patientens ønsker om at opnå og bevare et godt helbred.
Specifikke mål.
Forstå det teoretiske grundlag for 'Den motiverende samtale'
Opnå kendskab til, hvordan den motiverende samtale gennemføres

Lære at lytte aktivt (reflective listening)
Lære at etablere et bæredygtigt forhold til patienten ved hjælp af PEARLS
Lære at finde patienten, hvor han/hun er ved hjælp af VA-skaler og
"Forandringens hjul"
Lære at anvende 'Balanceskemaet'
Lære at rokke ved 'ambivalencen'.
Lære at styrke patientens ressourcer (empowering)
Lære at undgå 'fælderne'
Undervisningsmetode: Voksenundervisning a.m. Malcolm Knowles.
Adult learning is an internal process with the locus of control of that process residing in the learner, but the process
can be facilitated by outside helpers.
The learning is based on the assumption that you as a learner:
1.
have the self-concept of being an adult and the desire and capability of taking responsibility for planning
and managing your own learning with help from fellow students, the facilitator, and other helpers. It is further
assumed that what you learn through your own initiative you will learn more effectively than what you learn as a
requirement by others.
2.
bring with you a rich background of experience that is a valuable resource both for your own learning and
for the learning of fellow students. It further assumes that your experience is different from the experience of other
members of the course, and that your combined experiences represent a rich pool of resources for one another’s
learning.
3.
are most prepared to learn those things you perceive will be most helpful in performing your life´s work
and will allow you to achieve a higher level of performance. It further assumes that the facilitator has the obligation
to help you make the most use of the course, using your learning contract, in order to perform more effectively.
4.
are unique, along with every other member of the course, because you have your own style and pace of
learning, outside commitments and pressures, goals, and internal motivations. For these reasons your learning plan
and must be highly individualised.
1
1. Hvad er problemet?
Spørgsmål "Hvorfor gør patienterne ikke som vi
siger?"
Svar: Fordi ingen voksne mennesker ændre adfærd,
blot fordi vi siger det?
Vi har effektive behandlinger mod en lang række sygdomme.
Mindre end 50 % af patienterne tage medicinen som foreskrevet.
Vores store folkesygdomme er livsstilsrelateret.
Mindre end 25 % af patienterne følger vore velbegrundede opfordringer til
adfærdsændringer.
Dårlig adherence (compliance) er ingen naturlov.
Behandleren har stor indflydelse på patientens adherence.
Dårlig udnyttelse af imponerende lægevidenskabelige fremskridt er den største
udfordring for sundhedsvæsenet.
3. Motivation er handlingsorienteret
Motivation er parathed til at handle. Det kan være fortsættelse af en bestemt aktivitet
fx motion, eller parathed til adfærdsændring fx rygestop.
Motivationen udtrykker sandsynligheden for, at personen gennemfører en bestemt
handling.
4. Den motiverende samtale er baseret på:
•
•
•
•
•
•
Vi behandler ikke patienter. Når patienten er ude af døren, er det patienten, der
afgør, hvad der bliver gjort.
Ingen handler imod deres overbevisning. Ændre patienten overbevisning,
ændre patienten adfærd. Behandleren kan ikke ordinerer ændringer i patientens
overbevisning!
Det er en almenmenneskelig reaktion, at forsøg på påvirkning vækker
modstand. Opleves påvirkningen som forsøg på indskrænkning af
selvbestemmelsesretten, forstærkes modstanden.
Patientens ambivalens dvs diskrepansen mellem patienten ønsker om et godt
helbred og opretholdelse af den aktuelle adfærd. Patienten stimuleres til at
reflektere over diskrepansen
Løsningen skal findes i et samarbejde med den enkelte patient/klient og tage
udgangspunkt i forståelse af: Hvem er patienten, hvad mener patienten og hvad er
hendes situation, ønsker og muligheder?
Vi kan styrke patientens muligheder til at finde sine stærke sider og sine
ressourcer (empowering).
2
Hvad mener patienten?
Patientens overbevisning er afgørende for motivationen.
Nytter det?
Kan jeg?
Er det umagen værd?
Etik
Motivational interviewing is a directive client-centred counseling approach for
initiating behaviour change by helping clients to resolve ambivalence (Miller og
Rollnick).
Den motiverende samtale er både direktiv, non-direktiv og forhandlende
• Direktiv. Patienten fastholdes i samtalen om ambivalensen.
• Non-direktiv. Patienten skal selv definere sine mål.
• Forhandlende: Behandleren skal sammen med patienten finde en løsning.
Det er Behandlerens ansvar at informere og sikre, at patienten har forstået sin
situation og sine muligheder. Det er patientens ansvar at træffe en beslutning og
gennemføre den.
Nogle etiske grundbegreber
Teleologi (regeletik) Handlingens rigtighed er uafhængig af konsekvenserne.
Ex. Vi skal respektere patientens ret til oplysning om diagnose og prognose uanset at
det (efter vor opfattelse) skader patienten mere end det gavner patienten.
Deontologi (konsekvensetik) Handlingens rigtighed afhænger af konsekvenserne.
Ex. Patienten skal kun oplyses om diagnose og prognose, hvis det gavner ham/hende
mere end det skader. Handlingen er rigtig, hvis den gavner mere end den skader.
Regelutilitarisme. Reglen er rigtig, hvis den ud fra en generel og overordnet
betragtning gavner mere end den skader, dvs uanset, at den kan medføre skade i
enkelte tilfælde.
Ex. Patienter skal altid have sandheden at vide om deres diagnose og prognose, fordi
det gavner (skaber tryghed, tillid mm) mere end det skader, uanset at nogle patienter
bliver slået helt i stykker.
3
5. Patient-centreret medicin
Patient-centred medicine: To bridge the gab between a biomedical understanding of the
patients disease and understanding the patient as an individual in a unique situation.
Den kliniske diagnose
Den medicinske diagnose
Personen og situationen
Afvigelser fra en biologisk
norm (disease)
Patientens oplevelser
(Illness)
Naturvidenskab
Humanistiske videnskaber
Fælles og upersonligt
Individuelt
Objektive kriterier
Subjektive kriterier
Undersøgelser
Kommunikation
Kvantitative data
Kvalitative data
6. Hvordan kan vi hjælpe?
Eksperten
Rådgiveren
Katalysatoren
Paternalistisk
Behandleren definerer
problemet og finder
den rigtige løsning
Behandleren respekterer
patientens autonomi
Patienten tager ansvar
for beslutningerne
Behandleren tror
på patientens evner
til selv at finde en
løsning
Informerer og
ordinerer en behandling
Informerer og rådgiver.
Overtaler.
Stimulerer til
refleksion.
Behandleren tager ansvar
for beslutninger
Ansvar til patienten
Ansvar til patienten
Fokus på problemet
Forkus på pt´s adfærd
Fokus på pt’s
overbevisning
Sygdoms-centreret
Patient-centreret
4
7.
Modstand
Det er en almenmenneskelig reaktion, at forsøg på påvirkning vækker
modstand.
Opleves påvirkningen som forsøg på indskrænkning af
selvbestemmelsesretten, forstærkes modstanden.
Modstand er en etikette, som behandleren sætter på klienter med visse
typer af uønsket adfærd og ytringer.
Behandleren opfatter modstand som et karaktertræk hos patienten
- ikke som en reaktion på behandlerens forsøg på påvirkning.
For patienten er modstand en naturlig, forståelig og fornuftig reaktion på
behandlerens misforståelser og forsøg på overtalelse.
Det kan være nyttigt at se på modstand som et signal til behandleren om,
at han går for hurtigt frem.
8. Lytte aktivt
At lytte aktivt (Reflective listening) betyder:
• Du reflekterer non-verbalt (kropssprog og lyde) eller verbalt (brug papegøje metoden,
eller hellere omskrivninger).
• Du reflekterer og resumerer, hvad du har opfattet som meningen med det, patienten
siger, og de følelsesmæssige reaktioner, patienten viser.
• Du stimulerer patienten verbalt og non-verbalt til at fortælle.
• Du lytter hypotetisk og undersøger, om du har forstået korrekt. "Er det rigtigt forstået,
at ...?"
• Du styrer samtalen ved at reflektere på de informationer, du anser for vigtige.
5
9. Hvad skal der til for at opnå patientens tillid?
. The tree function model
• Relationship building
Develop, maintain, and conclude the therapeutic relationship
Patient to feel cooperative, satisfied, and better
• Understanding the problem
Determine and monitor the nature of the problem.
Data must be comprehensive, reliable, ands relevant
• Agreeing in management
Tell a meaningful diagnosis
Negotiate and implement a plan.
10. Samtalens lag
Kliché laget Formål: Bryder isen og skabe tryghed.
Ex.: "Kunne du finde en parkeringsplads". "Sikken et vejr"
Facts
referenceramme.
Meninger
Følelser
Formål: Forstå problemet inden for en sundhedsfaglig
Ex. "Hvornår begyndte det?" " Har du haft det før?"
Forstå patientens handlinger. Patientens tolkninger og opfattelse af
nøglen til forståelse af hendes handlinger. .
EX. Hvis patienten tolker sin hovedpine som et muligt tegn på
sygdom, går hun til læge. Hvis hun tolker det som tegn på et dårligt
indeklima, går hun til sin sikkerhedsrepræsentant. Hvis hun tolker det
som tegn på stres, går hun til sin arbejdsgiver.
Formål: Forstå, hvad det betyder for patienten.
Det er patientens følelsesmæssige reaktioner, der er nøglen til
forståelse af, hvad det betyder for hende.
Ex. Angsten for, hvad det kan være eller udvikle sig til.
12. Tænk over noget, du gør (eller ikke gør), der ikke er godt for dit
helbred, men som egentlig synes, du burde gøre anderledes af hensyn til dit
helbred
(fx. cykle til arbejde, dyrke mere motion, spise mindre fedt el. lign)
(Vigtigt: Det skal være noget, du ikke har noget imod at fortælle om i gruppen)
Hvad?
6
13. Hvad skal der til for at opnå patientens tillid?
Det er spild af tid at begynde, før der er etableret et bæredygtigt forhold baseret på:
PEARLS:
Partnerskab. Vi skal gøre noget sammen.
Empati. Vise, at du forstår, hvordan det er at være i patientens sko.
Accept. Møde patienten med en positiv og uforbeholden indstilling
Respekt. Viser, at du tro på, at patienten er i stand at tage ansvaret for sine
beslutnigner
Legitimering. Patienten tænker logisk og hans/hendes følelser er ikke forkerte.
Support. Jeg er her og vil gerne hjælpe dig - også fremover.
14. Hvad er patientens motivation?
Hvor vigtigt er det for dig? Angiv på en skala fra 0 til 10.
Hvordan vurderer du dine muligheder for at lave om på det? Skala 0-10.
7
15. Hvor finder jeg patienten?
Det er afgørende at finde patienten hvor han/hun er, og starte dér.
Forandringens hjul. Forandringens hjul efter Stage of Change Model, Prochaska &
DiCelemente
1. Førovervejelsesstadiet
Patienten er ikke motiveret for at ændre adfærd og har derfor heller ikke tænkt på at gøre noget ved det.
Der er modstand mod forandring. "Hvorfor skal jeg altid høre om …?" fornægtelse er karakteristisk.
Rygeren med bronkitis mener ikke, at rygningen er et problem. Patientens indstilling kan også være en
demonstration af, at patienten selv bestemmer.
Strategi:
Vær ikke konfronterende eller argumenterende. Spørg hellere: "Har du nogensinde overvejet at holde
op med at ryge?" "Hvad var grunden til, at du tænkte på at holde op?"
2. Overvejelsesstadiet
Patienten anerkender, at der er et problem og begynder at tænke på forandring.
Patienten kan tale med Behandleren om det hensigtsmæssige i at ændre adfærd. Men der er tale om løse
og uforpligtende planer. Rygeren kan i flere år tale om, at hun en dag vil holde op med at ryge. Det er
tale om en ambivalent indstilling.
Strategi:
.Forsøg at afdække ambivalensen sammen med patienten. Få patienten til at reflektere over
diskrepansen mellem ønsker og aktuelle adfærd. Brug balanceskemaet. Ingen forsøg på overtalelse.
3. Forberedelsesstadiet
Patienten har besluttet sig til, at der skal gøres noget. "Fra på mandag vil jeg …." Men ambivalenseen
er ikke afklaret. Patienten har fortsat behov for at overbevise sig selv om, at det er nyttigt , muligt og
umagen værd.
Strategi:
Empowering. Behandleren skal styrke patientens selvtillid og tro på, at det kan lade sig gøre. Han skal
også sørge for, at patienten har en realistisk vurdering af mulighederne for at løse opgaven. Det er
vigtigt, at det er patienten og ikke behandleren, der beslutter, at der skal ske noget.
4. Handlingsstadiet
Patienten er i gang med forandringen. Hun er holdt op med at ryge, spiser anderledes osv. Hun er
motiveret.
Strategi:
Behandleren skal hjælpe patienten til at nå frem til den mest egnede løsning. Behandleren skal finde
den rette balance mellem at påvirke patienten og motivere patienten til selv at finde løsninger på sine
problemer. Hyppige kontakter kan være med til at understrege opfattelsen af, at det er vigtigt og at
Behandleren går op i problemet. Blodprøver eller et vægtskema kan fungere som redskaber i
selvevalueringen og giver feed-back. Lad patienten opbevare resultaterne!
5. Vedligeholdelsesstadiet
Uden en stærk vilje og bevidsthed om, at indgroede vaner ikke ændres i løbet af få måneder, men over
år, er der stor risiko for tilbagefald. Et vægttab fjerner ikke i sig selv årsagen til overvægt. Det er jo
ikke vægten, men patientens kostvaner, der er problemet.
Strategi:
Behandleren skal hjælpe patienten med at identificere risici for tilbagefald og strategier for
forebyggelse af tilbagefald. Det er vigtigt, at patienten er instrueret i, hvad hun skal gøre hvis, eller
helst før, der er tilbagefald.
6. Tilbagefald
Succes er ikke en garanti mod tilbagefald. Det er vigtigt at patienten kommer videre i "hjulet" og ikke
låses fast i dette stadium. Hvad var det, der skete? Hvad skal der til for at undgå tilbagefald? Hvad skal
der til, for at komme i gang igen? Det er vigtigt, at behandleren hjælper patienten til at fatte mod og
vende tilbage til det overvejende stadium. Fokuser på patientens erfaringer. "Hvad var det, der gjorde
det så svært?"
8
12. Balanceskemaet
Skal jeg fortsætte?
Eller skal jeg ændre adfærd?
A.
Nævn mindst 3 gode grunde for dig til at
fortsætte, f. eks med at ryge. (Jeg kan lide
det. Jeg tror ikke, det er muligt osv.)
C.
Nævn mindst 3 fordele for dig ved at
ændre adfærd, f. eks holde op med at
ryge. (Jeg får det bedre med min
samvittighed. Mine børn bliver glade osv.)
B.
Nævn mindst 3 problemer for dig ved at
fortsætte, f. eks med at ryge. (Det er dyrt.
Det skader mit helbred osv)
D.
Nævn mindst 3 problemer for dig ved
ændre adfærd, f. eks at holde op med at
ryge (Jeg tager på i vægt. Jeg bliver
umulig at omgås osv)
Pas på ikke at lægge hovedvægten på B og C. Argumentation avler modargumentation.
Gevinster skal være konkrete, personlige og her og nu.
13. Rokke ved ambivalensen
Working with ambivalence is working with the hart of the problem.
Miller & Rollnick.
Ambivalens er en normal foreteelse.
Målet er at få patienten til at overveje sin situation og få patienten til at ændre adfærd i retning af sine
personlige mål. (hvis de er acceptable for Behandleren?)
Vi kan rokke ved ambivalensen i de situationer, hvor der er et misforhold mellem patientens adfærd og
patientens ønsker om et godt helbred.
Tro aldrig, at patienten opfatter cost-benefit på samme måde som du!
Prøv ikke at overtale patienten. Lad patienten selv komme med forslag og vær meget opmærksom på
reservationer.
Det er vigtigere at beskæftige sig med motiverne end med målene
Behaviour is more likely to be altered if affective or
value dimensions of desirability are affected. Miller & Rollnick
Hvad vil patienten gerne opnå? Vægt, kolesterol, blodtryk osv er ikke et mål i sig selv.
Patientens motiver kunne være: "Jeg er utilfreds med mig selv." "Jeg er træt at være
så tyk". "Jeg er bange for, at det skal gå mig lige som min mor" osv
Hvis patienten ændre overbevisning, ændre han/hun adfærd.
Når patienten hører sig selv fortælle om mål og adfærd øges hans/hendes bevidsthed om diskrepansen.
Motivationen opstår, når patienten forstår diskrepansen og er overbevist om nødvendighed og
muligheder for at ændre på forholdet.
9
14. Empowering
Du skal finde patientens ressourcer i stedet for kun at fokusere på patientens svage sider.
Du skal hjælpe patienten til at tro på, at han/hun selv kan finde løsninger på sine problemer, og selv
kan gennemføre en plan.
Dig for gold. Not for shit! Sam Putnam
Problem. Vores sygdomsmodel er fejlsøgende.
Vi er i langt højere grad uddannet til at finde patientens svagheder, end patientens stærke sider.
Empowering er udtryk for samarbejde og fordeling af ansvar og gensidig respekt.
Vær med til at skabe selvtillid hos patienten.
Ros er det stærkeste medikament!
Rollespil.
B. Hvad gør du for at bevare dit helbred? Tænk på alt.
A. Du skal: 1. Rose. Du skal vise din anerkendelser for patientens indsats. Når
patienten selv synes, at han/hun på trods af dårlige betingelser virkelig har gjort
en indsats, skal du udtrykke din tilslutning 2. Kun stille åbne spørgsmål. Du må
gerne gå tilbage i tiden. Du skal få B til at fortælle. 3. Ikke komme med gode
forslag, men demonstrere, at du tror på patientens gode vilje og sunde fornuft.
10
15. Forhandle en plan.
Ingen voksne mennesker ændre adfærd, blot fordi vi siger det?
I skal sammen finde en løsning, men det er patienten, der skal gennemføre den.
Give råd. Hvordan kan det gøres? Ikke: Hvorfor det skal gøres.
Patienten afgør om dine velmente råd kan bruges.
Vær ikke for ivrig. Hellere være lidt kostbar med gode råd.
• Er du sikker på, at jeg er bedre til at finde på løsninger, end du selv?
• Tror du, du kan bruge mine forslag?
Forslag kan gives i en uforpligtende og upersonlig stil:
"Det er en mulighed. Du kan måske bruge det."
Fjerne barrierer. Hjælpe med at identificere og overvinde forhindringer.
Vigtigt at patienten føler, at han/hun har valgmuligheder.
Reagér på modstand med eftergivenhed. Prøv at forstå og lad patienten forklare.
Pas på ikke at være for ivrig og negligere modstand!
Hvis sukkersygepatienten har en dårlig adherence, kan du ikke løse problemet, men hjælpe patienten til
at finde en løsning. Patienten er nøglen til forståelse af, hvorfor det ikke fungerer. Er patienten ikke
overbevist? Er der praktiske forhindringer. Er patienten bange for bivirkninger? Minder medicinen
hende for meget om sygdommen? Osv. Du skal undgå lukkede spørgsmål.
Undgå argumentation.
"Du burde gøre noget ved det" fører til: "Ja, men ...." - og Behandleren tror, at patienten er
uinteresseret. (The confrontation-denial trap)
Argumentation avler mod-argumentation. Patienten skal ikke overtales, men presses til at indse
konsekvenserne og overveje situationen i lyset af dine oplysninger.
Det er patienten, der skal præsentere argumenterne for adfærdsændringer.
Give feedback. Feedback skal være konkret og konstruktiv. Sig hvad du synes
patienten gør godt.
Vær rosende og konkret. Lad være med at kritisere. Kritik skaber afstand. Kom hellere med
konstruktive forslag om, hvad man også kan gøre. Styrke patientens selvtillid.
Resumere. Periodiske resumeringer sikre:
- at I er enige og har forstået, hvad er der er aftalt
- Reinforcerer aftaler og motivationen.
Rollespil. Hvad vil og kan patienten?
Oplæg. Brug f. eks. balanceskemaet
Hvor er du nu med din sukkersyge?
Rok ved ambivalensen og brug 'empowering'
Tag udgangspunkt i figuren "Vigtigheden-Kan jeg?" punkt 6.
Hvad er du god til?
Hvad vil du gerne opnå?
Hvad skal der til for at nå målet?
Hvad kan du selv gøre?
Hvad vil jeg gerne have, at andre hjælper dig med?
Hvad er det første, der skal ske?
Hvem vil du fortælle om din beslutning?
16. Pas på fælderne
11
Ekspertrollen
Jeg er eksperten på det medicinske område.
Patienten er eksperten i sit liv
Informationer modificeres
Alle informationer tilpasses patientens begrebsverden
For mange informationer
For mange informationer slår hinanden ihjel (som her?)
Mod-argumentation
Argumentation avler mod-argumentation
Skræmmebilleder
Får nogle patienter til at lukke øjnene
Spørgsmål-svar fælden
Pas på den interessere og videbegærlige patient
Utålmodighed
Pas på, du ikke taber patienten undervejs
Prøv ikke at løse for mange problemer på én gang
Det bedste er det godes fjende!
At overhøre modstand
Viser patienten modstand, skal du starte med den.
Patientens afvisning
Prøv ikke at presse dig igennem. Det øger patientens
modstand.
Den nemme og flinke patient
Overlader ansvaret til dig - og gør ikke noget selv!
Urørlighedszonen
Overtræd ikke patientens grænser.
Blaming the victim
Det er ikke et spørgsmål om placering af skyld, men af ansvar.
17. Vi er selv en del af processen!
12
"Min private huskeseddel"
1. Patienten handler i overensstemmelse med sin egen overbevisning.
Patienten handler ikke på grundlag af informationer og min overbevisning.
Patienten foretager en selvstændig tolkning af de givne informationer.
Mine vurderinger og forslag tolkes sammen med mange andre informationer og påvirkninger.
Resultatet af denne tolkning er afgørende for, hvordan hun handler.
Hvis patienten ændrer opfattelse, ændrer han/hun adfærd i overensstemmelse hermed.
Det nytter intet, at jeg er overbevist om at mine løsninger og forslag er geniale.
Ingen handler imod deres egen overbevisning, heller ikke patienten.
2. Gengælder jeg patientens tillid?
Med sin henvendelse viser patienten mig sin tillid. Gengælder jeg denne tillid?
Opfatter jeg og behandler jeg patienten som et selvstændigt og ansvarligt menneske, der er i
stand til på fornuftig vis at tage vare på egne forhold?
Viser jeg, at jeg tror på hende?
Hvis jeg ikke tror på, at patienten er den bedste til at løse sine problemer, hvad er det så, jeg
tror på?
3. Jeg kan ikke lave om på patienten. Det kan kun patienten selv.
Motivation til forandring skal komme fra patienten og ikke påduttes af mig.
Det er ikke mig, der skal vurdere fordele og ulemper ved adfærdsændringer?
Men jeg skal gøre mit bedste for at patienten forstår sin situation og sine muligheder.
Ambivalente følelser opstår, når der er uoverensstemmelse mellem mål og adfærd.
Balanceskema
Det er patientens opgave at formulere og finde en løsning på sine ambivalente indstilling.
Jeg forsøger at rokke ved ambivalensen med det formål at tippe balancen til fordel for en
sundhedsfremmende adfærd.
4. Patienten kender sin situation og sine muligheder bedre end jeg.
Jeg er eksperten på det medicinske område.
Men patientens situation er unik, og hun er eksperten, når det gælder kendskab til hendes
baggrund, viden, overbevisninger, værdinormer, situation, mål og ønsker.
Er det mig, der har fundet en løsning på patientens problemer med udgangspunkt i mine
personlige forestillinger om patientens liv?
Har jeg interesseret mig for patientens problemer eller for patientens ressourcer?
5. Hvis jeg ikke finder patienten der, hvor han/hun er og starter der, opnår jeg
ingenting.
Kirkegaard: At man, når det i Sandhed skal lykkes En at føre et Menneske hen til et bestemt
Sted, først og fremmest maa passe paa at finde ham der, hvor han er, og begynde der.
Motivationens stadier. Forandringens hjul.
6. Dårlig compliance afhænger af mig
90 % af alle patienter følger ikke vores gode råd om adfærdsændringer.
Det kan blive bedre. Jeg må tro på, at jeg kan gøre noget.
Parathed til forandring afhænger af mig.
Forsøg på overtalelse er ikke en effektiv metode til ændring af patientens adfærd.
Jeg skal undgå en egentlig diskussion med patienten.
Modstand mod forandring er ikke et karaktertræk hos patienten, men en reaktion på min
indsats.
7. Aldrig sige "bare"
13
"Bare" røber, at jeg ikke forstår, hvorfor det er så svært for patienten
Hvis det 'bare' var så let, søgte patienten ikke din hjælp.
Min rolle er at være lyttende, spørgende og tilbageholdende.
Med interesse og spørgsmål stimulerer jeg patienten til selv at reflekterer over sin situation og
sine muligheder.
8. Gentagelse hjælper ikke. prøv noget nyt
Hvis patienten ikke har handlet i overensstemmelse med mine gode råd og forslag, er der
måske noget galt med dem.
Ved jeg, hvorfor patienten ikke kan bruge dem?
Det nytter intet med gentagelser.
Prøv at finde på noget nyt.
9. Det er lettere at narre mig selv end patienten
Jeg vil så gerne hjælpe og vise, at jeg kan udrette noget. Det gør mig blind og ukritisk.
Al erfaring viser, at jeg uhyre let kan bilde mig ind, at patienten såmænd nok ændre mening
og handler i overensstemmelse med mine gode og velmente råd, når hun får tænkt sig godt
om.
Der er intet erfaringsmæssigt belæg for denne opfattelse. Derimod mange, der viser, at det er
forkert.
Tør jeg bede patienten om at resumere, hvad vi har talt om og er nået frem til?
10. Pas på fælderne
14
Appendix C
Spørgeskema tid 0
Løbenummer
Side 1
0. Hvad er dit personnummer?
-
Følgende 6 spørgsmål handler om dig og dit helbred generelt. Besvar spørgsmålene med
det udsagn, der bedst beskriver din helbredstilstand i dag.
Markér kun et svar ved de følgende spørgsmål.
1. Bevægelighed
Jeg har ingen problemer med at gå omkring
Jeg har nogle problemer med at gå omkring
Jeg er bundet til sengen
2. Personlig pleje
Jeg har ingen problemer med min personlige pleje
Jeg har nogle problemer med at vaske mig eller klæde mig på
Jeg kan ikke vaske mig eller klæde mig på
3. Sædvanlige aktiviteter (f.eks. arbejde, studie, husarbejde, familie- eller fritidsaktiviteter)
Jeg har ingen problemer med at udføre mine sædvanlige aktiviteter
Jeg har nogle problemer med at udføre mine sædvanlige aktiviteter
Jeg kan ikke udføre mine sædvanlige aktiviteter
4. Smerter/ubehag
Jeg har ingen smerter eller ubehag
Jeg har moderate smerter eller ubehag
Jeg har ekstreme smerter eller ubehag
5. Angst/depression
Jeg er ikke ængstelig eller deprimeret
Jeg er moderat ængstelig eller deprimeret
Jeg er ekstremt ængstelig eller deprimeret
6. Sammenlignet med min helbredstilstand gennem de seneste 12 måneder, er min
helbredstilstand i dag
Bedre
Stort set den samme
Værre
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Side 2
7. For at hjælpe dig med at sige, hvor god eller dårlig
din helbredstilstand er, har vi tegnet en skala (næsten
ligesom et termometer, hvor den bedste helbredstilstand du kan forestille dig, er markeret med 100 og
den værste helbredstilstand du kan forestille dig, er
markeret med 0.
Vi beder dig angive på denne skala, hvor godt eller
dårligt du mener dit eget helbred er i dag. Angiv dette
ved at tegne en streg fra kassen nedenfor til et hvilket
som helst punkt på skalaen (se eksempel), der viser,
hvor god eller dårlig din helbredstilstand er i dag.
Bedst
tænkelige
helbredstilstand
100
9
0
8
0
Eksempel:
7
0
.......
.......
.......
6
0
5
0
4
0
3
0
2
0
1
0
Skal ikke udfyldes.
Forbeholdt kodning
0
Værst
Bedst
tænkelige
tænkelige
helbredstilstand
regulering
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Side 3
Herunder finder du en række udsagn, som forskellige personer har brugt til at beskrive sig
selv. Læs hvert udsagn og sæt en markering i den cirkel, der bedst udtrykker, hvordan du
har det lige nu, i dette øjeblik.
Der er ingen rigtige eller forkerte svar. Brug ikke for meget tid på et enkelt udsagn, men
angiv det svar, som bedst beskriver dine nuværende følelser.
Slet ikke
8.
Jeg føler mig rolig
9.
Jeg er anspændt
10.
Jeg føler mig oprevet
11.
Jeg er afslappet
12.
Jeg føler mig tilfreds
13.
Jeg er bekymret
I nogen grad
I rimelig grad
Meget
Følgende spørgsmål handler om forskellige sider af livet. Hvert spørgsmål har 7 svarmuligheder
Du bedes besvare hvert spørgsmål ved at sætte en cirkel om det tal på hver af
skalaerne, du synes passer bedst med din mening.
14.
Oplever du at du er ligeglad med det, der sker omkring dig?
Ofte
15.
5
4
3
2
1
Meget sjældent/aldrig
7
6
5
4
3
2
1
Det er aldrig sket
Er det sket, at folk, som du stolede på, har skuffet dig?
Det er sket mange gange
17.
6
Er det sket for dig, at du er blevet overrasket over opførslen hos personer, du kendte godt?
Det er sket mange gange
16.
7
7
6
5
4
3
2
1
Det er aldrig sket
7
6
5
4
3
2
1
Haft både mål og mening
Indtil nu har dit liv .....
Helt savnet mål
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Side 4
18. Føler du dig uretfærdigt behandlet?
Meget ofte
7
6
5
4
3
2
1
19. Oplever du, at du i en uvant situation ikke ved, hvad du skal gøre?
Meget ofte
7
6
5
4
3
2
1
1
2
3
4
5
6
7
Smerte og
kedsomhed
5
4
3
2
1
1
20. Er din dagligdag kilde til .....
Glæde og dyb
tilfredsstillelse
21. Har du modstridige tanker og følelser?
Meget ofte
7
6
22. Sker det, at du har følelser i dig, som du helst ikke vil føle?
Meget ofte
7
6
5
4
3
2
23. Selv mennesker med stærk personlighed kan ind imellem føle sig som en taber. Hvor ofte
har du følt dig sådan?
Aldrig
1
2
3
4
5
6
7
Meget ofte
24. Hvor tit oplever du, at du over- eller undervurderer betydningen af noget, der sker?
Meget ofte
7
6
5
4
3
2
1
Aldrig
25. Hvor ofte føler du, at de ting, du foretager dig i din hverdag, er uden mening?
Meget ofte
7
6
5
4
3
2
1
26. Hvor ofte har du følelser, som du ikke er sikker på, at du kan kontrollere?
Meget ofte
7
6
5
4
3
2
1
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Side 5
Løbenummer
De følgende 6 spørgsmål handler om Deres motionsvaner.
Angående besvarelse af følgende spørgsmål
Hård fysisk aktivitet er en aktivitet, der kræver en stor fysisk anstrengelse og gør din
vejrtrækning meget hurtigere end normalt.
Moderat fysisk aktivitet er en aktivitet, der kræver en moderat fysisk anstrengelse og gør din
vejrtrækning noget hurtigere end normalt.
27. Hvor mange dage i løbet af de sidste 7 dage har du været i hård fysisk aktivitet, som fx tunge løft,
gravearbejde, konditræning eller cyklet hurtigt? Tænk kun på de aktiviteter, du udførte mindst 10
minutter ad gangen.
Dage
Ingen (gå til spørgsmål 28)
a) Hvor megen tid brugte du sædvanligvis på hård fysisk aktivitet en af disse dage?
Timer
Minutter
28. Igen skal du kun tænke på den fysiske aktivitet, du udførte mindst 10 minutter ad gangen.
Hvor mange dage i løbet af de sidste 7 dage har du været i moderat fysisk aktivitet, som fx at løfte
lettere ting, cykle i jævnt tempo eller spille en double i tennis? Gåture skal ikke medregnes.
Dage
a) Hvor megen tid brugte du sædvanligvis på moderat fysisk aktivitet en af disse dage?
Timer
Minutter
29. Hvor mange dage i løbet af de sidste 7 dage har du gået i mindst 10 minutter ad gangen?
Medregn, hvor meget du går på arbejdet og derhjemme, gåture for at komme fra et sted til et andet
og alle andre gåture, som du foretog i forbindelse med fornøjelse, sport, motion eller fritid.
Dage
a) Hvor megen tid brugte du sædvanligvis på at gå en af disse dage?
Timer
Minutter
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Side 6
30. Det sidste spørgsmål handler om, hvor lang tid du sidder ned på hverdage, både når du er på
arbejde, hjemme, på kursus og i fritiden. Medregn den tid du sidder ved et skrivebord, besøger
venner, læser, kører i bus eller sidder eller ligger, mens du ser fjernsyn.
I løbet af de sidste 7 dage, hvor lang tid har du i gennemsnit siddet ned i løbet af en almindelig
hverdag?
Timer
31. Har du et arbejde (ude eller hjemme)?
Minutter
Ja
Nej (gå til spørgsmål 32)
Hvis Ja, hvilken af følgende grupper mener du selv, at du tilhører på din arbejdsplads?
(Sæt kun én markering)
Du sidder for det meste ned og går ikke ret meget omkring på arbejdspladsen
(fx skrivebordsarbejde, samle smådele og lignende)
Du går en del omkring på arbejdspladsen uden at skulle slæbe på tunge ting
(fx lettere industriarbejde, ikke stillesiddende kokntorarbejde, husligt arbejde, undervisning og lignende)
Du går for det meste og må ofte gå op ad trapper og løfte forskellige ting
(fx postombæring, byggearbejde, flytte tunge møbler og lignenede)
Du har legemligt arbejde, løfter tunge ting og anstrenger dig fysisk
(fx gravearbejde, skovarbejde, jord- og betonarbejde og lignende)
32. Hvilken af følgende grupper mener du selv, at din fritidsbeskæftigelse omfatter?
Du sidder som regel og læser, ser fjernsyn, går i biografen og tilbringer fritiden med
stillesiddende sysler.
Du går tur, kører lidt på cykel eller er i legemlig aktivitet mindst 4 timer om ugen
(lettere fritidsbyggeri, bordtennis, bowling og lignende)
Du er aktiv idrætsudøver mindst 3 gange ugentlig. Hvis du ikke dyrker sport, men ofte
udfører tungt havearbejde eller tungt fritidsarbejde, hører du også til denne gruppe.
Du dyrker konkurrenceidræt (svømning, fodbold) eller langdistanceløb flere gange om
ugen.
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Side 7
33. Hvordan synes du, dit helbred er alt i alt?
(Sæt kun markering i én af cirklerne)
Fremragende
Vældig godt
Godt
Mindre godt
Dårligt
34. Sammenlignet med for ét år siden, hvordan er dit helbred alt i alt nu?
Meget bedre nu end for ét år siden
Noget bedre nu end for ét år siden
Nogenlunde det samme
Noget dårligere nu end for ét år siden
Meget dårligere nu end for ét år siden
35. De følgende spørgsmål handler om aktiviteter i dagligdagen. Er du på grund af dit helbred
begrænset i disse aktiviteter? I så fald, hvor meget?
(Sæt en markering i cirklen under det rigtige svar for hvert spørgsmål)
Ja, meget
begrænset
Ja, lidt
begrænset
Nej,
slet ikke
begrænset
a. Krævende aktiviteter, som f.eks. at løbe, løfte
tunge ting, deltage i anstrengende sport
b. Lettere aktiviteter, såsom at flytte et bord, støvsuge eller cykle
c. At løfte eller bære dagligvarer
d. At gå flere etager op ad trapper
e. At gå én etage op ad trapper
f. At bøje sig ned eller gå ned i knæ
g. Gå mere end én kilometer
h. Gå nogle hundrede meter
i.
Gå 100 meter
j. Gå i bad eller tage tøj på
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Spørgeskema tid 0
36.
Side 8
Løbenummer
Har du inden for de sidste 4 uger, haft nogen af følgende problemer med dit arbejde
eller andre daglige aktiviteter på grund af dit fysiske helbred?
JA
NEJ
a. Jeg har skåret ned på den tid, jeg bruger på arbejde eller
andre aktiviteter
b. Jeg har nået mindre, end jeg gerne ville
c. Jeg har været begrænset i hvilken slags arbejde eller
andre aktiviteter, jeg har kunnet udføre
d. Jeg har haft besvær med at udføre mit arbejde eller
andre aktiviteter (fx krævede det en ekstra indsats)
37.
Har du inden for de sidste 4 uger haft nogen af følgende problemer med dit arbejde eller
andre daglige aktiviteter på grund af følelsesmæssige problemer?
JA
NEJ
a. Jeg har skåret ned på den tid, jeg bruger på arbejde eller
andre aktiviteter
b. Jeg har nået mindre, end jeg gerne ville
c. Jeg har udført mit arbejde eller andre aktiviteter
mindre omhyggeligt, end jeg pleje
38.
Inden for de sidste 4 uger, hvor meget har dit fysiske helbred eller følelsesmæssige
problemer vanskeliggjort din kontakt med familie, venner, naboer eller andre?
Slet ikke
Lidt
Noget
En hel del
Virkelig meget
39.
Hvor stærke fysiske smerter har du haft i de sidste 4 uger?
Ingen smerter
Meget lette smerter
Lette smerter
Middelstærke smerter
Stærke smerter
Meget stærke smerter
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Spørgeskema tid 0
Løbenummer
Side 9
40. Inden for de sidste 4 uger, hvor meget har fysisk smerte vanskeliggjort dit daglige arbejde
(både arbejde udenfor hjemmet og husarbejde)?
Slet ikke
Lidt
Noget
En hel del
Virkelig meget
41. Disse spørgsmål handler om, hvordan du har haft det i de sidste 4 uger.
Hvor stor en del af tiden i de sidste 4 uger:
Hele
tiden
Det
meste
af tiden
En hel
del af
tiden
Noget
af
tiden
Lidt
af
tiden
På
intet
tidspunkt
a. Har du følt dig veloplagt og fuld af liv?
b. Har du været meget nervøs?
c. Har du været så langt nede, at intet
kunne opmuntre dig?
d. Har du følt dig rolig og afslappet?
e. Har du været fuld af energi
f. Har du følt dig trist til mode?
g. Har du følt dig udslidt?
h. Har du været glad og tilfreds?
i.
Har du følt dig træt?
42. Inden for de sidste 4 uger hvor stor del af tiden har dit fysiske helbred eller følelsesmæssige
problemer gjort det vanskeligt at se andre mennesker (fx besøge venner, slægtninge osv.)?
Hele tiden
Det meste af tiden
Noget af tiden
Lidt af tiden
På intet tidspunkt
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Spørgeskema tid 0
Side 10
Løbenummer
43. Hvor rigtige eller forkerte er de følgende udsagn for dit vedkommende?
(Sæt en markering i cirklen under det rigtige svar for hvert udsagn)
Helt
rigtigt
Overvejende
rigtigt
Ved ikke
Overvejende
forkert
Helt
forkert
a. Jeg bliver nok lidt lettere syg end
andre
b. Jeg er lige så rask som enhver anden,
jeg kender
c. Jeg forventer at mit helbred bliver dårligere
d. Mit helbred er fremragende
De næste spørgsmål handler om nervebetændelse
JA
NEJ
44. Er dine ben og fødder ofte følelsesløse?
45. Har du nogensinde en brændende smerte i dine ben og fødder?
46. Er dine fødder meget følsomme for berøring?
47. Har du ofte haft en prikkende følelse i dine ben eller fødder?
48. Gør det ondt, når sengetøjet rører huden på dine ben eller arme?
Hvis du har svaret ja til nogen af spørgsmålene 44-48
49. Er dine symptomer værre om natten?
50. Er du i stand til at mærke forskel på varmt og koldt vand, når du går i bad?
51. Har du nogensinde fået amputeret en tå, en fod eller en del af underbenet?
(Amputationer på grund af ulykke regnes ikke med)
52. Har du nogensinde haft et åbent fodsår?
53. Har din læge nogensinde sagt til dig, at du har diabetisk nervebetændelse?
54. Føler du dig træt i hele kroppen det meste af tiden?
55. Gør det ondt i dine ben, når du går?
56. Kan du mærke dine fødder, når du går?
57. Er huden på dine fødder så tør, at den sprækker?
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Spørgeskema tid 0
Side 11
Løbenummer
De sidste spørgsmål handler om dit medicinforbrug umiddelbart før du fik konstateret
diabetes
58. Tog du dagligt nogen form for medicin, der var ordineret af en læge (ikke vitaminpiller og
andet kosttilskud) umiddelbart før du fik konstateret diabetes?
Ja
Nej
Hvis Ja, beder vi dig skrive navn på medicinen, grunden til at du tog den samt det årstal, hvor du
startede med at tage medicinen
1) Medicin:
Grunden til at du tog medicinen:
Hvornår startede du med at tage medicinen:
Årstal
2) Medicin:
Årstal
3) Medicin:
Årstal
4) Medicin:
Årstal
Skal ikke udfyldes.
Forbeholdt instituttet
Mange tak fordi du tog dig tid til at udfylde skemaet
Skemaet indsendes snarest muligt i vedlagte portofrie svarkuvert
3091
Spørgeskema tid 12 måneder
Side 1
2004
1.
-
Hvad er dit personnummer?
Sundhedspersonale har forskellige måder at omgås patienter på, og vi vil gerne vide noget om,
hvordan du har haft det med sundhedspersonalet, når I har talt om din diabetes. Dine svar
bliver behandlet med fortrolighed. Vi beder dig være ærlig og oprigtig. Du bedes sætte én
markering i firkanten under det svar, der bedst passer til din grad af enighed.
Arbejd hurtigt og besvar alle punkterne så godt du kan.
Meget
uenig
Noget
uenig
Lidt
uenig
Neutral
Lidt
enig
Noget
enig
Meget
enig
2. Jeg føler, at sundhedspersonalet
præsenterede mig for valg og muligheder med hensyn til at håndtere
min diabetes.
3. Jeg føler mig forstået af sundhedspersonalet med hensyn til min
diabetes.
4. Sundhedspersonalet udtrykker tillid
til, at jeg kan foretage de ændringer, der er nødvendige for at styre
min diabetes.
5. Sundhedspersonalet opmuntrer
mig til at stille spørgsmål om min
diabetes.
6. Sundhedspersonalet prøver at
forstå, hvordan jeg ser på min
diabetes, inden de foreslår en ny
måde at gøre tingene på.
62215
Side 2
2004
Der er mange forskellige grunde til, at patienter tager deres medicin, checker deres blodsukker,
følger deres diæt eller motionerer regelmæssigt.
Vi beder dig overveje følgende udsagn og angive, i hvor høj grad du er enig eller uenig i hvert
udsagn ved hjælp af skalaen herunder.
A. Jeg tager min diabetesmedicin og/eller måler mit blodsukker, fordi:
Meget
uenig
Noget
uenig
Lidt
uenig
Neutral
Lidt
enig
Noget
enig
Meget
enig
7. Andre mennesker ville blive vrede
på mig, hvis jeg ikke gjorde det.
8. Det er en personlig udfordring for
mig at gøre det.
9. Jeg ved egentlig ikke hvorfor jeg
prøver, det nytter alligevel ikke.
10. Jeg tror personligt, at mit helbred vil
forbedres, hvis jeg har min diabetes
under kontrol.
11. Jeg ville føle skyld, hvis jeg ikke
gjorde, som min læge siger.
12. Jeg vil gerne have, at min læge
synes, jeg er en god patient.
13. Jeg ville have det dårligt med mig
selv, hvis jeg ikke gjorde det.
14. Det er spændende at prøve at holde
mit blodsukker inden for et område,
der er godt for mit helbred.
15. Jeg ønsker ikke, at andre mennesker skal blive skuffede over mig.
62215
2004
Side 3
B. Grunden til, at jeg følger min diæt og motionerer regelmæssigt, er at:
Meget
uenig
Noget
uenig
Lidt
uenig
Neutral
Lidt
enig
Noget
enig
Meget
enig
16. Jeg ville gøre andre kede af det,
hvis jeg ikke gjorde det.
17. Jeg tror personligt på, at disse forhold er vigtige for at forblive sund og
rask.
18. Jeg ville skamme mig over mig selv,
hvis jeg ikke gjorde det.
19. Det er lettere at gøre, hvad jeg får
besked på, end selv at skulle tænke
over det.
20. Jeg har tænkt grundigt på at følge
min diæt og motionere og tror på, at
det er det rigtige at gøre.
21. Jeg vil gerne have, at andre skal se,
at jeg kan følge min diæt og holde
mig i god form.
22. Jeg ved ikke hvorfor. Jeg gør det vel
kun, fordi min læge har sagt, at jeg
skal.
23. Jeg føler personligt, at det er bedst
for mig at være opmærksom på min
diæt og motion.
24. Jeg ville føle skyld, hvis jeg ikke var
opmærksom på min diæt og motion.
25. Regelmæssig motion og overholdelse af diæt er valg, jeg virkelig
ønsker at træffe.
26. Det er en udfordring at lære,
hvordan man lever med diabetes.
27. Jeg er ikke sikker på, hvorfor jeg
egentlig overholder min diæt eller
motionerer regelmæssigt; jeg må
vente og se tiden an.
62215
2004
Side 4
De næste spørgsmål handler om dine betragtninger vedrørende din diabetes. Vi er interesseret
i dit eget, personlige syn på, hvordan du opfatter din diabetes nu.
Sæt èn markering firkanten ud for hvert udsagn, der viser i hvor høj grad du er enig eller uenig i de
følgende udsagn
Meget
enig
Enig
Hverken
enig eller
uenig
Uenig
Meget
uenig
28. En bakterie eller virus er skyld i min diabetes
29. Kost spillede en stor rolle for udviklingen af
min diabetes
30. Miljøforurening er skyld i min diabetes
31. Min diabetes er arvelig - det ligger til familien
32. Det var bare et tilfælde, at jeg blev syg
33. Stress var en vigtig faktor for udviklingen af
min diabetes
34. Min diabetes skyldes overvejende min egen
adfærd
35. Andre mennesker spillede en stor rolle for
udviklingen af min diabetes
36. Min diabetes skyldes dårlig lægelig behandling
i fortiden
37. Min sindstilstand spillede en stor rolle for
udviklingen af min diabetes
38. Min diabetes vil vare i kort tid
39. Min diabetes vil snarere være permanent end
midlertidig
40. Min diabetes vil vare i lang tid
41. Mit liv vil blive kortere, fordi jeg har diabetes
42. Min diabetes vil hurtigt gå over
43. Jeg forventer at have diabetes resten af livet
44. Min diabetes er en alvorlig trussel mod mit
helbred
62215
2004
Side 5
Sæt èn markering firkanten ud for hvert udsagn, der viser i hvor høj grad du er enig eller uenig i de
følgende udsagn
Meget
enig
Enig
Hverken
enig eller
uenig
Uenig
Meget
uenig
45. Min diabetes har haft store konsekvenser for
mit liv
46. Jeg har kun diabetes i mild grad
47. Jeg er bekymret for at udvikle diabeteskomplikationer
48. Min diabetes vil ikke få stor indflydelse på mit liv
49. Min diabetes vil i høj grad påvirke andre
menneskers opfattelse af mig
50. Det vil ikke påvirke mit helbred at have diabetes
51. Jeg vil sandsynligvis udvikle diabeteskomplikationer
52. Min diabetes har alvorlige økonomiske konsekvenser
53. Min diabetes vil ændre mine dagelige aktiviteter
(venner, arbejde, skole)
54. Min diabetes vil i høj grad påvirke min opfattelse
af mig selv som menneske
55. Vær venlig at skrive de diabeteskomplikationer du kender til. Nævn så mange, du kan komme i
tanker om. Skriv med blokbogstaver
62215
2004
Side 6
56. Hvor STOR BETYDNING har hvert af følgende punkter haft for, at du har din diabetes under kontrol?
Sæt en markering i den firkant ud for hvert spørgsmål, der bedst beskriver dine følelser
Særdeles
stor
Ingen
Lille
Nogen
Stor
betydning betydning betydning betydning betydning
Regelmæssig motion?
Ikke at ryge?
Regelmæssig måling af dit blodsukker?
Holde regnskab med resultaterne af dine blodsukkermålinger?
At følge din kostplan?
Ikke at spise for mange søde sager?
At tage din medicin/insulin som ordineret?
Kun at drikke lidt eller ingen alkohol?
At gøre som anbefalet de dage, hvor du er syg?
57. Hvor SANDSYNLIGT er det, at hvert af følgende punkter kan hjælpe med til at forebygge diabeteskomplikationer i fremtiden?
Sæt en markering i den firkant ud for hvert spørgsmål, der bedst beskriver dine følelser
Ikke
Lidt
Noget
Meget
Højst
sandsynligt sandsynligt sandsynligt sandsynligt sandsynligt
Regelmæssig motion?
Ikke at ryge?
Regelmæssig måling af dit blodsukker?
Regelmæssig undersøgelse af dine fødder?
Holde regnskab med resultaterne af dine blodsukkermålinger?
At følge din kostplan?
Ikke at spise for mange søde sager?
At tage din medicin/insulin som ordineret?
Kun at drikke lidt eller ingen alkohol?
At gøre som anbefalet de dage, hvor du er syg?
Sikre, at du bliver undersøgt regelmæssigt for
diabetesrelaterede følgesygdomme (fx øjenus.)
62215
2004
Side 7
De næste spørgsmål handler om hvilke råd du har modtaget af dit behandlingsteam.
58.
Hvilke af følgende råd har dit behandlingsteam (læge, sygeplejerske, diætist eller
diabetesskole) givet dig? Sæt gerne flere markeringer
At følge en fedtfattig kostplan
At følge en diæt sammensat af kylhydrater, der optages langsomt (Fx kartofter, ris, pasta og lign.)
At reducere dit kalorieindtag for at tabe dig
At spise masser af fiberrig mad
At spise masser af frugt og grønsager (mindst 5 om dagen)
At spise meget få søde sager (fx desserter, ikke-sukkerfri sodavand, chokolade)
Du har ikke fået nogen kostråd af dit behandlingsteam
Andet. Beskriv:
Skal ikke udfyldes.
Forbeholdt kodning
59.
Dagligt at dyrke let motion (fx at gå en tur)
Motionere uafbrudt i mindst 20 minutter mindst 3 gange om ugen
Indpasse motion i dine dagelige vaner (Fx at tage trappen i stedet for elevatoren, parkere et stykke
fra dit bestemmelsessted og gå, osv.)
At dyrke en bestemt mængde motion af en bestemt type og varighed og på et bestemt niveau
Du har ikke fået nogen motionsråd af dit behandlingsteam
Andet. Beskriv
Skal ikke udfyldes.
Forbeholdt kodning
60.
At måle dit blodsukker ved hjælp af en dråbe blod fra fingeren
At måle dit blodsukker ved hjælp af et apparat, der kan aflæse resultaterne
At undersøge om du har sukker i urinen
Du har ikke fået nogen råd om hverken at undersøge dit blod eller urin af dit behandlingsteam
Andet. Beskriv
Skal ikke udfyldes.
Forbeholdt kodning
62215
Side 8
2004
61.
Hvilke af følgende former for medicin har din læge ordineret for din diabetes?
En insulinindsprøjtning 1 eller 2 gange dagligt
En insulinindsprøjtning 3 eller flere gange dagligt
Tabletter til at holde din blodsukkerværdi under kontrol
Skal ikke udfyldes.
Forbeholdtkodning
Du har ikke fået ordineret hverken insulin eller tabletter for din diabetes
Andet. Beskriv:
Medicin
Du bedes sætte en cirkel om det tal på skalaen, du synes passer bedst med din vurdering.
62.
Hvor mange dage ud af de sidste SYV DAGE har du taget din anbefalede diabetesmedicin?
0
1
2
3
4
5
6
7
Dage
63.
Hvor mange dage ud af de sidste SYV DAGE har du taget dine anbefalede insulinindsprøjtninger?
0
1
2
3
4
5
6
7 Dage
64.
Hvor mange dage ud af de sidste SYV DAGE har du taget dit anbefalede antal diabetestabletter?
0
1
2
3
4
5
6
7
Dage
Fodpleje
Du bedes sætte en cirkel om det tal på skalaen, du synes passer bedst med din vurdering.
65.
Hvor mange dage ud af de sidste SYV DAGE har du vasket dine fødder?
0
66.
2
3
4
5
6
7
Dage
7
Dage
Hvor mange dage ud af de sidste SYV DAGE har du taget et fodbad?
0
67.
1
1
2
3
4
5
6
Hvor mange dage ud af de sidste SYV DAGE har du tørret dig mellem tæerne efter at have
vasket dem?
0
1
2
3
4
5
6
7
Dage
62215
2004
Side 9
Rygning
68.
Har du røget - endog bare et sug - i løbet af de sidste SYV DAGE?
Nej
Ja
Antal
Hvis ja, hvor meget ryger du i gennemsnit om dagen?
cigaretter dagligt?
cerutter dagligt?
cigarer dagligt?
gram pibetobak om ugen?
Hvis ja, blev du spurgt om dine rygevaner ved dit sidste lægebesøg?
69.
Ja
Blev du rådet til at holde op med at ryge eller henvist til et rygestopkursus ved dit sidste lægebesøg?
Nej
70.
Nej
Ja
Hvornår har du sidst røget? Sæt kun én markering
For mere end to år siden, eller har aldrig røget
For et til to år siden
For fire til tolv måneder siden
For en til tre måneder siden
Inden for den sidste måned
I dag
71.
Hvor meget ønsker du at holde op med at ryge? Sæt kun én markering
Virkelig meget
Meget
Kun lidt
Slet ikke
62215
2004
Side 10
72. Hvor meget øl, vin og spiritus drikker du i gennemsnit på en almindelig uge?
(skriv 0, hvis det er mindre end én genstand om ugen)
Antal flasker
Almindelig pilsnerøl
Antal glas
Stærk øl?
Rød eller hvidvin?
eller
(ca. 6 glas pr. flaske)
Hedvin, f.eks. sherry, portvin?
eller
(ca. 9 glas pr. flaske)
Spiritus, f.eks. snaps, whisky?
eller
(1 glas = 4 centiliter)
73. Føler du, at du af hensyn til dit helbred burde nedsætte dit forbrug af alkohol (øl, vin, spiritus)?
Ja
Nej
74. Hvilken beskrivelse passer bedst på dig?
Jeg spiser nogenlunde som gennemsnittet
Jeg spiser mere sundt end de fleste
Jeg spiser nok lidt mere usundt end de fleste
Jeg spiser temmelig usundt
62215
2004
Side 11
De næste spørgsmål handler om fysisk aktivitet.
Hård fysisk aktivitet er en aktivitet, der kræver stor fysisk anstrengelse og gør din vejrtrækning meget
hurtigere end normalt.
Moderat fysisk aktivitet er en aktivitet, der kræver en moderat fysisk anstrengelse og gør din vejrtrækning
noget hurtigere end normalt.
Sammentællingen af den tid (timer/minutter) du har brugt på henholdvis hård fysisk aktivitet (spm. 75 a), moderat fysisk aktivitet (spm. 76 a), gåture (spm. 77 a), at sidde ned (spm. 78) og at sove (spm. 79) bør være = 24
timer.
75. Hvor mange dage i løbet af de sidste 7 dage har du været i hård fysisk aktivitet, som f.eks. tunge
løft, gravearbejde, konditræning eller hurtig cykling? Tænk kun på de aktiviteter, du udførte
mindst 10 minutter ad gangen.
Ingen
Dage (Gå til a)
a) Hvor meget tid brugte du i gennemsnit på hård fysisk aktivitet i løbet af 24 timer én af disse dage?
Timer
76.
Minutter
Igen skal du kun tænke på den fysiske aktivitet du udførte mindst 10 minutter ad gangen.
Hvor mange dage i løbet af de sidste 7 dage har du været i moderat fysisk aktivitet, som f.eks. at
løfte lettere ting, cykle i jævnt tempo eller spille en double i tennis? Gåture skal ikke medregnes.
Ingen
Dage (Gå til a)
a) Hvor meget tid brugte du i gennemsnit på moderat fysisk aktivitet i løbet af 24 timer én af disse
dage?
Timer
77.
Minutter
Hvor mange dage i løbet af de sidste 7 dage har du gået i mindst 10 minutter ad gangen?
Medregn gåture til og fra arbejdet, gåture for at komme fra et sted til et andet og alle andre gåture,
som du foretog i forbindelse med fornøjelse, sport, motion eller fritid.
Ingen
Dage (Gå til a)
a) Hvor megen tid brugte du i gennemsnit på at gå i løbet af 24 timer én af disse dage?
Timer
Minutter
62215
2004
Side 12
78. Hvor lang tid sidder du ned på hverdage, både når du er på arbejde, hjemme, på kursus og i fritiden.
Medregn den tid du sidder ved et skrivebord, besøger venner, læser, kører i bus eller sidder eller ligger,
mens du ser fjernsyn.
I løbet af de sidste 7 dage, hvor lang tid har du i gennemsnit siddet ned i løbet af et døgn (24 timer)?
Timer
Minutter
79. I løbet af de sidste 7 dage, hvor lang tid har du i gennemsnit sovet eller ligget ned i løbet af et
døgn (24 timer)?
Timer
80. Har du beskæftigelse?
Ja
Minutter
Nej (gå til spørgsmål 82)
81. Hvis ja, hvilken af følgende grupper mener du selv, at du tilhører på din arbejdsplads?
Jeg sidder for det meste ned og går ikke ret meget omkring på arbejdspladsen
(f.eks. skrivebordsarbejde, samle smådele og lignende)
Jeg går en del omkring på arbejdspladsen uden at skulle slæbe på tunge ting
(f.eks. lettere industriarbejde, ikke stillesiddende kontorarbejde, husligt arbejde, undervisning og lign.)
Jeg går for det meste og må ofte gå op ad trapper og løfte forskellige ting
(f.eks. postombæring, byggearbejde, flytte tunge møbler og lignende)
Jeg har legemligt arbejde, løfter tunge ting og anstrenger mig fysisk
(f.eks. gravearbejde, skovarbejde, jord- og betonarbejde og lignende)
82. Hvor mange dages sygefravær har du haft inden for de sidste 4 arbejdsuger? (Benyt gerne din kalender)
Sygefravær er hvor du bliver hjemme fra arbejde på grund af sygdom .
Sygefravær pga. lægebesøg, hospitalsindlæggelse, fysioterapi, kiropraktisk behandling, alternativ
behandling og lignende skal ikke tælles med. Sygefravær pga. børns eller øvrig families sygdom skal
heller ikke tælles med.
Jeg har haft
dages sygefravær fra mit arbejde/uddannelse
83. Hvilken af følgende grupper mener du selv, at din fritidsbeskæftigelse omfatter?
Jeg sidder som regel og læser, ser fjernsyn, går i biografen og tilbringer fritiden med
stillesiddende sysler
Jeg går tur, kører lidt på cykel eller er i legemlig aktivitet mindst 4 timer om ugen (lettere
fritidsbyggeri, husligt arbejde, bordtennis og bowling)
Jeg er aktiv idrætsudøver mindst 3 gange ugentligt. (Hvis du ikke dyrker sport, men ofte
udfører tungt havearbejde eller tungt fritidsarbejde, hører du også til denne gruppe)
Jeg dyrker konkurrenceidræt eller langdistanceløb flere gange om ugen
Mange tak for hjælpen
62215
Spørgsmål til alle læger i interventionsgruppen
ADDITION Spørgeskema 2/SR-SM Juni 2002
Side 1
Eksempel på en case, som du møder i din praksis:
Tænk på en patient med type 2-diabetes og høj kardiovaskulær risiko (>40% ifølge DSAMs
Hjertevejledning), som du har forsøgt at behandle i 1 år uden effekt på risikoprofilen. Hvad
gør du i følgende situationer?
1. Hvad vil du gøre, når patienten åbenlyst ikke vil følge dine råd?
Helt
enig
Lidt
enig
Hverken
enig eller
uenig
Lidt
uenig
Helt
uenig
a. Forklare behandlingsplanen igen
b. Orientere dig yderligere om patientens
evner og muligheder for at løse
problemet
c. Forklare hvorfor det er vigtigt at følge
behandlingsplanen med saglige
argumenter
d. Undersøge om patienten tror på, at de
planlagte tiltag vil gavne patienten selv.
e. Få patienten til at redegøre for fordele og
ulemper ved aktuel adfærd i forhold til
sygdom og behandlingstiltag
f.
Informere yderligere for at overtale
patienten til en aftale
g. Fremhæve hvad konsekvenserne bliver,
hvis planen ikke overholdes
h.
Få patienten til at resumere aftalen
i.
Spørge om hvilke forventningerer
patienten har til, hvad du kan gøre i den
aktuelle situation
Af mulighederne "a - i" nævn de 3, som du finder væsentligst
43806
Side 2
2. Hvad vil du gøre, når du har på fornemmelsen, at patienten ikke vil følge dine råd?
Helt
enig
a.
b.
c.
d.
Lidt
enig
Hverken
enig eller
uenig
Lidt
uenig
Helt
uenig
Forklare behandlingsplanen igen
Orientere dig yderligere om patientens
problemet
Forklare hvorfor det er vigtigt at følge
argumenter
Undersøge om patienten tror på, at de
planlagte tiltag vil gavne patienten selv
e.
Få patienten til at redegøre for fordele og
f.
g.
Fremhæve hvad konsekvenserne bliver,
h.
i.
aktuelle situation
3. Hvad vil du gøre, når patientens egne mål fx ønsket om et godt helbred, ikke stemmer overens med
patientens adfærd?
Hverken
Helt
enig
a.
b.
c.
Undersøge om patienten tror på, at de
planlagte tiltag vil gavne patienten selv
e.
Få patienten til at redegøre for fordele og
f.
g.
Forhæve hvad konsekvenserne bliver,
i.
enig eller
uenig
Lidt
uenig
Helt
uenig
Forklare behandlingsplanen igen
Orientere dig yderligere om patientens
problemet
Forklare hvorfor det er vigtigt at følge
argumenter
d.
h.
Lidt
enig
aktuelle situation
43806
Side 3
4. Hvad mener du er afgørende for, hvad patienten vælger at gøre?
Helt
enig
a.
At der er tillid mellem dig og patienten
b.
At patienten grundigt forklares om
argumenter for planen
c.
At du informerer mest muligt
d.
At du som læge lægger en klar plan for
patienten
e.
At patienten er informeret om konsekvenserne af manglende handling
At patienten selv kommer med løsningsforslag
f.
g.
At patienten selv vælger en behandlingsplan blandt dine forslag
h.
At patienten kan udtrykke sin opfattelse
af sygdomssituationen og sin forståelse
for behandlingsplanen
Lidt
enig
Hverken
enig eller
uenig
Lidt
uenig
Helt
uenig
Sjældent
Aldrig
Af mulighederne "a - h" nævn de 3, som du finder væsentligst
5. Hvilke muligheder anvender du for at motivere en patient til ændring af adfærd?
Altid
a.
Aktiv lytning
b.
Forbereder patienten på behandlingsmuligheder inden valg af løsning på
problemet
Klare argumenter for ændring af adfærden, som tydeliggør konsekvenserne af
fortsat uændret adfærd
c.
d.
Klargør for patienten hvad strategien er
i forhold til tidsaspektet
e.
Fremhæver patientens ressourcer
f.
Klargør hvilke fordele og ulemper
patienten selv opfatter ved sygdommen
og behandlingsplanen
g.
Viser patienten empati, støtte og respekt
h.
Fokuserer på det positive ved patientens
adfærd i forhold til sygdomsforløb
Ofte
Ind
imellem
Af mulighederne "a - h" nævn de 3, som du finder væsentligst
43806
Side 4
6. Hvad er for dig "Den vanskelige patient"?
Helt
enig
a. Det er patienten, der kommer igen og
igen med det samme problem, som der
ikke er nogen løsning på (fx diabetespatienten med dårligt reguleret sukkersyge, der mener, at der må være noget
medicin, der er mere effektivt)
Lidt
enig
Hverken
enig eller
uenig
Lidt
uenig
Helt
uenig
b. Det er patienten, der kommer igen og
igen fordi hun ikke gør det, der skal til for
at løse problemet, men forventer, at du
løser hendes problemer (fx diabetespaienten, der fortsætter med at spise
usundt og ikke taber i vægt)
c. Det er patienten, der altid er skeptisk og
kun er optaget af, hvorfor det er umuligt
at gennemføre de handlinger/adfærdsændringer, der skal til (fx diabetespatienten, der gerne til have hjælp til at
holde op med at spise usundt, men
afviser alle dine forsøg på at hjælpe)
d. Det er patienten, som slet ikke selv kan
forstå, at der en sammenhæng mellem
adfærd og problemer (fx diabetespatienten, der er helt afvisende overfor tanken
om, at hendes ustabile blodsukker ved
kontrol kan have noget med hendes
usunde spisevaner at gøre)
e. Andre? Beskriv situationen.
Skal ikke udfyldes
Forbeholdt kodning
7. Havde du forud for ADDITION-projektet kendskab til principperne i "Den Motiverende Samtale"?
Nej
Ja, fra DSAMs bog "Den motiverende samtale"
Ja, fra Ugeskrift for Læger
Ja, fra Månedsskrift for Praktisk Lægegerning
Ja, fra andre kurser
Andet? Hvis ja. Angiv hvorfra:
Skal ikke udfyldes
Forbeholdt kodning
43806
Side 5
8.
Havde du forud for kurset kendskab til de teknikker, der er forbundet med "Den Motiverende Samtale"?
Nej
Ja, men jeg havde ikke anvendt disse teknikker i praksis
Ja, men jeg havde kun anvendt disse teknikker i begrænset omfang
Ja, disse teknikker indgik i min daglige patientbehandling
Ja,
i høj
grad
9.
Nogenlunde
Hverken
/
eller
I
Nej
begrænset overhovedet
omfang
ikke
Har du efter kurset dannet dig et
overblik over metoderne i "Den
Motiverende Samtale"?
10. Føler du dig efter kurset rustet til
at anvende "Den Motiverende
Samtale" i praksis?
11. Er "Den Motiverende Samtale" i
praksis realistisk?
12. Hvad er din opfattelse af metoderne i "Den Motiverende Samtale"?
Helt
enig
a.
De er generelt særdeles velegnede til brug i
almen praksis
b.
De er kun egnede til specielle situationer/
patienter
c.
De er mere effektive end traditionel
information og rådgivning
d.
De er for tidsrøvende
e.
Patienterne vil have, at lægen fortæller,
hvad der skal gøres
f.
Det er svært at ændre mine indøvede
rutiner og metoder
g.
Jeg har ikke haft patienter, der passer
til "Den Motiverende Samtale"
Lidt
enig
Hverken
enig eller
uenig
Lidt
uenig
Helt
uenig
43806
Side 6
13. Har du efter kurset anvendt nogle teknikker fra "Den Motiverende Samtale"?
Nej
Gå til spørgsmål 14
Ja, jeg har anvendt en eller flere af følgende teknikker, beskrevet i 13a - 13g:
13a. PEARLS (Partnerskab, Empati, Accept, Respekt, Legitimering, Støtte)
Nej
Ja
Hvis ja, hvor ofte anvender du PEARLS?
Altid
Ofte
Indimellem
Sjældent
Aldrig
Hvis ja, er du enig i, at metoden er velegnet til almen praksis?
Helt enig
Lidt enig
Hverken enig eller uenig
Lidt uenig
Helt uenig
13b. AKTIV LYTTEN
Nej
Ja
Hvis ja, hvor ofte anvender du AKTIV LYTTEN?
Altid
Ofte
Indimellem
Sjældent
Aldrig
Helt enig
Lidt enig
Lidt uenig
Helt uenig
43806
13c. DEN VISUELLE ANALOGSKALA
Nej
Side 7
Ja
Hvis ja, hvor ofte anvender du DEN VISUELLE ANALOGSKALA?
Altid
Ofte
Indimellem
Sjældent
Aldrig
Helt enig
Lidt enig
Lidt uenig
Helt uenig
13d. FORANDRINGENS HJUL
Nej
Ja
Hvis ja, hvor ofte anvender du FORANDRINGENS HJUL?
Altid
Ofte
Indimellem
Sjældent
Aldrig
Helt enig
Lidt enig
Lidt uenig
Helt uenig
43806
Side 8
13e. BALANCESKEMAET (opstilling af fordele og ulemper ved at fortsætte adfærd)
Nej
Ja
Hvis ja, hvor ofte anvender du BALANCESKEMAET?
Altid
Ofte
Indimellem
Sjældent
Aldrig
Helt enig
Lidt enig
Lidt uenig
Helt uenig
13f. ROKKE VED AMBIVALENSEN
Nej
Ja
Hvis ja, hvor ofte anvender du "AT ROKKE VED AMBIVALENSEN"?
Altid
Ofte
Indimellem
Sjældent
Aldrig
Helt enig
Lidt enig
Lidt uenig
Helt uenig
43806
13g. EMPOWERING / ROS
Nej
Side 9
Ja
Hvis ja, hvor ofte anvender du EMPOWERING / ROS?
Altid
Ofte
Indimellem
Sjældent
Aldrig
Helt enig
Lidt enig
Lidt ueig
Helt uenig
Helt
enig
14. "Den Motiverende Samtale" er bedre
end mine nuværende arbejdsmetoder
Lidt
enig
Hverken
enig eller
uenig
Lidt
uenig
Helt
uenig
15. Jeg kan ikke omstille mine indarbejdede
rutiner og implementere "Den
Motiverende Samtale"
16. Det kan betale sig at skifte abejdsmetode
17. De pædagogiske redskaber / teknikker
fra kurset hjælper mig i patientbehandlingen
18. Har du oplevet, at samtalen flyttede
noget konkret ved patientens adfærd?
Beskriv:
Skal ikke udfyldes
Forbeholdt kodning
19. Hvad skal der til, for at du vil anvende "Den
Motiverende Samtale" i større omfang?
Beskriv:
Skal ikke udfyldes
Forbeholdt kodning
Mange tak for hjælpen
43806
Appendix D
Registreringsblanket for praktiserende læger
CRF 4: Tid 0
Ydernummer:
Lægeinitialer:
-
Patientens personnummer:
- 2 0 0
-
Dato:
Dag
Blodtryk:
Løbenummer
Måned
År
- Personen skal være siddende og have været hvilende i 10 minutter
- Hvis BT > 120/80 gentages BT efter 5 minutter. Skriv det lavest
målte BT
- Der anvendes en bred manchet, hvis omkredsen af armen > 32 cm
Vægt:
,
kg
Fodundersøgelse:
Systolisk
Diastolisk
Personen vejes uden overtøj eller sko
Højre fod
Ja
Nej
Venstre fod
Ja
Nej
Er der sår på:
Medicin:
Notér navn og mængde på den medicin, som patienten har indtaget dagligt gennem den sidste måned
1.
2.
3.
4.
5.
Hvis patienten får mere medicin, fortsæt på bagsiden.....
Tobaksoplysninger:
Forbeholdt instituttet
Patienten ryger ikke
Cigaretter
Antal pr. dag
Cigarer/cerutter
Antal pr. dag
Patienten ryger pibe
Pakker (50 g) pr. uge
14991
Registreringsblanket for praktiserende læger
CRF 4: Tid 0
Løbenummer
Til patienten
INFORMERET SAMTYKKE
Jeg accepterer deltagelse i projektet som beskrevet i udleveret brev. Jeg kan til enhver tid
trække min deltagelse tilbage, uden at dette på nogen måde vil forringe forholdet til min
praktiserende læge eller påvirke dennes undersøgelse eller behandling af mig i negativ
retning.
Mit cpr.nr.:
-
Dato
Underskrift
14991
Registreringsblanket for læger CRF 6: Tid 6 måneder
Interventionsgruppen
Løbenummer
Side 1
Ydernummer:
Lægeinitialer:
-
- 2 0 0
-
Dato:
Dag
Måned
År
,
mmol/l
Blodglukose måles på kapillært blod og analyseres ved brug af HemoCue-apparat
fBG:
,
mmol/l
HbA1c:
,
%
rBG:
og/eller
Blodtryk:
Vægt:
målte BT
,
kg
Systolisk
Diastolisk
Hvor mange gange har patienten haft hypoglykæmifølinger inden for den sidste uge
(symptomer på hypoglykæmi, hvor patienten kunne klare situationen selv ved at drikke eller spise
noget)?
antal gange
Hvor mange gange har patienten i løbet af de sidste 4 uger haft så svær hypoglykæmi,
at det krævede hjælp fra andre?
antal gange
9408
Løbenummer
Side 2
Hvilken behandling får patienten?
1) Diæt
Nej
Ja
2) Oral diabeticum
Nej
Ja,
Hvis Ja, navn og dosering:
Døgndosis
1.
,
mg
2.
,
mg
3.
,
mg
3) Insulin
Nej
ATC-kode
Skal ikke
udfyldes.
Forbeholdt
instituttet
ATC-kode
Skal ikke
udfyldes.
Forbeholdt
instituttet
ATC-kode
Skal ikke
udfyldes.
Forbeholdt
instituttet
ATC-kode
Skal ikke
udfyldes.
Forbeholdt
instituttet
Ja,
Hvis Ja, type og dosering:
Døgndosis
1.
IE
2.
IE
3.
IE
4) Antihypertensiva
Nej
Ja,
Døgndosis
1.
,
mg
2.
,
mg
3.
,
mg
5) Lipidsænkende medicin
Nej
Ja,
Døgndosis
1.
mg
2.
mg
3.
mg
9408
6) Antitrombotica
Nej
Løbenummer
Side 3
Ja,
Døgndosis
ATC-kode
1.
mg
2.
mg
3.
mg
Tobaksoplysninger:
Skal ikke
udfyldes.
Forbeholdt
instituttet
Cigaretter
Antal pr. dag
Cigarer/cerutter
Antal pr. dag
Er der ved denne konsultation
Talt om
Ja
Nej
Medgivet pt. pjecer om
Ja
Nej
Generel information om Type 2 diabetes?
Mad og alkohol?
Motion?
Tobaksophør?
Den diabetiske fod?
Insulinbehandling?
Andet materiale?
(Skriv venligst hvilket)
Har patienten ved denne konsultation lånt videoen
Ja
Nej
"Fedt nok"
"Mads og Birte"
9408
Registreringsblanket for læger CRF 8: Tid 1 år
Ydernummer:
Løbenummer
Side 1
Lægeinitialer:
-
- 2 0 0
-
Dato:
Dag
Måned
År
,
mmol/l
fBG:
,
mmol/l
HbA1c:
,
%
rBG:
og/eller
Blodtryk:
målte BT
Vægt:
,
Systolisk
Diastolisk
kg
Hvor mange gange har patienten haft hypoglykæmifølinger inden for den sidste uge
(symptomer på hypoglykæmi, hvor patienten kunne klare situationen selv ved at drikke eller spise
noget)?
antal gange
Hvor mange gange har patienten i løbet af de sidste 4 uger haft så svær hypoglykæmi,
at det krævede hjælp fra andre?
antal gange
Fodundersøgelse:
Højre fod
Ja
Nej
Venstre fod
Ja
Nej
Er der sår på:
19287
Løbenummer
Side 2
Hvilken behandling får patienten?
1) Diæt
Nej
Ja
2) Oral diabeticum
Nej
Ja,
Døgndosis
1.
,
mg
2.
,
mg
3.
,
mg
3) Insulin
Nej
ATC-kode
Skal ikke
udfyldes.
Forbeholdt
instituttet
ATC-kode
Skal ikke
udfyldes.
Forbeholdt
instituttet
ATC-kode
Skal ikke
udfyldes.
Forbeholdt
instituttet
ATC-kode
Skal ikke
udfyldes.
Forbeholdt
instituttet
Ja,
Døgndosis
1.
IE
2.
IE
3.
IE
4) Antihypertensiva
Nej
Ja,
Døgndosis
5)
1.
,
mg
2.
,
mg
3.
,
mg
Lipidsænkende medicin
Nej
Ja,
Døgndosis
1.
mg
2.
mg
3.
mg
19287
6) Antitrombotica
Nej
Løbenummer
Side 3
Ja,
Døgndosis
ATC-kode
1.
mg
2.
mg
3.
mg
Skal ikke
udfyldes.
Forbeholdt
instituttet
Tobaksoplysninger:
Cigaretter
Antal pr. dag
Cigarer/cerutter
Antal pr. dag
19287