Reviews and feature articles
Brief motivational interviewing as a clinical strategy to promote asthma medication adherence

https://doi.org/10.1016/j.jaci.2007.08.017Get rights and content

Patient-centered approaches are associated with better patient retention and treatment outcomes, without increased time and cost. Motivational interviewing (MI) is a patient-centered counseling approach that can be briefly integrated into patient encounters and is specifically designed to enhance motivation to change among patients not ready to change. Existing asthma management approaches (eg, education and self-management) increase resistance among patients not ready or willing to follow medical recommendations. MI helps patients resolve their ambivalence about behavior change and builds their intrinsic motivation before providing education. Although MI overlaps with patient-centered communication, it additionally includes some concrete motivational strategies that can be briefly and easily implemented in medical settings (eg, setting an agenda, assessing motivation and confidence for change, helping the patient weigh the costs and benefits of change, and providing medical advice and health feedback). Reflective listening is used to help patients clarify their ambivalence and diffuse resistance. MI has been shown to be efficacious across a wide variety of health behavior change areas. This article will describe the method and spirit of MI as applied to asthma management by reviewing the principles of MI, brief MI strategies to motivate medication adherence, the evidence base for MI, and the costs and benefits of building MI into clinical practice.

Section snippets

MI: basic principles

MI involves 2 key aims: (1) building patients' intrinsic motivation to adopt health recommendations and (2) resolving patients' ambivalence about behavior change (eg, adherence).21 In MI intrinsic motivation is strengthened by discussing how change is consistent with the patient's own values and goals.26 For example, if a patient loves to play basketball, the HCP asks how taking his or her asthma medication can help him or her play better. Intrinsic motivation is also increased by having the

Patient-practitioner communication strategies: foundation of MI

An important goal of MI is to establish a comfortable and noncoercive atmosphere so that patients feel free to discuss their feelings about the recommended treatment. This is particularly relevant for asthma medication, about which patients might falsely self-report adherence.3 Creating a nonjudgmental atmosphere enhances the likelihood of accurate self-report.30 Four communication components engender MI spirit: open-ended questions, affirmations, reflective listening, and summary statements

Setting an agenda

Koning et al47 found that one third of patients with asthma or chronic obstructive pulmonary disease desired greater participation in decision making about their treatment. Patients with asthma who report active participation in treatment decisions are more adherent.48 However, patients might be hesitant to voice their agendas without being prompted.49 MI provides a framework to actively solicit patients' agendas. The HCP provides a menu of options for discussion and lets the patient decide

The effectiveness of MI as a patient-centered method

MI overlaps with patient-centered medicine in that both approaches involve patient acceptance, collaboration, open-ended questions, and listening skills. MI uses patient-centered communication but also includes a set of strategies to help move patients toward change. Patient-centered approaches improve health outcomes for a variety of conditions, such as asthma,62 diabetes,28, 63 obesity,64 and blood pressure.65, 66 In asthma management physicians trained in patient-centered communication have

Building MI into clinical practice

Although HCPs might be concerned about the time it takes to integrate MI into a busy clinical practice, studies have shown minimal time differences (typically no more than 2 minutes) between delivery of patient-centered counseling and delivery of standard approaches.89 One study of primary care physicians found that MI took an average of 9.69 minutes.90 The small amount of extra counseling time might be well spent, given that patient-centered approaches are associated with better adherence,

Conclusion

Patient-centered approaches improve the HCP's performance, patient satisfaction, and health outcomes without an increased burden of time and cost. MI is a patient-centered approach that is effective for promotion of health behavior across a wide variety of areas. MI involves fostering practitioner-patient communication and using brief strategies to help patients resolve their ambivalence about change and build intrinsic motivation for change. MI strategies have been modified such that HCPs can

References (95)

  • R.S. Irwin et al.

    Patient-focused care: using the right tools

    Chest

    (2006)
  • T. Boardman et al.

    Using motivational interviewing with smokers: do therapist behaviors relate to engagement and therapeutic alliance?

    J Subst Abuse Treat

    (2006)
  • J.N. Fuertes et al.

    The physician-patient working alliance

    Patient Educ Counseling

    (2007)
  • T.B. Moyers et al.

    Therapist influence on client language during motivational interviewing sessions

    J Subst Abuse Treat

    (2006)
  • D.J. Bem

    Self-perception theory

  • W.R. Miller et al.

    Two-year follow-up of bibliotherapy and therapist-directed controlled drinking training for problem drinkers

    Behav Psychother

    (1983)
  • C.V. Chambers et al.

    Health beliefs and compliance with inhaled corticosteroids by asthmatic patients in primary care practices

    Respir Med

    (1999)
  • N.C. Stott et al.

    Professional responses to innovation in clinical method: diabetes care and negotiating skills

    Patient Educ Counseling

    (1996)
  • B. Borrelli et al.

    Home health care nurses as a new channel for smoking cessation treatment: outcomes from project CARES (Community-nurse Assisted Research and Education on Smoking)

    Prev Med

    (2005)
  • S. Rollnick et al.

    Helping smokers make decisions: the enhancement of brief intervention for general medical practice

    Patient Educ Counseling

    (1997)
  • C.S. Lee et al.

    Do patient intervention ratings predict alcohol related consequences?

    Addict Behav

    (2007)
  • B.G. Bender et al.

    Factors influencing patient decisions about the use of asthma controller medication

    Ann Allergy Asthma Immunol

    (2007)
  • L.E. Boulware et al.

    An evidence-based review of patient-centered behavioral interventions for hypertension

    Am J Prev Med

    (2001)
  • C. DiIorio et al.

    Using motivational interviewing to promote adherence to antiretroviral medications: a pilot study

    J Assoc Nurses AIDS Care

    (2003)
  • J.L. Treasure et al.

    Engagement and outcome in the treatment of bulimia nervosa: first phase of a sequential design comparing motivation enhancement therapy and cognitive behavioural therapy

    Behav Res Ther

    (1999)
  • V. DiLillo et al.

    Incorporating motivational interviewing into behavioral obesity treatment

    Cogn Behav Pract

    (2003)
  • A.G. Weinstein

    Should patients with persistent severe asthma be monitored for medication adherence?

    Ann Allergy Asthma Immunol

    (2005)
  • National Heart, Lung, and Blood Institute

    National Asthma Education and Prevention Program. Expert panel report 2: guidelines for the diagnosis and management of asthma

    (1997)
  • J. Sherman et al.

    Adherence to oral montelukast and inhaled fluticasone in children with persistent asthma

    Pharmacotherapy

    (2001)
  • J.A. Krishnan et al.

    Corticosteroid use after hospital discharge among high-risk adults with asthma

    Am J Respir Crit Care Med

    (2004)
  • E.L. McQuaid et al.

    Medication adherence in pediatric asthma: reasoning, responsibility, and behavior

    J Pediatr Psychol

    (2003)
  • A.J. Apter et al.

    Adherence with twice-daily dosing of inhaled steroids. Socioeconomic and health-belief differences

    Am J Respir Crit Care Med

    (1998)
  • L.J. Bauman et al.

    Relationship of adherence to pediatric asthma morbidity among inner-city children

    Pediatrics

    (2002)
  • E. Hing et al.

    National ambulatory medical care survey: 2004 summary

    Adv Data

    (2006)
  • J.P. Guevara et al.

    Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis

    BMJ

    (2003)
  • J.R. Smith et al.

    The Coping with Asthma Study: a randomised controlled trial of a home based, nurse led psychoeducational intervention for adults at risk of adverse asthma outcomes

    Thorax

    (2005)
  • C. Put et al.

    Evaluation of an individualised asthma programme directed at behavioural change

    Eur Respir J

    (2003)
  • W. Miller et al.

    Motivational interviewing: preparing people for change

    (2002)
  • J.O. Prochaska et al.

    Stages and processes of self-change of smoking: toward an integrative model of change

    J Consult Clin Psychol

    (1983)
  • K. Schmaling et al.

    A randomized controlled pilot study of motivational interviewing to change attitudes about adherence to medications for asthma

    J Clin Psych Med Settings

    (2001)
  • S. Rollnick et al.

    Health behavior change: a guide for practitioners

    (1999)
  • W. Miller

    Motivational interviewing in service to health promotion

    Am J Health Promot

    (2004)
  • S. Greenfield et al.

    Expanding patient involvement in care. Effects on patient outcomes

    Ann Intern Med

    (1985)
  • S. Greenfield et al.

    Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes

    J Gen Intern Med

    (1988)
  • M. Stewart et al.

    The impact of patient-centered care on outcomes

    J Fam Pract

    (2000)
  • S.A. Flocke et al.

    Relationships between physician practice style, patient satisfaction, and attributes of primary care

    J Fam Pract

    (2002)
  • W.R. Miller et al.

    Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles

    J Consult Clin Psychol

    (1993)
  • Cited by (85)

    • Development of a motivation-based tool to facilitate individualized self-management interventions for adolescents with asthma

      2022, Patient Education and Counseling
      Citation Excerpt :

      It involves leveraging a patient’s intrinsic motivation to adopt recommended treatment and medication regimens as well as helping the patient to resolve ambivalence about behavior change. The overall idea is to relate the change to the patient’s values and goals [13,14]. A pilot study of black inner-city adolescents showed that motivational interviewing is feasible and acceptable in this patient population.

    • CBT-I in patients with obstructive sleep apnea

      2022, Adapting Cognitive Behavioral Therapy for Insomnia
    • Cystic fibrosis

      2020, Adherence and Self-Management in Pediatric Populations
    • Where does health communication technology fit into allergy practice?

      2018, Annals of Allergy, Asthma and Immunology
    View all citing articles on Scopus

    Supported in part by grants R01 HL062165-06 (BB) and HL079301 and HL075344 (KAR).

    Disclosure of potential conflict of interest: B. Borrelli has consulting arrangements with and has received grant support from the National Institutes of Health. A. Weinstein has patent licensing arrangements with Asthma Management Systems and is employed by Asthma and Allergy Care. The rest of the authors have declared that they have no conflict of interest.

    View full text