BACKGROUND/RATIONALE:
Obesity is linked with major health implications in the general population and people with spinal cord injuries and disorders (SCI/D). Implementing provider training and education in patient counseling is important for the prevention and treatment of weight-related problems and to lessen the health risks associated with obesity. This project examined the effectiveness of a training method on the use and acceptance of motivational interviewing (MI) skills, an evidence-based counseling technique that is applicable among a wide range of Spinal Cord Injury Quality Enhancement Research Initiative projects

OBJECTIVE(S):
This project was a pilot study which evaluated provider: (a) MI knowledge; (b) MI competency; (c) satisfaction with training; and (d) perceptions of barriers and facilitators to MI adoption and implementation into practice for Veterans with SCI/D.

METHODS:
Interdisciplinary teams of clinicians from two VA Spinal Cord Injury (SCI) centers participated in sixteen-hour workshops on MI, and then received additional instruction through mock counseling sessions with expert feedback. The mock counseling sessions with simulated patients were audio-recorded and scored using the Motivational Interview Treatment Integrity (MITI) Scale. Individual feedback and tailored coaching to improve MI skills was provided for each of these sessions via telephone by a Motivational Interviewing Network of Trainers trainer. Mock counseling sessions and coaching continued until participants reached basic MI proficiency per MITI thresholds, or until five total sessions were reached. Data was collected from participants at baseline, after the training session, and after the mock counseling sessions to assess MI knowledge and reflective listening skills using the Helpful Response Questionnaire. Post-training, participants also responded to a series of questions, on their satisfaction with five aspects of their MI training experience: training format, its applicability to their work, trainer characteristics, overall experience, and practicing with the simulated patients. Participants were also asked to describe ways to improve each aspect of their training experience. Additionally, semi-structured telephone interviews were conducted to collect information on their training experience, their use of MI in their clinical setting, and to gain insight into perceived barriers and facilitators to adoption of MI in their clinical setting. Interviews were audio-recorded and transcribed verbatim. Interview data were analyzed using constant comparative analysis to assess provider satisfaction with the training and identify common barriers and strategies for overcoming them. The analysis of the qualitative data was conducted to elicit themes, patterns and inconsistencies. Descriptive statistics were computed for all quantitative variables.

FINDINGS/RESULTS:
Nine SCI/D providers (88.9% females) completed the two-day training and all other study procedures. Average scores on the MI knowledge test and reflective listening skills measure were higher after the training session, compared to baseline. MI proficiency, as measured by MITI summary measures, also increased from baseline. At the first counseling session after training, the average values for global therapist rating (M=3.8), reflections to question ratio (M=1.4:1) and percent open questions (M=64%) met MITI thresholds for beginning proficiency. Other MITI categories increased with practice and feedback afforded by the mock counseling sessions. On average, beginning proficiency in percent complex reflections and percent MI adherent giving information were met at the third mock counseling session. No participants met the MITI beginning proficiency thresholds on all measures before the MI training. Two met or exceeded the MITI beginning proficiency thresholds on all measures after the MI workshop. All participants met the MITI beginning proficiency goal after the workshop plus three mock counseling and coaching sessions. Results from the satisfaction survey showed that a majority of providers were moderately or very satisfied with their training experience. On a 1-to7 point scale (1=very dissatisfied, 7=very satisfied) participants reported high satisfaction with the training format, M (SD)=6.7 (0.5); its applicability to their work M (SD)=6.2 (0.3); trainer characteristics M (SD)=6.6 (0.3); overall experience M (SD)=6.5 (0.4); and mock practice sessions M (SD)=6.4 (0.1). Analysis of qualitative interview data showed that the training and its components were well received. Participants viewed MI as a useful tool to draw on in their practice to promote behavior change; some participants also wanted more support as they used it in clinical care. Suggestions for improving the current training format included providing time at the two-day training to talk about MI implementation and incorporation into clinical care as well as adding more follow-up sessions with the trainer to refresh, reinforce and practice MI skills. After completing the training, participants wanted more time to discuss clinical situations and problem solve specific clinical issues and patients with the trainer and their colleagues. Barriers cited include time constraints during in-patient visits, conflicting demands in care, insufficient number of MI trained staff, and lack of an organized approach and tools to assist with obesity management. Perceived facilitators included having more staff from multiple disciplines trained in MI, more consistent use of MI, agreement about what setting is most effective, having more time with patients to use MI, and opportunities to practice and to follow-up and ascertain whether MI counseling is working.

IMPACT:
This pilot study was undertaken to help guide decision making regarding the use of MI as an adjunct to behavioral modification techniques in the VA SCI/D system of care. MI training was well received by the SCI/D providers and they provided valuable feedback on how to facilitate their use of MI. Factors that would impede or facilitate MI adoption in clinical care identified in this study need to be addressed for successful implementation. Results from this study suggest many opportunities for future work in weight management in general, as well as in MI training and delivery for other health conditions. The generalizability of our findings is limited due to the small number of providers who participated. A larger study is needed to confirm the results; this pilot study will form the foundation for the development of a larger-scale study in the SCI/D system of care to assess the efficacy of MI in improving obesity-related outcomes in individuals with SCI/D.

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PUBLICATIONS:

None at this time.

DRA: Brain and Spinal Cord Injuries and Disorders
DRE: Treatment - Comparative Effectiveness
Keywords: none
MeSH Terms: none