Training Providers in Motivational Interviewing to Promote Behavior Change

INTRODUCTION

Motivational Interviewing (MI) is a highly specified behavior change communication approach to improve patient-provider relationships and care outcomes.^1,2 MI is a goal-oriented style of collaborative communication; in the delivery of MI, particular attention is given to the specified language of change. This MI language is crafted to strengthen patient’s motivation and commitment to a behavior change goal by eliciting and exploring the patient’s personal reasons for change which is done within a non-stigmatizing and non-judgmental atmosphere of acceptance and compassion.³ MI has been shown to promote behavior change and treatment engagement across multiple behaviors, in multiple formats, and across multiple disciplines.^4-6 Reviews of MI’s mechanisms of change have concluded that clients’ (patients’) motivational statements about their own desire, ability, reasons, need for, or commitment to behavior change (referred to as “change talk”) during MI interactions consistently predicts patient behavior change.^7,8 This predictive value, along with MI’s emphasis on autonomy support and ability to address apathy toward behavior change, makes MI, tailored for adolescents and youth,⁹ an optimal evidence-based approach to scale-up across pediatric and emerging adult care delivery settings. MI is already embedded within clinical guidelines for human immunodeficiency virus (HIV) care and HIV risk reduction in the United States;¹⁰ yet, scale-up and wide spread adoption has been inconsistent. Considering the promise of MI, including data indicating that MI-based interventions, when tailored and delivered with fidelity, positively impact the health and well-being of adolescents and youth, we aim to (1) offer an orientation to MI in pediatric, adolescent, and emerging adult contexts, (2) share examples of MI-based interventions that successfully targeted behavior change leading to enhanced HIV-related outcomes among adolescents and emerging adults that can be extended, adapted, and applied to non-HIV environments, and (3) describe considerations relevant to the successful delivery of MI that are pertinent to researchers and providers, alike. In combination, these sets of information offer a comprehensive primer on youth-focused MI and MI delivery to address health outcomes among adolescents, youth, and emerging adults.

COMPONENTS OF MOTIVATIONAL INTERVIEWING

While MI can seem nebulous, it is actually highly specified, includes multiple well-defined components, and incorporates various processes to address a range of patient responses. MI is defined by three key qualities:^9,11 (1) MI leverages a guiding communication style that balances following the patient through active and attentive listening and offers direction through the provision of advice and information. (2) MI is crafted with attention to empowerment; patients are empowered to change by eliciting their own personal meaning, assessing importance of the change, and reflecting honestly on their personal capacity for change. (3) MI is based on respect and embraces the notion that patients have autonomy, and that autonomy must be honored. These qualities can balance the power differential between providers and patients wherein the patient’s priorities and wishes are honored in the course of their care. In combination, these three key qualities inform the spirit of MI.

This MI spirit, a concept central to MI, is informed by partnership, evocation, acceptance, and compassion.^9,12 MI is a collaborative process built upon a mutually respectful partnership. While the MI-trained provider is an expert in behavior change, the youth living with HIV (YLHIV) is responsible for changes that affect their own lives and well-being. MI evokes personal priorities, beliefs, and values to examine why the patient wants to change. MI adopts an accepting and non-judgmental stance centering on the patient’s path to change based upon their own experiences and personal characteristics, while concurrently respecting the patient’s personal autonomy to make decisions and choices. This commitment to centering the patient exemplifies a compassionate approach wherein welfare and well-being are paramount, and the path to change is personalized.

MI is informed by four fundamental processes that describe the bi-directional patient-provider conversation flow:^3,9,11 engaging, focusing, evoking, and planning. When engaging, it is imperative to establish a functional relationship with the patient through careful listening and sincere understanding leading to the provider being able to accurately reflect the patient’s experience and perspectives while concurrently affirming the patient’s strengths and providing autonomy support. In the process of focusing, the provider and patient negotiate a change agenda built upon a shared purpose; doing this gives the provider permission to guide current and subsequent conversations into the agreed upon direction for change. During evoking, the provider graciously assists the patient to name their reasons for seeking change by eliciting motivations and thoughts. Ambivalence towards behavior change is normalized, examined without critique or judgement and, therefore, has the potential to be resolved. Planning encompasses the mechanisms, or how, of change. During planning, the provider supports the patient to consolidate commitment and craft a personalized behavior change roadmap.

MI, more often than not, is referred to as a method of communication rather than an intervention in and of itself. MI can be used on its own or in combination with other treatment or behavioral approaches. Because MI is multicomponent, including defined processes and core skills, it can act as a framework for behavior change interventions. MI has been developmentally and culturally tailored for youth in diverse contexts.⁹ Our group specifically tailored MI for youth HIV contexts using communication science methods to analyze real records of youth-pediatrician interactions in an adolescent HIV clinic.¹³ Figure 1 illustrates MI’s mechanisms of change specifically for YLHIV by demonstrating which provider communication behaviors are most critical in this context.

Figure 1.

Integrating communication science, implementation science, and Motivational Interviewing

Adapted with permission.¹

1. Naar SS, Mariann. Motivational Interviewing with Adolescents and Young Adults. Routledge; 2021.

YOUTH ARE RECEPTIVE TO MOTIVATIONAL INTERVIEWING

Adolescence and emerging adulthood (together included in the broad categorization of youth) is a time of neurocognitive developmental, personal growth, and social experimentation.¹⁴ Youth who acquired HIV through perinatal exposure can become fatigued with their daily medication routine and frequent clinic visits, contend with mental health issues, and have to navigate disclosure concerns during sexual debut, and therefore, may respond by reductions in antiretroviral adherence and may resist recommendations from those perceived as holding power and authority.^15-17 Additionally, behaviors that put a young person at risk of being exposed to HIV, such as unprotected sex and substance use, peak during this period. During adolescence and emerging adulthood, poor health behaviors, such as living a sedentary lifestyle and inconsistent self-management of medications, can set the stage for lifelong health problems.¹⁸ Social conflicts with parents, peers, teachers, and providers intersect with biological factors, such as changes in hormones and potentially coping with health conditions, exacerbating the known challenges of this life stage. Since MI is a non-judgmental communication strategy with built-in autonomy support that is designed to navigate ambivalence, a hallmark of adolescence, MI is a rare framework that has successfully engaged youth to work toward promoting positive behavior change.⁹

Emerging adulthood is a critical period for developing healthy habits in the context of increased cognitive control. The transition from late adolescence to emerging adulthood is marked by anatomical maturation of various brain regions that are associated with cognitive control.¹⁹ Studies suggest that YLHIV, regardless of mode transmission, may at higher risk for disruptions in this maturation process from a highly impulsive state of being toward being more controlled with the ability to weigh consequences of actions; thus, ensuring that YLHIV stay engaged in care is critical to their well-being.^19,20 Considering this transitory development period, approaches that embed autonomy support, such as MI, have the greater potential to keep YLHIV engaged in care as compared to interventions that exclusively deliver content or coaching.

MOTIVATIONAL INTERVIEWING FOR HIV AND RELATED OUTCOMES

Among YLHIV, MI has indicated positive impact on an array of outcomes including but not limited to reducing substance abuse, promoting HIV knowledge, improving antiretroviral medication adherence, reducing viral load, and maintaining condom use over time.^5,21-24 For youth at elevated risk of contracting HIV, MI has effectively promoted HIV counseling and testing, reductions in substance use, and routine condom use; MI’s ability to deeply engage with youth is one of the reasons MI-based interventions to promote PrEP uptake have been developed and are being tested.^25-27 To our knowledge, MI is the only evidence based intervention that has been tested across different points of the youth HIV continuum, has been shown effective in reducing HIV-related stigma (a notable barrier to care), and has been successfully implemented to support behavior change among YLHIV across an array of diverse geographic and clinical settings.^21,22

Furthermore, tailored interventions to promote autonomy supportive behavior change are particularly needed when working with stigmatized or minoritized YLHIV (including adolescents and emerging adults) who have disproportionally higher rates of HIV infection but lower rates of linkage and retention in care compared to older adults who are living with HIV.^24,28 Failure to successfully link to care and thereafter be retained, means that the full benefits of antiretroviral initiation to obtain early viral suppression, leading to benefit in the individual’s health as well as reduced risk of transmission, are unrealized.²⁹

MI provides a highly specified framework for improving patient-provider communication and promoting behavior change, and high quality patient-provider relationships are associated with greater likelihood of PLHIV receiving antiretroviral therapy, adhering to regimens, attending care appointments, and having lower viral loads.^21,30,31 Studies have found that MI was effective in demonstrating positive impact across the entire youth HIV continuum of care.^21,30,31 An evaluation of five studies on MI’s impact on highly active antiretroviral therapy regimens found that the majority of these studies indicated that MI increased adherence rates; two or the five studies noted significant decreases in viral load, and one of the five studies found that MI was associated with an increase in CD4 cell count.³² Under the auspices of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) funded Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN), multiple MI studies have been conducting with YLHIV and youth who are at risk of contracting HIV; evidence consistently indicates that delivering MI improves HIV prevention and treatment outcomes.³³

Mechanistic studies of MI show correlations between provider behaviors and patient change talk, defined as the youth’s statement of desire, ability, reason, need, or commitment to change behavior,³⁴ all of which are necessary to promote behavior change for improved HIV outcomes among YLHIV. MI has also been shown to reduce stigmatizing attitudes towards mental illness and substance abuse, conditions that are of particular importance when treating adolescents and emerging adults.^35,36 See Figure 2 for an illustration of how provider communication behaviors promote change talk among youth patients which then influences behavior change.^13,37

Figure 2.

Motivational Interviewing communication strategies linked to patient change talk

Note: Percentages represent the likelihood of producing change talk. “Provider questions phrased to elicit change talk were followed by a patient change talk statement more often than other provider communication strategies. Closed questions phrased to elicit change talk were followed by change talk 67% of the time and open questions were 58% of the time. In addition, reflections of patient change talk (43%), affirmations (28%), statements emphasizing the patient’s decision-making autonomy (15%), and information presented in a patient-centered manner (11%) were also more likely to elicit a patient change talk statement. All p ≤ .0001.”¹

1. Carcone AI, Naar S, Clark J, MacDonell K, Zhang L. Provider behaviors that predict motivational statements in adolescents and young adults with HIV: a study of clinical communication using the Motivational Interviewing framework. AIDS Care. 2020/09/01 2020;32(9):1069-1077. doi:10.1080/09540121.2019.1679709

MOTIVATIONAL INTERVIEWING INTERVENTIONS

MI has been leveraged in the creation of interventions designed to improve HIV-related outcomes among youth. Below, we present summaries on six examples of ATN-affiliated MI-informed interventions to illustrate how MI has been adapted to address HIV outcomes among youth. While not all examples have efficacy data from full scale trials, each offers a unique model of MI. More detailed information on these interventions are provided in Table 1.

Table 1.

HIV interventions that include Motivational Interviewin

Intervention	Study Participants	MI Trainees	Select Outcomes	Trial Type
Healthy Choices1,2	YLHIV aged 16 to 24 years	Community health workers	Antiretroviral medication adherence and alcohol use	Comparative Effectiveness (for clinic or community delivery)
FLEX3	African American YLHIV aged 18 to 24 years with suboptimal levels of physical activity	Paraprofessionals	Strength assessments, number of push-ups, number of curl-ups, chester step, and body mass index (BMI), with HIV viral load	Proof of Concept
SMART4	YLHIV aged 15 to 24; viral load ≥200 copies/mL, prescribed an antiretroviral treatment, and sole owner of a device capable of sending and receiving calls and text messages	Staff who are not licensed providers but have some clinical training	Antiretroviral medication adherence	Sequential Multiple Assignment Randomized Trial
YMHP5,6	YMSM, aged 15 to 24 years at elevated risk for HIV exposure	Master’s level therapists	Substance use and sexual health management	Comparative Effectiveness Type 2 Hybrid Randomized Controlled Trial of the (for clinic or remote delivery)
We Test7	Adolescent male couples, specifically: cis-male gender identity; 15 to 19 years, in a relationship, with a cis-gender male with whom they have or anticipate having sex, and HIV-negative or status unknown.	Community health workers	HIV testing and counseling	Hybrid Type 1 Implementation-Effectiveness Randomized Controlled Trial
TMI8	YLHIV and clinical providers	HIV clinical providers	HIV cascade outcomes from YLHIV and MI fidelity from providers	Stepped Wedge Randomized Controlled Trial

• Healthy Choices,^22,38 based on Motivational Enhancement Therapy (MET)³⁹ is a four-session manualized intervention that combines MI with personalized feedback on patient behavior and goal setting. MET was originally developed to address alcohol abuse among adults and was adapted to target sexual risk practices and substance use among adult men who have sex with men who are living with HIV.⁵ Healthy Choices has shown to reduce sexual risk, alcohol and marijuana use, and HIV-related stigma, while also improving viral load among YLHIV.^22,40-43

• FLEX²³ focuses on the coaching and goal settings aspects of MI. Developed to concurrently improve physical health and HIV outcomes among YLHIV, while considering the socioeconomic and environmental conditions that limit access to gyms, FLEX includes 3-months of high intensity interval training, yoga stretching and breaking, resistance training, with self-monitoring and goal settings related to fitness and HIV targets, all delivered in-home with MI.

• SMART⁴⁴ tests adaptive antiretroviral therapy adherence interventions for YLHIV. Different that traditional intervention trials, SMART tests a series of layered interventions using an Adherence Facilitator to support the YLHIV through processes. Adherence Facilitators were expected to have proficiency in MI and used their MI skills in all communications with YLHIV.

• Young Men's Health Project (YMHP)^27,45 targets HIV risk reduction and substance use among young men who have sex with men (YMSM). YMHP is a manualized structured 4-session intervention using MI and problem-solving skills building. In the original YMHP trial, master’s level therapists were trained in MI with ongoing fidelity monitoring using the Motivational Interviewing Treatment Integrity (MITI) coding system (detailed later in this paper).

• We Test⁴⁶ adapts and delivers video-based content in a dyadic format with an individual-level single session of MI focused on assisting with identification and development of sexual goals and communication skills. A single-session MI intervention was used because this format was previously shown to have the optimal reach among youth at elevated risk for HIV.^47,48

• Tailored Motivational Interviewing (TMI)⁴⁹ is the summation of the growing body of work of MI for youth HIV contexts. While the above described interventions are specified with formal structure and dose, TMI generalizes MI for any HIV-related context, any provider type, any delivery setting or modality, and any HIV prevention or treatment behavior. TMI for HIV has three stated goals: (1) Improve HIV-related self-management for prevention and treatment including other related behaviors such as substance abuse and unprotected sexual activity; (2) Provide developmentally tailored strategies to engage young people, considering that the social and emotional needs of youth differ than those of adults; (3) Train providers from any discipline to integrate MI with fidelity in any setting, from brief 15 minute single sessions to longer multi-session interventions.

LEARNING MI

Several studies suggest that achieving MI competence is difficult for many providers,⁵⁰ and that a lecture or workshop alone is insufficient for providers to deliver MI with fidelity.^51-54 Fidelity refers to adherence to an intervention implementation plan, in this case to MI or an MI-informed intervention, as well as competency in delivering MI in scripted practice, routine care, and thereafter for a sustained period of time. Fidelity is discussed in greater detail later in this paper. In a study of adolescent HIV care providers from different disciplines across 10 clinics in the United States, only 7 percent scored in the intermediate or advanced MI competence range (part of fidelity) utilizing a standardized assessment of simulated patient interactions,⁵⁵ although providers reported receiving some prior MI training.

An array of providers may benefit from developing mastery in MI. Studies have shown that clinical providers, allied health professionals, paraprofessional and support staff, as well as community and outreach workers, can all learn and deliver MI with fidelity.^31,56-58 One model found that training youth peer mentors, who were adolescent men who have sex with men, in MI skills was feasible resulting in trainees exceeding established MI fidelity thresholds.⁵⁶ What appears to be consistent is that trainees who are committed to learning MI, can develop MI skill when trainees are encouraged through the learning process.

Learning MI occurs across eight distinct steps, leading to mastery: (1) understanding the philosophy of MI (inclusive of collaboration, evocation, and autonomy); (2) acquisition of fundamental patient-centered counseling skills; (3) recognizing and reinforcing change talk; (4) developing the ability to ask about, reflect upon, and emphasize statements related to behavior change; (5) reorient one’s views toward resistive behavior as a natural part of the change process; (6) hone skills in behavior change plan development; (7) learn to develop commitment from patients to their change plans, and (8) integrating MI with other interventions.^58-60 Learning MI through these sequential steps is time intensive but can be facilitated through a high-quality MI training program that is tailored to the specific needs of trainees and the demands of their work environments.

MI TRAINERS

Crafting an MI training program, standalone or part and parcel of an intervention package, requires thoughtful consideration. Training often consists of some combination of workshops, boosters, and coaching. All components should be led by a senior-level, expert MI facilitator who will be participating through the whole process from design to sustainment to routinzation into care or practice. Ideally, the lead facilitator is a member of the Motivational Interviewing Network of Trainers (MINT) so that the trainer is an expert on the most up-to-date conceptualizations of MI. Some experienced MI facilitators are not MINT-affiliated; regardless of MINT affiliation, lead facilitators should be up-to-date and proficient in the most current version or formulation of MI. We recommend establishing a training plan that includes the recipient agency evaluating the proposed lead trainer’s MI training experience and if the lead trainer is sufficiently skilled in connecting with the intended audience. The lead trainer may engage more junior facilitators during the process; if this occurs, the lead trainer should be actively involved providing consistent oversight throughout.

IMPLEMNTATION SCIENCE TO GUIDE MI TRAINING

The TMI^49,57 research protocol includes a replicable model for developing a feasible and acceptable training program. TMI is guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework^61,62 as an implementation framework to understand the integration of MI into real-world settings. Under the EPIS model, there are four phases of evidence based practice (EBP) implementation.⁶² The exploration phase involves the recognition of a concern or opportunity for improvement. In TMI, the exploration phase includes a qualitative assessment of potential barriers and facilitators to implementation within the inner and outer contexts as specified by the EPIS model. In Preparation, there is a decision to adopt (and how to adopt) an EBP. In the TMI preparation phase, information about the training on ongoing supports to promote MI learning were developed. During this phase, the team may identify strategies that may overcome barriers to MI training and adoption. Implementation refers to the active integration of the EBP into routine care, whereas Sustainment examines the continued use of the new EBP. MI training occurs in the EPIS implementation phase. After implementation, trainees enter a sustainment phase; assessment feedback halts.

At each of these four stages, EBP implementation is impacted by inner (internal to the organization, e.g., organizational leadership, clinician characteristics), outer (external systems, e.g., political environment, funding and other resources) contextual factors, as well as bridging factors (e.g., community-academic partnerships) and innovation factors (innovation characteristics and perceived fit for the organization).^62,63 Thus, EPIS represents a set of factors likely to influence adoption and implementation in complex service systems such as those involved in implementing EBPs into HIV prevention and treatment.

TRAINING COMPONENTS: WORKSHOPS AND COACHING

Training components may be delivered either face-to-face or virtually, synchronously or asynchronously, as determined in the exploration and preparation phases of EPIS.^49,61 As an evidence-informed example, the TMI training began with a baseline assessment of trainee competence and skill in MI followed with a 10-hour group workshop delivered by a MINT-affiliated facilitator. Workshop length is variable depending on agency needs, but often consists of 5-18 hours of didactic and interactive training including presentations, peer discussions, role plays, reflections, and cooperative learning, spread over 2-3 days. Workshop content can include an orientation to MI, in addition to specified modules.

Informed by prior research,⁶⁴ MI workshops are structured with cooperative learning activities, video examples and behavioral skills acquisition steps (modeling, verbal and behavioral rehearsal, feedback). Cooperative learning is a system for teaching trainees in small group settings, using highly specified instructional strategies to encourage trainees to collaborate in teams and work towards a common goal while teammates encourage each other learn.^64,65 Cooperative learning has three core ideas that are embedded within instructional activities: (1) group work as a method to enhance individual learning and program retention; (2) positive attitudes and optimism toward subject matter and the learning process; and (3) promotion of problem-solving and interpersonal skills. Studies have demonstrated improved learning outcomes when leveraging cooperative learning.

After the completion of the group workshop, training participants engage in ongoing one-on-one coaching. Based upon the TMI model,^49,57 coaching should follow a standardized process: (1) elicit motivation around learning MI; (2) engagement in a scripted standard patient roleplay interaction or discussion of an audio recorded patient interaction; (3) feedback on two highest and two lowest trainee MI proficiency ratings, and (4) standardized experiential activities targeting the lowest ratings to improve MI skills. Providers should complete two mandatory 1-hour individual coaching sessions soon after workshop completion. Thereafter, providers should complete 4 quarterly, brief competence assessments and receive a feedback report.

TRAINING COMPONENT: BOOSTERS

Boosters sessions may be necessary if individual coaching is not feasible in certain settings.⁶⁶ Booster sessions engage trainees in brief workshop sessions that are shorter than full workshops (~4-6 hours) and focus on specific areas of MI skill enhancement. While boosters may be preferred by trainees, they are costly and may not lead to enhanced MI competence. In a study on modes of MI training in the Caribbean, researchers found that boosters did not produce a notable increase in outcomes, but were viewed favorably by trainees.⁶⁶ Booster session, similar to workshops, can be delivered in a range of modalities, and can be coupled with coaching.

CODING FOR FIDELITY

Ensuring MI competence and fidelity are critical to success in real world settings.⁶⁷ Fidelity can include individual and aggregated metrics, such as attendance, workshop completion, submitting of recorded sessions, coaching scheduling, coaching engagement, and so on. Fidelity is also assessed via coding of patient-provider sessions. Audio-recorded, patient interactions and standard role plays are mechanisms to assess competency, and these are evaluated applying a standardized coding scale. Two commonly used scales are the Motivational Interviewing Treatment Integrity (MITI)⁶⁸ and MI Coach Rating Scale (MI-CRS).^9,69

The MITI was developed from the Motivational Interviewing Skill Code (MISC); the MITI reduces the MISC’s length and focuses on the verbal behavior of the trainee, ignoring patient responses in the coding process.⁶⁸ The MITI tool is scientifically reliable and valid enabling use across different settings. Two components are included in the MITI: global variables and behavior counts. Global ratings reflect the coder's overall impression of how well or poorly a trainee performed in a certain element of MI practice, rated on a five point Likert scale. Behavior counts capture the trainee’s verbal behaviors on appropriate practice of MI.

The MI-CRS has been tailored for young populations, and is therefore preferred in the context of MI delivery for youth.⁶⁹ The MI-CRS consists of 12 items rated on a 4-point scale (Beginner, Novice, Intermediate, Advanced) representing essential MI components such as a collaborative stance, autonomy support, open questions to elicit motivational language, reflections of change talk, affirmations, cultural humility, and summaries. To apply the MI-CRS, a trained coder will review the audio-recorded or role-play session and code sections using this framework. Trainees receive an auto-generated report based on scores, with recommendations for practice activities.

Regardless of if the MI-CRS or MITI is used to assess trainee’s MI capability, it is important to capture the following elements prior to the delivery of any training: (1) baseline competence in MI by trainees to measure growth and impact, if any, of training package, (2) identification of which and what (audio recorded or role plays) samples of MI sessions will be collected and evaluated; (3) determination of who will conduct the coding and assessment, and (4) making a decision on how scored results be reported back to the trainees.

ORGANIZATIONAL FACTORS AFFECTING IMPLEMENTATION

Implementation science is the study of methods and factors influencing the translation of research and other EBPs into routine care.⁷⁰ Multiple implementation theories and models have been proposed for the prediction or explanation of the process for adopting and sustaining evidence-based practices such as MI. Determinant models originating from child welfare and mental health fields may be particularly pertinent for the HIV field because of the similar ways in which social context influences program delivery to youth and the adoption of new practices by the clinical care providers.

Our analysis of qualitative interviews with over 100 providers from adolescent HIV clinics across the United States suggested several organizational factors associated with adherence to an MI training program designed to improve MI fidelity.^49,71,72 Adherence to the MI training program was associated with flexibility in adapting MI to the particularly clinic setting. That is, clinics with high adherence appeared to be more optimistic about the MI implementation strategies fitting into their setting, to have more innovative ideas about handling implementation barriers, and to have a deeper understanding of the EBP and the needs of patients than providers at clinics with low adherence. Clinics who struggled with adherence discussed funding as a primary trigger of turnover and losing staff who had more experience with MI and were more likely to report policy environments that were more restrictive and autocratic in how services are delivered and documented. Clinics with high adherence to implementation strategies appeared to be more autonomous and had greater flexibility with service delivery. They also reported more coping strategies with routine job stress such as maintaining work-life balance and using humor in the workplace. Finally, there are several components of leadership that appeared to be relevant to uptake of implementation strategies including autonomy supportive leadership with buy-in and MI champions at multiple levels of management.

SUMMARY

Motivational Interviewing (MI) is a highly specified behavior change communication approach to improve patient-provider relationships and care outcomes.^1,2 There is ample evidence to indicate MI’s positive effects on HIV-related outcomes among YLHIV and youth who are at higher risk of HIV exposure;^21,22,57 however, ensuring fidelity to MI can be challenging, since MI is multicomponent including multiple processes, making it difficult to learn and embed into routine practice.^9,11 We suggest that the TMI model of training, informed by the EPIS framework,^62,63 is ideal for HIV settings that serve adolescent and young adults.^49,57 The TMI model of training includes a workshop followed by ongoing tailored coaching; coaching occurs through the evaluation of recorded patient sessions or standard role plays, coded using the MI-CRS.⁶⁹ To promote the adoption of EBPs, including MI, we suggest that trainings should be tailored to consider organization and bridging factors, as well and inner and outer contexts. The universal inclusion of youth-focused MI in adolescent care delivery settings can make a significant and notable impact on the HIV epidemic and other chronic conditions.

SYNOPSIS.

Motivational Interviewing (MI) is a highly specified behavior change communication approach to improve patient-provider relationships, provider communication, and patient health outcomes. Since MI is built upon a foundation of patient autonomy support, a feature known to positively influence behavior change during adolescence and emerging adulthood, MI is an evidence-based framework that can inform interventions targeting improvements in health outcomes among youth. MI can be difficult to implement with adequate fidelity, since learning MI requires time and commitment from busy providers with competing priorities. This review addresses best practices for implementing MI within adolescent serving medical settings (e.g., pediatrics, family practices, rural health clinics, community health organizations, etc.), including an orientation to MI, examples of efficacious interventions that were developed leveraging MI, and consideration for the design of training programs that include ongoing support to maximize the likelihood of sustainment.

KEY POINTS.

• Motivational Interviewing is a multi-component, highly specified communication strategy that can be applied by providers during clinic sessions or in community settings, to promote behavior change among adolescents, youth, and emerging adults.

• Motivational Interviewing training programs should consider inner and outer contexts, alongside bridging and innovation factors, informed by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

• The Tailored Motivational Interviewing (TMI) model provides an evidence based approach to training; it suggests delivery of 10 hours of group workshop training, personalized individual coaching sessions, and tailored assessment based on MI-CRS coding of standard patient role plays or audio recorded sessions with patients.

• Promoting Motivational Interviewing fidelity is critical to routinizing delivery in clinical settings; embedding Motivational Interviewing into care delivery has the potential to improve youth outcomes across the entire continuum of care.

CLINICAL CARE POINTS.

• Behavior change in resistant adolescents and youth may require multiple Motivational Interviewing sessions to build provider-patient trust and address apathy.

• The Ask-Tell-Ask technique can be leveraged as a standalone strategy when providers feel stuck in a conversation about behavior change.

• Motivational Interviewing training can be as short or as comprehensive, depending on agency needs, priorities, and limitations.

• When assessing motivation and priorities, providers can apply the ruler technique by asking: On a scale from 0 to 10, where 0 means “not at all important” and 10 means “the most important,” how important would you say [behavior change] is for you to? Followed by: 1) Why are you at a [their response] and not a [one point lower]?, and 2) What would it take for you to go from [their response] to [one point higher]?

• If experiencing hostility towards behavior change, providers can affirm that patient’s independence, agency, and autonomy for their own health and decisions.