Jennifer E. Hettema

Motivational Interviewing for Smoking Cessation: A Meta-Analytic Review.

OBJECTIVE Motivational interviewing (MI) is a treatment approach that has been widely examined as an intervention for tobacco dependence and is recommended in clinical practice guidelines. Previous reviews evaluating the efficacy of MI for smoking cessation noted effects that were modest in magnitude but included few studies. The current study is a comprehensive meta-analysis of MI for smoking cessation. METHOD The meta-analysis included 31 controlled trials with an abstinence outcome variable. Studies with nonpregnant (N = 23) and pregnant samples (N = 8) were analyzed separately. RESULTS For nonpregnant samples, combined results suggest that MI significantly outperformed comparison conditions at long-term follow-up points (dc = .17). The magnitudes of this result represented a 2.3% difference in abstinence rates between MI and comparison groups. All analyses investigating the impact of moderating participant, intervention, and study design characteristics on outcome were nonsignificant, with the exception of studies including international, non-U.S. samples, which had larger effects overall. Several subgroups of studies had significant combined effect sizes, pointing to potentially promising applications of MI, including studies that had participants with young age, medical comorbidities, low tobacco dependence, and, consistent with clinical practice guidelines, low motivation or intent to quit. Effects were smaller among pregnant samples. In addition, significant combined effect sizes were observed among subgroups of studies that administered less than 1 hr of MI and among studies that reported high levels of treatment fidelity. CONCLUSIONS The results are interpreted in light of other behavioral approaches to smoking cessation, and the public health implications of the findings are discussed.

A Pilot Randomized Clinical Trial of Two Medication Adherence and Drug Use Interventions For HIV+ Crack Cocaine Users

BACKGROUND Crack cocaine use undermines adherence to highly active antiretroviral therapy (HAART). This pilot randomized clinical trial tested the feasibility and efficacy of 2 interventions based on the Information-Motivation-Behavioral Skill model to improve HAART adherence and reduce crack cocaine problems. METHODS Participants were 54 adults with crack cocaine use and HIV with <90% HAART adherence. Most participants were African-American (82%) heterosexual (59%), and crack cocaine dependent (92%). Average adherence was 58% in the past 2 weeks. Average viral loads (VL) were detectable (logVL 2.97). The interventions included 6 sessions of Motivational Interviewing plus feedback and skills building (MI+), or Video information plus debriefing (Video+) over 8 weeks. Primary outcomes were adherence by 14-day timeline follow-back and Addiction Severity Index (ASI) Drug Composite Scores at 3 and 6 months. Repeated measure ANOVA assessed main effects of the interventions and interactions by condition. RESULTS Significant increases in adherence and reductions in ASI Drug Composite Scores occurred in both conditions by 3 months and were maintained at 6 months, representing medium effect sizes. No between group differences were observed. No VL changes were observed in either group. Treatment credibility, retention, and satisfaction were high and not different by condition. CONCLUSIONS A counseling and a video intervention both improved adherence and drug problems durably among people with crack cocaine use and poor adherence in this pilot study. The interventions should be tested further among drug users with poor adherence. Video interventions may be feasible and scalable for people with HIV and drug use.

A Randomized Trial of a Hepatitis Care Coordination Model in Methadone Maintenance Treatment

OBJECTIVES We evaluated the efficacy of a hepatitis care coordination intervention to improve linkage to hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination and clinical evaluation of hepatitis C virus (HCV) infection among methadone maintenance patients. METHODS We conducted a randomized controlled trial of 489 participants from methadone maintenance treatment programs in San Francisco, California, and New York City from February 2008 through June 2011. We randomized participants to a control arm (n = 245) and an intervention arm (n = 244), which included on-site screening, motivational-enhanced education and counseling, on-site vaccination, and case management services. RESULTS Compared with the control group, intervention group participants were significantly more likely (odds ratio [OR] = 41.8; 95% confidence interval [CI] = 19.4, 90.0) to receive their first vaccine dose within 30 days and to receive an HCV evaluation within 6 months (OR = 4.10; 95% CI = 2.35, 7.17). A combined intervention adherence outcome that measured adherence to HAV-HBV vaccination, HCV evaluation, or both strongly favored the intervention group (OR = 8.70; 95% CI = 5.56, 13.61). CONCLUSIONS Hepatitis care coordination was efficacious in increasing adherence to HAV-HBV vaccination and HCV clinical evaluation among methadone patients.

Development of a personalized bidirectional text messaging tool for HIV adherence assessment and intervention among substance abusers

We describe the development of a two-way text messaging intervention tool for substance users who are non-adherent with HIV medications, and examine message flow data for feasibility and acceptability. The assessment and intervention tool, TxText, is fully automated, sending participants mood, substance use, and medication adherence queries by text message. Participants respond, the tool recognizes the category of response, and sends the personalized intervention message that participants designed in return. In 10months, the tool sent 16,547 messages (half initial, half follow-up) to 31 participants assigned to the TxText condition, who sent 6711 messages in response to the initial messages. Response rates to substance use (n=2370), medication (n=2918) and mood (n=4639) queries were 67, 69, and 64%, respectively. Responses indicating medication adherence, abstinence from substances, and good moods were more common than negative responses. The TxText tool can send messages daily over a 3month period, receive responses, and decode them to deliver personalized affirming or intervention messages. While we await the outcomes of a pilot randomized trial, the process analysis shows that TxText is acceptable and feasible for substance abusers with HIV, and may serve as a complement to HIV medical care.

Preconceptional motivational interviewing interventions to reduce alcohol-exposed pregnancy risk

Alcohol exposed pregnancy (AEP) is a leading cause of preventable birth defects. While randomized controlled trials (RCTs) have shown that multi-session motivational interviewing-based interventions reduce AEP risk, a one-session intervention could facilitate broader implementation. The purposes of this study were to: (1) test a one-session motivational AEP prevention intervention for community women and (2) compare outcomes to previous RCTs. Participants at risk for AEP (N=217) were randomized to motivational interviewing+assessment feedback (EARLY), informational video, or informational brochure conditions. Outcomes were drinks per drinking day (DDD), ineffective contraception rate, and AEP risk at 3 and 6 months. All interventions were associated with decreased DDD, ineffective contraception rate, and AEP risk. Participants who received EARLY had larger absolute risk reductions in ineffective contraception and AEP risk, but not DDD. Effect sizes were compared to previous RCTs. The one-session EARLY intervention had less powerful effects than multi-session AEP prevention interventions among community women, but may provide a new option in a continuum of preventive care.

Pilot RCT of bidirectional text messaging for ART adherence among nonurban substance users with HIV.

OBJECTIVE This pilot study tested the preliminary efficacy of a theory-based bidirectional text messaging intervention (TEXT) on antiretroviral (ART) adherence, missed care visits, and substance use among people with HIV. METHOD Participants with recent substance use and ART nonadherence from 2 nonurban HIV clinics were randomized to TEXT or to usual care (UC). The TEXT intervention included daily queries of ART adherence, mood, and substance use. The system sent contingent intervention messages created by participants for reports of adherence/nonadherence, good mood/poor mood, and no substance use/use. Assessments were at preintervention, postintervention, and 3-month postintervention follow-up. Objective primary outcomes were adherence, measured by past 3-month pharmacy refill rate, and proportion of missed visits (PMV), measured by medical records. The rate of substance-using days from the timeline follow-back was a secondary outcome. RESULTS Sixty-three patients participated, with 33 randomized to TEXT and 30 to UC. At preintervention, adherence was 64.0%, PMV was 26.9%, and proportion of days using substances was 53.0%. At postintervention, adherence in the TEXT condition improved from 66% to 85%, compared with 62% to 71% in UC participants (p = .04). PMV improved from 23% to 9% for TEXT participants and 31% to 28% in UC participants (p = .12). There were no significant differences between conditions in substance-using days at postintervention. At 3-month follow-up, differences were not significant. CONCLUSIONS Personalized bidirectional text messaging improved adherence and shows promise to improve visit attendance, but did not reduce substance using days. This intervention merits further testing and may be cost-efficient given its automation.

A SBIRT curriculum for medical residents: development of a performance feedback tool to build learner confidence.

ABSTRACT A major barrier to actualizing the public health impact potential of screening, brief intervention, and referral to treatment (SBIRT) is the suboptimal development and implementation of evidence-based training curricula for healthcare providers. As part of a federal grant to develop and implement SBIRT training in medical residency programs, the authors assessed 95 internal medicine residents before they received SBIRT training to identify self-reported characteristics and behaviors that would inform curriculum development. Residents’ confidence in their SBIRT skills significantly predicted SBIRT practice. Lack of experience dealing with alcohol or drug problems and discomfort in dealing with these issues were significantly associated with low confidence. To target these barriers, the authors revised their SBIRT curriculum to increase residents’ confidence in their skills and developed an innovative SBIRT Proficiency Checklist and Feedback Protocol for skills practice observations. Qualitative feedback suggests that, despite the discomfort residents experience in being observed, a proficiency checklist and feedback protocol appear to boost learner confidence.

Feasibility and Reliability of Interactive Voice Response Assessment of HIV Medication Adherence: Research and Clinical Implications

Abstract Background: There are well-documented negative consequences of nonadherence to HIV medications. Telephone-based interactive voice response (IVR) technologies may hold promise for assessing nonadherence in both research and clinical contexts; however, little psychometric research has been conducted on this topic.Objective: In the present pilot study, we test the feasibility and reliability of a simplified patient-initiated, daily IVR system with a convenience sample of HIV patients attending a university-affiliated infectious disease clinic.Methods: Participants were asked to call in to an IVR system to report adherence daily during 2 weeks of a larger prospective study. Response rates and patterns were analyzed for feasibility and compared to retrospective, self-report timeline follow-back (TLFB) adherence reporting.Results: The IVR protocol showed moderate feasibility, with participants reporting adherence behavior on 63.4% of days. However, agreement with TLFB data was low, particularly for days in which participants reported incomplete adherence.Conclusions: The IVR protocol tested in the current trial shows some promise. Completion rates were higher than in previous trials. Future research is needed to further enhance the feasibility of IVR for HIV medication adherence and to compare responses to more objective measures on HIV adherence.

Parallel Processes: Using Motivational Interviewing as an Implementation Coaching Strategy

In addition to its clinical efficacy as a communication style for strengthening motivation and commitment to change, motivational interviewing (MI) has been hypothesized to be a potential tool for facilitating evidence-based practice adoption decisions. This paper reports on the rationale and content of MI-based implementation coaching Webinars that, as part of a larger active dissemination strategy, were found to be more effective than passive dissemination strategies at promoting adoption decisions among behavioral health and health providers and administrators. The Motivational Interviewing Treatment Integrity scale (MITI 3.1.1) was used to rate coaching Webinars from 17 community behavioral health organizations and 17 community health centers. The MITI coding system was found to be applicable to the coaching Webinars, and raters achieved high levels of agreement on global and behavior count measurements of fidelity to MI. Results revealed that implementation coaches maintained fidelity to the MI model, exceeding competency benchmarks for almost all measures. Findings suggest that it is feasible to implement MI as a coaching tool.

Feasibility and Promise of a Remote-Delivered Preconception Motivational Interviewing Intervention to Reduce Risk for Alcohol-Exposed Pregnancy

BACKGROUND Alcohol-exposed pregnancy (AEP) is a leading cause of birth defects. Effective face-to-face preconception interventions based on motivational interviewing (MI) exist and should be translated into remote formats for maximum public health impact. This study investigated the feasibility and promise of a one-session, remote-delivered, preconception, MI-based AEP intervention (EARLY Remote) for non-treatment-seeking community women. SUBJECTS AND METHODS This was a single-arm, prospective pilot intervention study. All participants received the intervention via telephone and mail. Feasibility of remote-delivery methods, treatment engagement, treatment credibility, MI treatment integrity, and therapeutic alliance were examined. Outcomes were 3- and 6-month drinks per drinking day (DDD), rate of unreliable contraception, and proportion of women at risk for AEP due to continued risk drinking and no or unreliable contraception use. RESULTS Feasibility of remote delivery was established; participants were engaged by the intervention and rated it as credible. Integrity to MI and therapeutic alliance were good. Both DDD and rate of unreliable contraception decreased significantly over time. Proportions of women who drank at risk levels, used unreliable or no contraception, and/or were at risk for AEP in the past 90 days decreased significantly from baseline to 6 months. CONCLUSIONS Remote delivery was feasible, and the translated remote intervention may reduce AEP risk. Refinement of EARLY Remote may facilitate its placement within a spectrum of effective MI-based preconception AEP interventions as part of a stepped-care approach. EARLY Remote may have an important role within a stepped-care model for dissemination to geographically disperse women at risk for AEP. This could result in substantial public health impact through reduction of AEP on a larger scale.