Motivational Interviewing to Improve Exercise Attitudes and Behavior: Implications for Antihypertensive Therapy

Transcription

1 Motivational Interviewing to Improve Exercise Attitudes and Behavior: Implications for Antihypertensive Therapy Brian E. Sandoval, M.A. Stephanie C. Wood, Ph.D., MHA Christopher A. Neumann, Ph.D. Beverly Spray, Ph.D. The School of Professional Psychology at Forest Institute Springfield, Missouri

2 Purpose of the Current Study: To determine how Motivational Interviewing (MI) impacts hypertension patients adherence to exercise recommendations in primary care Specifically, the current study examines how MI influences: 1. Exercise behaviors 2. Behavior change factors Stages of Change Intrinsic Motivation Self-Efficacy

3 Overview of Hypertension More than 73 million people in the U.S. have a diagnosis of hypertension (140/90 mm Hg) and over 1 billion worldwide (AHA, 2009) Hypertension is a primary or contributing cause of 319,000 deaths annually and is a risk factor for stroke, heart attack, and CHF which account for more than 50% of all deaths nationwide (Gatchel & Oordt, 2003) Total expenditures are estimated at $73 billion annually which is nearly twice the costs in 1999 (AHA, 2009)

4 Treatment Failure and Non-Adherence Only 25% of hypertension patients have well-controlled blood pressure despite an abundance of lifestyle and pharmacologic treatments available (JNC,( 2004) Non-adherence is one of most common obstacles to treatment success, with 30% to 60% of patients NOT following recommendations (Baum et al., 1997) Among all antihypertensive therapies, physical exercise programs account for the lowest levels of adherence,, with rates as low as 14% to 17% (Brodie & Inoue, 2005) However, exercise significantly reduces blood pressure in monotherapy (Bacon et al., 2004) and combination therapy while also leading to additional CV risk reductions (Reaven et al., 1996) therapy (Villareal et al., 2006)

5 Motivational Interviewing to Improve Adherence Motivational Interviewing (MI) is a a directive, client-centered centered counseling style for eliciting behavior change by helping patients ts explore and resolve ambivalence (Rollnick & Miller, 1995, p. 325) MI is well-researched and has been shown to have positive outcomes for alcohol, drugs, diet, and exercise (Burke et al., 2003; Dunn et al., 2001) Only 3 studies total have examined MI and exercise in a cardiovascular population, with only 1 study including patients whose primary diagnosis was hypertension (Woollard et al., 1995). Although understudied, these trials provide some support for MI to improve treatment adherence for a cardiovascular population (Brodie & Inoue, 2005; Brodie, Inoue, & Shaw, 2008; Woollard et al., 1995)

6 Purpose of Current Study 1) To determine if MI can impact exercise behavior change for patients with hypertension (Goal: Improve adherence by increasing exercise behaviors ) Hypothesis: Patients receiving MI would have better increases in exercise behavior compared to those receiving a standard recommendation.

7 Purpose of Current Study 2) To determine how MI influences behavior change factors for hypertension patients (Goal: Improve exercise adherence by impacting change factors) A) Stages of Change B) Intrinsic Motivation C) Self-Efficacy Hypothesis: Patients receiving a MI session will experience better gains in exercise change factors when compared those receiving a standard recommendation

8 Participants Methods Recruited from outpatient primary health care clinic for low income and uninsured Inclusion Criteria Age > 18 years Hypertension diagnosis (SBP > 140 mm Hg or DBP > 90 mm Hg) Medically Suitable for Exercise Available for 30 day follow-up appointment Exclusion Criteria Age < 18 years No diagnosis of hypertension Contraindication or Inability to Exercise Patients leaving clinic or Unavailable for 30 day follow-up

9 Procedures Methods Patients who met inclusion criteria were contacted by phone Those who agreed to participate were asked to arrive approximately 1 hour prior to their scheduled appointment After informed consent, patients were randomly assigned to MI Group or ST Group MI Group Completed measures, received 30 minute MI session ST Group Completed measures, received standard exercise recommendation and psychoeducational handout ALL patients were scheduled for 30 day follow-up to complete measures

10 Methods Measures Godin Leisure-Time Exercise Questionnaire (LTEQ) (Godin & Shepard, 1985) University of Rhode Island Change Assessment Exercise 2 (URICA-E2) (Marcus et al., 1992; Reed, 1994) Intrinsic Motivation Inventory (IMI) (Buckworth et al., 2007) Barriers Self-Efficacy Scale (BARSE) (McAuley, 1992)

11 Results Table 1 Participant Demographic Characteristics by Motivational Interviewing (MI) Group versus Standard Treatment (ST) Group Characteristics MI Group Test ST Group Statistic p-value p Observations n Age, years (mean + SD) a.128 Gender n (%) Male 20 (66.7) 16 (55.2) 0.8 b.366 Female 10 (33.3) 13 (44.8) Ethnicity n (%) White 24 (80.0) 23 (79.3) Black 5 (16.7) 6 (20.7) - c.126 Asian 1 ( 3.3) 0 ( 0.0) a Based on F ratio. b Based on chi-square. Based on Fisher s s exact test which does not yield a table value, only a probability. ity. square. c Based on Fisher

12 Results Table 2 Least Squares Means and Standard Errors for Exercise Behavior (LTEQ) Measure MI Group ST Group F-value p-valuep LTEQ ( ) ( ) 42.8 <.001 * Note. LTEQ is the Godin Leisure- Time Exercise Questionnaire.

13 Results

14 Results Table 3 Participant Exercise Stage of Change (URICA-E2) Results for Motivational Interviewing (MI) Group versus Standard Treatment (ST) Group Test URICA-E2 Pre/Post Comparison MI Group ST Group p Statistic p-valuep Stages Changed (mean + SD) ( ) (-.14( ) 14.5 a <.001 Direction of Change Positive n (%) 21 (70.0) 8 (27.6) Negative 1 ( 3.3) 9 (31.0) Unchanged 8 (26.7) 12 (41.4) * Note. URICA-E2 is the University of Rhode Island Change Assessment Exercise 2. a Based on Kruskal-Wallis test.

15 Results Table 4 Least Squares Means and Standard Errors for Intrinsic Motivation (IMI) and Self-Efficacy (BARSE) Measures MI Group ST Group F-value p-valuep IMI ( ) ( ) 17.4 <.001 * BARSE ( ) ( ) 12.6 <.001 * Note. IMI is the Intrinsic Motivation Inventory. BARSE is the Barriers s Self-Efficacy Scale.

16 It was Hypothesized: Discussion Patients receiving MI would have better increases in exercise behavior compared to those receiving a standard recommendation. This hypothesis was CONFIRMED MI helped increase frequency and/or strenuousness of exercise behaviors according to LTEQ Consistent with previous studies examining MI s s impact on exercise behaviors for CHF (Brodie & Inoue, 2005) and other chronic diseases ses (Ang et al., 2007; Bennett et al., 2007) MI facilitated exercise behavior increases regardless of initial activity level

17 It was Hypothesized: Discussion Patients receiving a MI session will experience better gains in exercise change factors when compared those receiving a standard recommendation This hypothesis was also CONFIRMED The MI Group had a mean increase of nearly 1.5 Stages of Change, while ST Group showed no mean change with a slight decrease. Post-intervention, the MI Group had significantly higher mean IMI and BARSE scores when compared to the ST Group Results provide insight into how MI impacts the process of change Addresses gap in literature - Few published trials have demonstrated how MI influences intrinsic motivation and self-efficacy efficacy

18 Limitations Discussion Small Sample Size (n = 59) Racially homogenous sample (80% White) Sample predominately middle-aged Short duration of follow-up to MI session Unequal time spent with MI vs. ST groups Strengths Brief MI session likely adaptable to other primary care/hospital settings Low-income sample (greater barriers to adherence) Randomization produced homogenous groups for comparison

19 Discussion Future Directions Replicate current study design with larger, more diverse sample Examine MI s s impact over long-term follow-up appointments Assess if MI increases adherence for other antihypertensive therapies

20 Implications for Findings Discussion By demonstrating utility of one brief MI session may lead to increased utilization in primary care Understanding how MI affects behavior change factors may help practitioners become more effective at delivering MI interventions ns By improving exercise adherence, may rely less on pharmacologic therapy Better adherence to hypertension treatment would lead to decreased ed costs to the patient and health care system as a whole

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22 References Burke, B., Arkowitz, H., & Menchola, M. (2003). The efficacy of motivational interviewing: A meta-analysis analysis of controlled clinical trials. Journal of Consulting and Clinical Psychology, 71, Dunn, C., Deroo, L., & Rivara, F. (2001). The use of brief interventions adapted from motivational interviewing ewing across behavioral domains: A systematic review. Addiction, 96, Gatchel, R., & Oordt, M. (2003). Clinical health psychology and primary care. Washington, D.C.: American Psychological Association. Godin, G., & Shepherd, R. (1985). A simple method to assess exercise behavior in the community. Canadian Journal of Applied Sport Science, 10, Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. (2004). The seventh report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC).. Bethesda, MD: National Heart, Lung, and Blood Institute. Marcus, B.H., Selby, V.C., Niaura, R.S., & Rossi, J.S. (1992). SelfS elf-efficacy efficacy and the stages of exercise behavior change. Research Quarterly for Exercise and Sport, 63, McAuley, E. (1992). The role of efficacy cognitions in the prediction of exercise behavior in middle-aged adults. Journal of Behavioral Medicine, 15, Reaven, G., Lithell, H., & Landsberg, L. (1996). Hypertension and d associated metabolic abnormalities: The role of insulin resistance and the sympathoadrenal system. New England Journal of Medicine, 334,

23 References Reed, G.R. (1994). Measuring stage of change for exercise behavior change, URICA-E2 E2.. Unpublished doctoral dissertation, University of Rhode Island. Rollnick, S., & Miller, W. (1995). What is motivational interviewing? Behavioral and Cognitive Psychotherapy, 23, Villareal, D., Miller, B., Banks, M., Fontana, L., Sinacore, D., & Klein, S. (2006). Effect of lifestyle intervention on metabolic coronary heart disease risk factors in obese older adults. American Journal of Clinical Nutrition, 84, Woollard, J., Beilin, L., Lord, T., Puddey, I., MacAdam, D., & Rouse, R I. (1995). A controlled trial of nurse counseling on lifestyle change for hypertensives treated in general practice: Preliminary results. Clinical and Experimental Pharmacology and Physiology, 23,