ReviewMechanisms of change within motivational interviewing in relation to health behaviors outcomes: A systematic review
Introduction
Leading causes of death have changed dramatically in the last few decades, shifting from infectious diseases to non-communicable causes [1]. Changing unhealthy lifestyle behaviors is an important issue. A key barrier to behavior change is a lack of motivation [2]. Motivational interviewing (MI) is a counseling approach designed to promote behavior change. It aims to strengthen personal motivation for, and commitment to a specific goal by eliciting and exploring the person's own reasons for change within an atmosphere of acceptance and compassion [3]. There is a lack of evidence for specific mechanisms that may account for its efficacy within health behaviors [4], [5] such as exercise or adhering to a medical regime. Looking at mechanisms of change (mediators) means attempting to understand what it is that brings about change. Understanding how MI works could lead to improvements in practice and efficacy, focus research efforts and further enhance our understanding of behavior change processes [6].
There have been at least 12 reviews that have found statistically significant effects of MI in relation to health outcomes [5], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17]. However, these reviews do not examine the mechanisms of MI. Potential mechanisms relate to counsellors’ skills such as empathy [18], [19], while others relate to client behavior such as change talk [20], [21], [22]. There are potential mediators ‘within the individual’ for example self-efficacy and readiness to change which have also been linked to outcomes within MI (see Section 2 for full list of mechanisms). Few systematic reviews explore mechanisms of MI. One review examining mechanisms of MI and substance abuse found the most consistent evidence pointed to change talk, clients’ experience of discrepancy and therapist MI-inconsistent behaviors as being important [4]. The review however, investigates substance abuse outcomes and not health behaviors. Health behavior outcomes are “behavior patterns, actions and habits that relate to health maintenance, to health restoration and to health improvement” [23]. This includes behaviors such as exercise, diet, weight loss, managing bulimia or anorexia or adhering to a medical regime. These health behaviors may involve different mechanisms [15], [24] as they require the modification or addition of a behavior rather than the termination of a behavior as for addictions [10], [15]. Therefore mechanisms found to be important previously in the addictions field [4] may be different from those found to predict behavior change in these health behaviors. To date there has not been a systematic review looking at health behaviors and mechanisms within MI.
The aim of this review is to systematically review studies identifying possible mechanisms underlying the effectiveness of MI in relation to health behaviors. It will look at mechanisms identified in the MI literature (addictions and health behaviors) to asses if the mechanisms of change in relation to health behaviors are the same or different from those in the addictions field. The review will look at the extent to which MI is associated with a particular mechanism and whether this mechanism is related to health outcomes.
Section snippets
Study eligibility criteria
The papers included within this review must examine all three of these aspects: MI, a mechanism of MI and a health outcome otherwise they will not be included.
Selected studies met the following inclusion criteria:
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Articles published from 1980 to the present.
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Participants received MI or an intervention referred to as motivational enhancement therapy (MET), motivational enhancement or brief motivational intervention. These interventions all incorporate the techniques of MI [5]. Throughout this
Study characteristics
The search identified 291 papers, after duplicates were excluded and search limits applied. After screening abstracts using the inclusion and exclusion criteria, 87 papers were obtained in full text. The final number of included studies which includes unpublished studies, and studies obtained from reference lists was 37 (see Fig. 3).
The total numbers of participants included in this systematic review are: RCTs = 4946; non-randomized controlled studies = 316; non-controlled studies = 478;
Discussion
This review highlights that despite statistically significant evidence that MI positively influences health outcomes [5], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], there are few studies looking at the mechanisms of MI. This review shows that there is varying and limited evidence for the different links in the causal chain (Fig. 1). The mechanisms [15], [24] may be different from addictions as mentioned earlier [10], [15], however from the limited number of studies exploring
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