Spring Streamline: Motivational Interviewing: A Primer for Improving Outcomes for Patients with Diabetes

[Editor’s Note: Our spring issue of Streamline is arriving in mailboxes around the country. This issue helps clinicians uncover jobs in the ‘gig economy’ to better understand environmental and occupational health in the primary care setting; gives key strategies for helping mobile patients exit a trafficking situation; and provides new resources for clinicians to help patients affected by intimate partner violence. View the whole issue, and back-issues, at our Streamline page.]

Rocio*, an agricultural worker, has just been diagnosed with diabetes. With an A1C of 12 and a plan to return to Florida in about three weeks, Rocio is at risk for her diabetes to continue out of control unless she invests time and effort to develop, and then stick to, a self-management plan. Her physician sits down with Rocio and gathers his thoughts: How can the provider impress upon Rocio the seriousness of her situation and the dangerous consequences of inaction, especially considering the health center is unlikely to see her for any follow-up?

In a recent Migrant Clinicians Network webinar, Sarah Solis, LCSW, put forth that a patient may have greater success in changing behavior if the clinician engages the patient through motivational interviewing. “The righting reflex is the attempt to verbally -- or nonverbally -- persuade an individual to stop a behavior that we’ve assessed as maladaptive,” Solis noted, a common pitfall of patient-clinician interactions. Motivational interviewing, she says, seeks to do the opposite of the righting reflex. But what exactly is the opposite? 

Motivational interviewing emphasizes empathetic listening, reflecting, querying, and affirming in order to reveal the discrepancy between a patient’s current behaviors that aggravate a health concern, and the patient’s personal values and goals. Rocio’s physician recognized that, for some patients, a run-down of diet and lifestyle changes, along with medication, may be enough to inspire change. As a mobile agricultural worker patient, however, Rocio may be unable to attend diabetes education classes or easily refill prescriptions as she moves; there may also be fewer food choices and food access; additionally, Rocio’s mobile lifestyle, rural location, and occupation may inhibit the recommended physical activity. 

With a litany of barriers to successfully implementing a self-management plan, motivational interviewing may bring forward patient-identified values, obstacles, and solutions, and give the clinician a chance to reflect back those values, and develop a collaborative plan that brings the patient in. 

“Our patients have 98 percent of the wisdom and motivation to complete their goals, and we’re about 2 percent in facilitation,” said Solis, a social worker, the Director of Seeds of Change Consulting, and a member of the Motivational Interviewing Network of Trainers. Solis outlined the main challenges we face when we bring motivational interviewing into the exam room, and tips for addressing the challenges through a Motivational Interviewing lens:

Develop a Collaboration with the Patient
Solis notes that, at the onset, the conversation is not level: a patient is vulnerable when entering the exam room, but it is up to the clinician to develop a partnership despite the hierarchical relationship. Some steps include: asking for permission when approaching a sensitive topic, using open-ended questions, and using reflective listening.

Rocio’s clinician starts by asking if they can talk about her diabetes diagnosis, and, after permission is granted, to ask her what her perspective is on the diagnosis, and how she is feeling about it. The clinician then begins using open-ended questions, affirmations, reflections, and summaries (OARS) questions, the foundation of motivational interviewing. (See sidebar for more on OARS.) The clinician reflects back the patient’s answers, restating what Rocio had said to make sure he properly understood, and giving Rocio confirmation that he is listening. Solis notes that, during this stage, a wide net is cast, likely soliciting lots of information that the clinician may not utilize. But often, patients offer up fears, concerns, or desires around their health that they might not have expressed under more narrowly presented questions.

Evoke A Commitment to Change
After establishing this base of the conversation, the clinician can move to evoke what may truly motivate a patient to change. The clinician continues with OARS questions, guiding Rocio to explore why change is important to her, to identify the values the patient has, and the connection those values have to the health scare that she is facing. Solis also recommends exploring the patient’s ambivalence, using, for example, a Decisional Balance worksheet, on which a patient can think through the pros and cons of both action and inaction. “A lot of the times when I use the Decisional Balance worksheet with folks, I’m astounded by what I didn’t know,” she admitted.

Rocio’s clinician discovers something important when he asked more questions and filled in the worksheet with her: Rocio is scared that she’ll be too sick to take care of her children. She values her time with her family, and already sees how diabetes has disrupted her family time.  Rocio’s clinician asks more about this value and reflects back what he heard. Rocio is now thinking about how she might implement change.

They speak for a few minutes longer, the clinician asking Rocio whether she wants to take any action, and hearing what she’s already done to start taking steps to reduce her A1C. Rocio says she’s trying to eat more vegetables, and taking walks before work, a few times a week. Her clinician is noting that Rocio is using “change talk,” language that exposes a consideration of or commitment to change. Many of the clinician’s questions allow the patient space to elaborate on her commitment, thinking through it more.

From here, with Rocio feeling committed, connected to the values that spur her on to address her diabetes, and confident that she’s on the right path already, the clinician and Rocio begin to build out a specific plan for her for the weeks ahead, including after she moves. Rocio is engaged in the conversation, and driving it forward. The hierarchical relationship of a clinician telling his patient what to do is nowhere in sight.

Barriers and Time Crunches
Solis recognizes that such scenarios sound a little too perfect: “How do we balance the work-related expectations and stressors with the need to have meaningful, and sometimes time-intensive, conversation with clients?” she questioned. But she also knows that motivational interviewing is an investment in the patient that pays out over the course of their treatment.  “It’s front-end time that pretty drastically decreases the steps that you need to take with the patients later,” Solis said. For mobile patients with diabetes like Rocio, where clinicians may never see them again after diagnosis, it may be the best chance the clinician has at eliciting meaningful and lasting change.

“Rolling with discord” is another aspect of motivational interviewing for which Solis has some ideas. “Externalize the fear of creating a plan,” she says, and recommends asking patients, “Have you ever had a family member or friend with a similar issue, and what was the solution and outcome?” She also says that a quick and easy “slippery yes” may mean a lot of head nods and not a lot of action. “If I hear a slippery yes, I go silent. I get quiet and we’ll sit there. Instead of pinning them down with logistics -- ‘how are you going to get there’ -- I get quiet because then they will tell me why it doesn’t work.” The process doesn’t always work, but giving space allows clients to sustain their own narrative, she says.

Motivational interviewing isn’t simple, and isn’t easy at times. But research shows its worth. A meta-analysis in 2005 showed significant improvements for both physiological and psychological concerns. And, critical for patients like Rocio, 64 percent of the research studied in the analysis showed an effect of motivational interviewing in encounters of just 15 minutes. [1]

OARS
Motivational interview trainers favor several mnemonics, among them OARS, which stands for the key questions and statements that clinicians can use to move their conversation forward to create that partnership and begin to elicit “change talk.”

Open-ended questions are those that can’t be answered by yes or no, or a very limited piece of information. They require more thought on the part of the patient. Examples: “How do you hope your life might be improved, this time next year?” or, “You just said it was important -- why do you think it’s important?”

Affirmations are positive statements (that are genuine from the part of the clinician) that recognize and acknowledge the patient’s efforts toward health. Examples: “You’re taking walks several times a week! That is impressive! It’s difficult to fit in -- and it’s an important step for your health.” “Look at the weight you’ve lost -- you’ve made a big effort!”

Reflective listening entails reflecting back what the patient is saying. It can be as simple as repeating the same phrasing back. Example: “So what I’m hearing is that you’re feeling overwhelmed with all this information. It sounds like it’s difficult to try to incorporate all the changes into your life at once.”

Summaries are a deeper form of reflection, when a clinician can tie together different thoughts the patient has expressed, to help the patient see how thoughts or motivations are related. It’s a good time to talk about both sides of ambivalence that the patient has expressed, or recap the “change talk” that the clinician has heard, to help frame the next step in the conversation: developing an action plan. “I hear you saying that you want to change quickly, and earlier you said you really wanted your energy back to play with your kids.” “Here’s what I’ve heard so far…”

Diabetes Risk Factors for Mobile Agricultural Workers
Although accurate current data on diabetes among mobile agricultural workers are lacking, many factors point to a higher diabetes rate for mobile agricultural workers than the overall population. Diabetes prevalence is 15 to 17 percent higher in America’s rural areas than its urban areas.[2] In a 2018 study by the Southwest Rural Health Research Center, the likelihood of dying due to diabetes-related hospitalizations was 3.4 percent higher in rural areas than in urban areas.[3]  With most mobile agricultural workers identifying as Hispanic, it is worth noting that Hispanics continue to have a higher risk than whites or Asian Americans, and that Mexicans and Puerto Ricans are about twice as likely to die from diabetes as whites.[4] A recent meta-study found an association between exposure to pesticides like organochlorines and Type 2 diabetes.[5]  In a study of 2012 data pulled from the Uniform Data System, 71 percent of adult mobile agricultural workers lacke­­­d health insurance.[6]  The stress of farm work and of living in poverty is yet another diabetes risk factor.

Diabetes and Health Network
When faced with the task to renew a prescription in a new community, some patients with diabetes have rationed their insulin. Such a move highlights the struggles that patients face in connecting to services at their next location. Health Network, Migrant Clinicians Network’s virtual case management system, connects patients with diabetes to care at their next destination, to assure they can refill their prescriptions before their insulin runs out. Health Network Associates can link a patient with health services and even track a patient’s progress after he or she moves. Enrollment is free and must be initiated by a clinic. Learn more and download enrollment forms in four languages:
https://www.migrantclinician.org/services/network/enrollment-in-health-network.html

[1] Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005;55(513):305-12.

[2] Brown-Guion SY, Youngerman SM, Hernandez-Tejada MA, Dismuke CE, Egede LE. (2013). Racial/ethnic, regional, and rural/urban differences in receipt of diabetes education. Diabetes Educ, 39(3), 327-334.

[3] Ferdinand AO, Akinlotan MA, Callaghan TH, Towne SD Jr, Bolin JN. (2017). Diabetes-Related Hospital Mortality in Rural America: A Significant Cause for Concern. Policy Brief #3. Southwest Rural Health Research Center. Available at: https://www.ruralhealthresearch.org/centers/southwest

[4] Hispanic Health. Centers for Disease Control and Prevention. Accessed 2/25/19. Available at: https://www.cdc.gov/vitalsigns/hispanic-health/index.html.

[5] Evangelou E, Ntritsos G, Chondrogiorgi M, et al. Exposure to pesticides and diabetes: A systematic review and meta-analysis. Environ Int. 2016;91:60-8.

[6] Boggess B, Bogue HO. The health of U.S. agricultural worker families: A descriptive study of over 790,000 migratory and seasonal agricultural workers and dependents. J Health Care Poor Underserved. 2016;27(2):778-92.