The primary goal of health care is to reduce morbidity and mortality through the prevention and treatment of disease. Health-care providers are also charged with promoting behavioral change strategies that support wellness. When thinking of causes of death, diseases such as heart disease, cancer, and respiratory disease come to mind. Underlying these causes of death, however, often lie modifiable behavioral risk factors, such as tobacco use, poor diet and physical activity, and alcohol misuse.¹ Termed “actual causes of death,” these preventable behaviors account for about half of all deaths and underscore the importance of prioritizing the promotion of behavior change in health-care settings. Furthermore, psychosocial issues, such as mental illness, substance abuse, trauma, and poverty, when left unaddressed by the health-care system, can cause and exacerbate illness among the world’s most vulnerable populations. Two decades of behavioral research indicate that physicians can successfully promote health behavior change in their patients.^2,3 Health-care providers who understand behavior change theory and who practice a patient-centered approach to behavior change counseling achieve the best outcomes.

When envisioning the promotion of behavior change, it is common to picture a prototypical counseling setup, which involves a series of long intervention sessions focused on specific psychosocial stressors or mental health disorders. It is no wonder that many providers choose to avoid behavior change counseling altogether, when this is their perception of what promotion of behavior change entails. Providers in medical settings typically have neither the time nor the specialty training to operate using a counseling paradigm. However, empirical evidence suggests that relatively brief interventions can have powerful effects and that a single brief empathic discussion can promote long lasting behavior change.⁴ For many areas, interventions as short as 5 minutes can change important health behaviors.⁵

Another barrier to the promotion of behavior change in medical settings may be perceptions regarding who is appropriate for intervention. For example, when thinking about a patient who would benefit from behavior change around alcohol, many providers picture a patient with a severe alcohol use disorder, many complicating psychosocial stressors, and a history of unsuccessful quit attempts. While such patients are certainly in need of services and their medical providers should address their alcohol use, they are less likely to respond to brief interventions and more likely to benefit from referral to more intensive specialty treatment. When such patients are the first, or perhaps only, to come to mind when thinking about behavior change counseling, providers may shy away from engaging patients in discussions about behavior change altogether. However, most of the behaviors our patients would benefit from changing are less intensive and more modifiable. With the case of alcohol, for example, as many as one in five patients, such as Mr. Nguyen described in the vignette earlier, may be drinking at levels that put them at risk for a range of medical and social consequences, but do not meet criteria for an alcohol use disorder. More than half of alcohol-related deaths and two-thirds of the potential life-years lost because of alcohol are among such risky drinkers. This is an example of a phenomenon known as the “prevention paradox,” wherein a large number of people at small risk cause more health burden than a small number of people at greater risk.⁶ These patients tend to be quite responsive to brief interventions in medical settings. Shifting one’s frame of reference regarding which patients may benefit from behavior change promotion may promote implementation of such practices.

Promoting behavior change is especially important with socially vulnerable populations. Behavioral health issues, such as sedentary lifestyle, obesity, and smoking, are more prevalent in people of lower socioeconomic position, and among certain racial and ethnic minorities.^7,8 Moreover, physicians are less likely to initiate conversations about health behavior change with lower-income patients.⁹ This is the case even though low-income patients are more likely to report acting on these physician recommendations than are middle- and higher-income patients.¹⁰

Research suggests that health-care provider’s attitudes and behavior often differ based on patient socioeconomic status (SES) and ethnic minority status. Providers tend to spend less time, use fewer rapport building statements, speak more quickly, and demonstrate more verbally dominant behavior with ethnic minority patients compared with white patients.¹¹ When working with lower SES patients, providers are also more directive, less collaborative, are less likely to use partnership building statements, and are less likely to initiate conversations about behavior change.^9,12 These differences in communication may be due to provider’s attitudes. Providers have reported less trusting attitudes toward ethnic minority patients, viewing patients of lower SES and/or ethnic minority status as less intelligent, more likely to abuse substances, lacking self-control, and having less desire to be physically active.^13,14 Differences in provider’s attitudes and behaviors toward ethnic minority and lower SES patients undoubtedly have an impact on engagement, which in turn can affect important patient outcomes. Compounding this issue, ethnic minority patients report less trust in physicians and the medical system compared with white patients.^11,15,16 This is important because patient trust is associated with treatment adherence and improved health.^17,18

Motivational interviewing is style of communication that can be used by health-care providers to strengthen a patient’s own motivation and commitment to change.¹⁹ Motivational interviewing is a collaborative, goal-oriented approach, which encourages providers to pay particular attention to patients’ language regarding change. It has been applied to a range of health behaviors, including medication adherence (in HIV, cardiovascular disease, diabetes, contraception), treatment engagement (continuous positive airway pressure [CPAP] use, group participation, diabetes self-management, prenatal care), screening compliance (mammography, sexually transmitted disease, colorectal cancer), and lifestyle management (diet, physical activity, safe sex).²⁰ Motivational interviewing has been found to be effective cross-culturally and may even differentially benefit ethnic minority patients.²¹

In this chapter, we explore four processes inherent to motivational interviewing and how they may be applied to promote behavior change with vulnerable and underserved populations. The four processes include engaging, focusing, evoking, and planning for behavior change (see Box 12-1). We provide a brief description of each process, as it relates to the promotion of behavior change among vulnerable populations and provide practical strategies for effectively counseling patients in each process.

The first step in promoting behavior change involves the development of a good patient–provider relationship. Forming a meaningful connection with patients is a necessary precursor to focused behavior change work and remains of central importance throughout the course of the working relationship. Humanistic theory asserts that people are naturally driven to seek health and happiness. Three conditions in therapeutic relationships are necessary to enhance this powerful inner drive toward health: warmth, accurate understanding of the person by the helper, and unconditional positive regard.²²

Empirical research also underscores the importance of engaging the patient. A recent meta-analysis of randomized controlled trials evaluating the impact of the patient–provider relationship on validated medical outcomes found a significant positive effect across 13 trials, and the magnitude of the observed effect was nearly double the effect of aspirin in reducing myocardial infarction.²³

The costs of failed engagement in promoting behavior change are high. While a range of patient and systems level factors can impact engagement, provider behavior plays a key role. Poor engagement can lead to treatment dropout, poor treatment compliance or medication nonadherence, and failure to make healthy choices for a variety of medical conditions. The issue of engagement may be particularly important for vulnerable populations, for whom both provider and patient behaviors can present barriers to a mutually trusting and respectful relationship.

STRATEGIES FOR ENGAGEMENT

While we are often focused on the role of the patient in the development of engagement, the provider’s communication style can significantly impact the development of engagement. A number of studies have found that patients are more likely to trust providers who are collaborative, comforting, listen carefully, and explore patient experience of disease and illness.^24,25,26,27 A recent meta-analyses examining the relationship between physician communication and treatment adherence found that a communication style which included empathy and rapport building resulted in greater treatment adherence.²⁸ In sum, a collaborative and empathic communication style is key to developing relationships that increase the likelihood of health behavior change, especially in ethnic minority and lower SES populations. In the following subsections, we focus on several concrete strategies that can be used by providers, even in busy clinic settings, to promote engagement.

Being Present and Mindful

In busy clinic settings, it can be a challenge to be present and mindful with each patient. When working with vulnerable populations, it can be hard to avoid ruminative thinking about challenging patients or barriers to effective care. When pressed with the daunting task of caring for those who are in such great need, it can be easy to neglect important self-care activities. In medicine, mindfulness is the purposeful and nonjudgmental attention to one’s own experiences, thoughts, and feelings.²⁹ Physician mindfulness has been found to improve patient care and is associated with better rapport building, increased discussion of psychosocial issues, and higher patient satisfaction. Mindfulness has also been found to improve practitioner’s well-being, stress levels, and burnout.^30,31 Several simple strategies may be used to promote mindfulness with patients (see Box 12-2).

Empathy and Reflective Listening

Empathy is a construct that is often discussed as a critical clinical skill for health-care providers to promote client engagement. Some ambiguity surrounds the term “empathy,” with interpretations ranging from the ability to share the feelings of another to general warm or caring personality traits. In health-care communication, one helpful way to think of empathy is the extent to which the clinician makes an effort to understand the unique perspective of the patient.¹⁹

Frequent and accurate use of reflections, or statements that paraphrase or infer the underlying meaning of what a client has said, is the primary means by which we operationalize empathy. In health-care settings, provider’s empathy has been found to be predictive of patient outcome across a range of issues. For example, in one correlational study of patients with diabetes treated by family physicians, physicians’ scores on a self-report scale of empathy were highly predictive of patient control of hemoglobin A_1c and low-density lipoprotein.³² Provider’s empathy has also been found to be related to outcomes in depression,³³ cancer,³⁴ and the common cold.³⁵

Motivational interviewing provides us with guidance on how to empathically listen to our patients using the skill of reflection. During the engagement process, we should rely heavily on the use of reflective listening. Taking the time to understand our patients’ unique situations and perspectives promotes trust and alliance. Reflective listening can also help us ensure accurate understanding, which may be particularly important for vulnerable populations whose cultural and experiential background may differ significantly from the provider, leading to misinterpretation.

With reflective listening, providers are essentially making guesses about what patients mean by what they say. However, instead of stating the guess in the form of a question, communication is streamlined by transforming the hypothesis into a declarative statement with a downward inflection at the end. Box 12-3 provides several examples. As can be seen, there are often multiple possible meanings underlying what a patient has said, and a provider will use his or her understanding of the patient’s individual circumstances and strategic aims to determine what aspect of what the patient has said might be most helpful to reflect. When conducting motivational interviewing, providers are encouraged to use at least two reflections for every question that they ask.

Values Exploration

Another strategy for promoting engagement involves taking time to ask about and understand the patients’ goals and values.¹⁹ This may involve briefly talking about life activities and relationships important to the patient. Not only do such conversations build rapport, they simultaneously increase patients’ motivation to change by giving them a chance to verbalize the healthy ideals that are important to them. One simple method for understanding the motivators that drive your patients is by asking them open-ended questions and then listening empathically using the skills of reflection. Examples of values questions adapted from Miller and Rollnick¹⁹ can be found in Box 12-4.

Responding to Discord

Even when we invest in efforts to engage with patients, discord or disharmony in the collaborative relationship may still arise.¹⁹ Discord often takes the form of a “fight or flight” response on the part of the patient. This may involve taking an oppositional stance (“You’d never be able to understand what this is like.”) or disengagement from the interaction. Discord can often be perceived as wrestling with the patient, versus the perception of dancing that is often experienced when collaboration is high.

In motivational interviewing, relationship discord is distinguished from the expression of reasons not to change or barriers to change (e.g., “Drinking helps to ease my anxiety.”). Such counter-change talk is more indicative of underlying ambivalence about change versus problems with the interpersonal relationship. The section “Evoking from the Patient” provides guidance on responding to language about reasons or barriers to change. When it comes to discord, however, several strategies are available. First, engaging in active listening using reflection to understand and explore patient discord is often sufficient to extinguish it. Similarly, clinicians could validate and apologize for any missteps perceived by the patient, shift focus to another topic, emphasize the patient’s choice or autonomy, or return to earlier processes to determine whether they inadvertently or prematurely moved into a later process, such as focusing, evoking, or planning.

A good working relationship leaves providers and patients with the groundwork they need to identify and pursue a specific direction. This focusing is the second process in motivational interviewing. Developing clear and collaboratively generated goals or areas for exploration allows for purposeful interactions aimed at promoting behavioral change. Interactions without focus are less likely to lead to behavioral change.

There are several potential sources of focus in medical interactions.¹⁹ In many circumstances, the patient will present with a problem or concern that becomes the area of focus (e.g., “I’d like to quit smoking.”). Other times, the setting itself will determine the direction of an interaction (e.g., an HIV testing and counseling center). Finally, the medical provider may be a source of focus (e.g., a physician is concerned about the diabetes self-management practices of a patient with poorly controlled blood sugar).

In motivational interviewing and other patient-centered approaches, providers are encouraged to find direction collaboratively by using a guiding style that actively integrates all potential sources of focus. In situations in which direction is clear, focusing may simply involve confirming the goal of one’s work with a patient. However, in other cases, direction may be unclear or there may be many competing priorities to choose from, in which case specific focusing skills will be called into play.

Focusing skills become even more important with vulnerable populations as providers seek to efficiently identify areas of greatest need. Even with an average patient panel, a provider could easily spend all of his or her time with a patient assessing and intervening to promote behavioral change.³⁶

Related posts:

The Hidden Poor: Care of the Older Adult The Family as the Context for Care Community Engagement and Partnership Health-Care Disparities: An Overview Dental Care: The Forgotten Need Trauma and Trauma-Informed Care

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