Health and Social Development, Faculty of (Okanagan)
Health and Exercise Sciences, School of (Okanagan)
DSpace
UBCO
Cranston, Kaela
Master of Science - MSc
University of British Columbia
Background: Motivational interviewing (MI) has been demonstrated to be an effective counselling style for changing lifestyle behaviours. Fidelity of delivering MI skills has received little attention in health behaviour change research. The objective of this thesis was to examine the MI skills of newly trained coaches delivering a diabetes prevention program for six months after training. Methods: MI skills were monitored monthly, starting immediately post-MI training to six months post-training. The Motivational Interviewing Competency Assessment (MICA) was used to code audio recordings of interactions between coaches and clients. The MICA breaks MI skills into seven categories, with MICA ≧ 3/5 for each category considered client-centered. Two independent coders coded one session for each client in a coaches’ first six months post-training. MI-competency scores were generated by averaging MICA scores for six months. Results: Coaches were 25±2 years of age, 71% female, and 43% had less than a bachelor’s degree. Mean MI-competency was 3.3±0.24 over six months. The majority (71%) of all coded sessions were classified as client-centered for all seven MICA categories. Conclusion: Inexperienced coaches attending a brief three-phase MI training were able to deliver MI-informed client-centered care in a community setting with high fidelity up to six months without the use of any booster training sessions. Results of this thesis will provide recommendations for training coaches in real-world settings.
SUSTAINABILITY OF MOTIVATIONAL INTERVIEWING SKILLS IN NEW SMALL STEPS FOR BIG CHANGES COACHES by Kaela Cranston B.Sc., Brandon University, 2016 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE COLLEGE OF GRADUATE STUDIES (Health and Exercise Sciences) THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan) July 2019 © Kaela Cranston, 2019 ii The following individuals certify that they have read, and recommend to the College of Graduate Studies for acceptance, a thesis/dissertation entitled: Sustainability of Motivational Interviewing Skills in New Small Steps for Big Changes Coaches submitted by Kaela Cranston in partial fulfillment of the requirements of the degree of Master of Science . Dr. Mary Jung, School of Health and Exercise Sciences Supervisor Dr. Heather Gainforth, School of Health and Exercise Sciences Supervisory Committee Member Dr. Tanya Forneris, School of Health and Exercise Sciences Supervisory Committee Member Dr. Shelley Ben-David, School of Social Work University Examiner Dr. Eric Li, Faculty of Management External Examiner iii Abstract Background: Motivational interviewing (MI) has been demonstrated to be an effective counselling style for changing lifestyle behaviours. Fidelity of delivering MI skills has received little attention in health behaviour change research. The objective of this thesis was to examine the MI skills of newly trained coaches delivering a diabetes prevention program for six months after training. Methods: MI skills were monitored monthly, starting immediately post-MI training to six months post-training. The Motivational Interviewing Competency Assessment (MICA) was used to code audio recordings of interactions between coaches and clients. The MICA breaks MI skills into seven categories, with MICA  3/5 for each category considered client-centered. Two independent coders coded one session for each client in a coaches’ first six months post-training. MI-competency scores were generated by averaging MICA scores for six months. Results: Coaches were 25±2 years of age, 71% female, and 43% had less than a bachelor’s degree. Mean MI-competency was 3.3±0.24 over six months. The majority (71%) of all coded sessions were classified as client-centered for all seven MICA categories. Conclusion: Inexperienced coaches attending a brief three-phase MI training were able to deliver MI-informed client-centered care in a community setting with high fidelity up to six months without the use of any booster training sessions. Results of this thesis will provide recommendations for training coaches in real-world settings. iv Lay Summary Motivational interviewing (MI) is a counselling style that aims to strengthen a client’s motivation to change. MI is used within Small Steps for Big Changes (SSBC), a diabetes prevention program in Kelowna, Canada. MI has been shown to be effective in helping individuals make health behaviour changes. Fidelity of MI skills have received little attention in research. It is imperative to assess fidelity of MI skills to ensure that SSBC is being delivered as intended. This thesis aimed to examine the MI skills of newly trained SSBC coaches for six months post-training. MI skills were monitored and scored monthly from immediately post-training to six months post-training. Generally, coaches were operating at a level of client-centered MI immediately post-training and remained at this level for six months. Results of this thesis will provide recommendations for training coaches in real-world settings and will provide a model to use to monitor fidelity. v Preface I declare that the composition of this thesis in its entirety is my own. Ms. Kaela Cranston’s thesis is a smaller portion of a larger overarching project Small Steps for Big Changes. Drs. Mary Jung and Jonathan Little conceived the larger study idea in 2012. Drs. Jung and Little were responsible for conception of idea and writing of ethics and proposal for the Small Steps for Big Changes program. In regard to Ms. Cranston’s thesis, she was responsible along with Dr. Elena Ivanova and Connie Davis for the conception of methods to assess the fidelity of the motivational interviewing skills of Small Steps for Big Changes coaches. Ms. Cranston and Dr. Ivanova were together responsible for data analyses during the time of Ms. Cranston’s thesis. Ms. Cranston was also responsible for performing data analyses and interpretation, and the writing and editing of the thesis. Dr. Jung was responsible for overseeing all aspects of the study, contributing to data interpretation and editing of the thesis. Ethics approval was obtained from the University of British Columbia Clinical Research Ethics Board (H16-02028). vi Table of Contents Abstract .......................................................................................................................................... iii Lay Summary ................................................................................................................................. iv Preface ..............................................................................................................................................v Table of Contents ............................................................................................................................ vi List of Tables ................................................................................................................................ viii List of Figures ................................................................................................................................. ix Acknowledgements ...........................................................................................................................x Dedication ...................................................................................................................................... xii Chapter 1: Introduction ....................................................................................................................1 1.1 The Issue of Type 2 Diabetes and Physical Inactivity in Canada ......................................... 1 1.2 Preventing Type 2 Diabetes .............................................................................................. 2 1.3 The Challenge with Health Behaviour Change ................................................................... 2 1.4 What is Motivational Interviewing? .................................................................................. 3 1.5 Why is Motivational Interviewing Important?.................................................................... 5 1.6 Motivational Interviewing in Health Behaviour Change Research ....................................... 6 1.7 Physical Activity and Dietary Behaviour Change Interventions .......................................... 7 1.8 Motivational Interviewing in Prediabetes and Type 2 Diabetes Research ........................... 10 1.9 Fidelity ......................................................................................................................... 12 1.9.1 Fidelity in Motivational Interviewing Research.......................................................... 12 1.9.2 The Importance of Assessing Fidelity ....................................................................... 13 1.10 How to Assess Motivational Interviewing Fidelity ........................................................... 14 1.10.1 Motivational Interviewing Skill Code ................................................................... 15 1.10.2 Motivational Interviewing Treatment Integrity ...................................................... 16 1.10.3 Motivational Interviewing Competency Assessment .............................................. 17 1.11 Motivational Interviewing Workshop Effectiveness ......................................................... 18 vii 1.11.1 Drift in Motivational Interviewing Skills ............................................................... 22 1.12 Small Steps for Big Changes .......................................................................................... 24 1.12.1 What is Small Steps for Big Changes? .................................................................. 24 1.12.2 Motivational Interviewing Training for Small Steps for Big Changes Coaches......... 25 1.13 Objective ...................................................................................................................... 26 1.14 Hypothesis .................................................................................................................... 26 Chapter 2: Manuscript .................................................................................................................. 27 2.1 Overview ...................................................................................................................... 27 2.2 Methods ........................................................................................................................ 32 2.3 Results .......................................................................................................................... 35 2.4 Discussion .................................................................................................................... 48 2.4.1 Strengths and Limitations ......................................................................................... 50 2.4.2 Future Directions ..................................................................................................... 51 2.4.3 Findings .................................................................................................................. 51 Chapter 3: Conclusion ................................................................................................................... 52 3.1 Fidelity ......................................................................................................................... 53 3.2 Strengths and Limitations ............................................................................................... 55 3.3 Future Directions ........................................................................................................... 56 3.4 Conclusion .................................................................................................................... 58 Bibliography .................................................................................................................................. 59 Appendices .................................................................................................................................... 69 Appendix A............................................................................................................................. 69 Appendix B ............................................................................................................................. 75 Appendix C ............................................................................................................................. 97 viii List of Tables Table 1. MICA scoring definitions. ................................................................................................... 37 Table 2. Average MICA scores of Small Steps for Big Changes coaches each month post-training. ...... 38 Table 3. Number of clients each coach had per month. ....................................................................... 39 ix List of Figures Figure 1. Coaches’ Strategically Responding to Sustain Talk scores post-training. .............................. 40 Figure 2. Coaches’ Strategically Responding to Change Talk scores post-training. ............................. 41 Figure 3. Coaches’ Supporting Autonomy and Activation scores post-training. ................................... 42 Figure 4. Coaches’ Guiding scores post-training. .............................................................................. 43 Figure 5. Coaches’ Expressing Empathy scores post-training. ............................................................ 44 Figure 6. Coaches’ Partnering scores post-training. .......................................................................... 45 Figure 7. Coaches’ Evoking scores post-training. .............................................................................. 46 Figure 8. Coaches’ total scores post-training. ................................................................................... 47 x Acknowledgements I would first like to thank my supervisor, Dr. Mary Jung. Two years ago, I moved from the prairies to Kelowna excited at being given the opportunity to work in your lab and to learn from you. At that point, I had no idea just how much I was going to get out of this experience. You have helped grow my passion for helping others, and I am excited to continue to work with you for the next four years. Thank you for your patience, the countless hours you spent reading and editing my thesis, and for pushing me to continue to become a better researcher and writer. I admire your leadership, work ethic, and passion for the work you do. I am very appreciative of everything you have done for me, and I am excited to start my PhD with you! I would also like to acknowledge my committee members: Dr. Heather Gainforth, Dr. Tanya Forneris, and Dr. Shelley Ben-David. Thank you for your insight, guidance and expertise. Thank you to my wonderful lab mates, who made coming into the lab something I looked forward to. DPRG, you went from being colleagues to becoming family. I am forever grateful for the mentorship, support, guidance, laughs and love that you continue to provide me. Drs. Sean Locke, Corliss Bean, and Matt Stork, thank you for being amazing mentors and providing me with opportunities to learn from you all in different ways to help advance my understanding of research and academia. Jodi Langley and Alex Santos, thank you for being wonderful lab mates and providing me with support and laughs. Tineke Dineen and Alissa Smith, thank you for coordinating our lab, your hard work kept our lab and research running over the last couple of years. Tineke Dineen (again) and Megan MacPherson, you two have been amazing colleagues and friends, and you were both there no matter what I needed – thank you! A special thank you to my lab mate and mentor, Dr. Elena Ivanova. Thank you for the countless hours you spent teaching me about MI, helping to code and analyze my data, reading and editing xi my work, and lastly for the support and kindness you have provided me as a friend. This thesis would not have been possible without you. I’d like to extend a thanks to the Kelowna Downtown YMCA and all of our Small Steps for Big Changes clients. The research that we do would not be possible without any of you. My participants have impacted my life in so many ways, and remind me of the importance of compassion, courage and dedication. Thank you to the YMCA staff for their kindness and the smiles on their face every day. Lastly, I would like to acknowledge my family. Thank you, Mom, Dad, Ty and Cody, for all the love you give, and for inspiring me to always work to be the best I can be. The countless Facetime calls and family group chats makes being away from you easier. Mom and Dad, you have shown me the importance of working hard, and thank you for supporting me in chasing this opportunity. Ty and Cody, even though you’re my younger brothers, I look up to both of you (literally and figuratively) and I could not have done this without your support and the many laughs. You are my best friends! xii Dedication My Master’s thesis is dedicated to my amazing family. Thanks Mom, Dad, Ty and Cody. I love you all. 1 Chapter 1: Introduction 1.1 The Issue of Type 2 Diabetes and Physical Inactivity in Canada More than 6 million Canadians are living with prediabetes (Diabetes Canada, 2017). Prediabetes is a condition that is characterized by elevated fasting glucose and/or impaired glucose tolerance that increases the risk of type 2 diabetes (T2D) (Tabák, Herder, Rathmann, Brunner, & Kivimäki, 2012). Untreated prediabetes can develop into T2D within five years (CDC, 2017; Ramachandran & Snehalatha, 2011). The prevalence of T2D in Canada has more than doubled since 2000 (Diabetes Canada, 2017). It is projected that by 2025 the prevalence and healthcare costs associated with diabetes will increase by 25% (Diabetes Canada, 2017). This is foreshadowed by the increasing rates of physical inactivity, obesity, and poor diet (Boniol, Dragomir, Autier, & Boyle, 2017; Diabetes Canada, 2017). Diabetes and its related complications cost the Canadian health care system more than $3 billion annually (Diabetes Canada, 2017). A common way to determine whether someone has prediabetes or T2D, and the magnitude of effect an intervention has on diabetic outcomes, is by assessing glycated haemoglobin (HbA1c) levels, or average plasma glucose concentration. An individual is considered to have prediabetes in Canada if their HbA1c is between 6.0 and 6.4% (Diabetes Canada, 2017). The American Diabetes Association (ADA) cut points for prediabetes are between 5.7 and 6.4%. Both Diabetes Canada and the ADA have a cut point of  6.5% for a T2D diagnosis. The ADA cut points for classifying prediabetes are commonly used throughout the world as they provide a greater opportunity to intervene and reduce the risk of developing T2D (Heianza et al., 2012). Individuals with, or at risk for T2D, can reduce their HbA1c levels by engaging in physical activity (Boniol et al., 2017; Boulé, Haddad, Kenny, Wells, & Sigal, 2007; Jadhav, Hazari, Monterio, Kumar, & Maiya, 2017). Adults between the ages of 18-64 years are recommended to engage in at least 150 minutes of moderate-to-vigorous intensity aerobic physical activity per week, in bouts of 10 minutes or more, to achieve health benefits (Canadian Society for Exercise Physiology, 2018). Less than 1 in 5 (18%) Canadian adults met this recommendation in 2017 (Statistics Canada, 2017). Physical activity 2 levels are even lower among individuals living with chronic disease, including T2D (Morrato, Hill, Wyatt, Ghushchyan, & Sullivan, 2007; Zhao, Ford, Li, & Mokdad, 2008). 1.2 Preventing Type 2 Diabetes It is important to prevent the progression of prediabetes to T2D to reduce morbidity, mortality and the burden on the health care system. Lifestyle interventions aimed at increasing physical activity and improving diet have been shown to be efficacious in randomized controlled trials, such as the Diabetes Prevention Program (Knowler et al., 2002), the Finnish Diabetes Prevention Study (Lindström et al., 2003), and the Da Qing IGT and Diabetes Study (Pan et al., 1997). The aforementioned lifestyle interventions, however, were highly controlled, time-intensive for both highly qualified health care professionals and participants, and very costly. The Diabetes Prevention Program demonstrated that it cost $2780 USD per participant (Hernan et al., 2003). Established lifestyle programs are also lengthy. The Diabetes Prevention Program consisted of approximately 16 hours of core curriculum sessions over 24 weeks administered by a lifestyle case manager one-on-one (Hernan et al., 2003). In the next six months, participants met with their lifestyle coach face-to-face at least once every two months and had phone check-ins at least once between each of these meetings. Participants were also provided 118 pages of health education materials (Hernan et al., 2003). In the first year, participants had an average of 4.27 hour-long supervised activity sessions, and an average of 7.65 35-minute in-person individual sessions with the lifestyle case manager (Hernan et al., 2003). Follow-up lifestyle group sessions were offered, and in the first year each participant attended an average of 1.89 of these sessions. This makes the program, as well as similar interventions designed to test the efficacy of lifestyle modification, not sustainable in community settings because of the time and resource intensity they require. 1.3 The Challenge with Health Behaviour Change Behaviour change interventions have traditionally been conducted using brief education and advice giving (Rollnick & Miller, 2013). The health care practitioner is considered the expert and gives general behaviour change recommendations, leaving the client with limited power or control in the 3 decision making (Hawkins, 2010). Brief education and advice giving are often ineffective in health behaviour change for a number of reasons. A systematic review was conducted investigating the effect of advice giving compared to offering advice by physicians for smoking cessation. A total of 13 studies were included, and the authors concluded that “physicians may be more effective in promoting attempts to stop smoking by offering assistance to all smokers than by advising smokers to quit and offering assistance only to those who express an interest in doing so” (Aveyard, Begh, Parsons, & West, 2012). Advice giving is often met with resistance because clients perceive lack of autonomy and control (Rollnick & Miller, 2013). Information alone is not adequate in helping individuals to make behaviour changes (Bundy, 2004; Kelly & Barker, 2016; Miller & Rollnick, 2009; Robbins, Pfeiffer, Maier, Ladrig, & Berg-Smith, 2012). The gap between knowledge of the information and applying the information is termed ambivalence. Ambivalence is a state where an individual is able to see both the positive and negative sides to change, and therefore does not take action to make change (Christie & Channon, 2013). Motivational interviewing (MI) is a counselling style built to address ambivalence for health behaviour change in clients, or to assist clients to transition from a state of ambivalence to implementing change. 1.4 What is Motivational Interviewing? MI is a client-centered collaborative counselling style that aims to help clients strengthen their motivation and commitment to change (Rollnick & Miller, 2013). One aim of MI is to help resolve a client’s ambivalence. MI centres around the quality of the interaction between client and counsellor (Morton et al., 2015). It is important to note that MI aims to avoid a number of biases. Two key biases are the righting reflex and the expert trap. The righting reflex is attempting to ‘fix’ a client’s unhealthy behaviours. The expert trap is concerned with the counsellor assuming that they have the best answers to a client’s difficulties. Four processes occur during an interaction using MI, and may be visited and revisited at any time to help build a therapeutic relationship between client and counsellor (Rollnick & Miller, 2013). They are: 1) engaging with the client, 2) focusing the conversation to help create specific goals, 3) evoking a 4 client’s own reasons and motivation for change, and 4) planning specific actions to take towards reaching their goals. There are four communication skills emphasized in MI that are known as the OARS acronym: open-ended questions, affirmations, reflections, and summaries. The OARS combine to make up the communication micro-skills that counsellors use to engage with their clients (Rollnick & Miller, 2013). Counsellors use OARS to help clients explore the changes that they want to make and their motivation for making those changes. Asking open-ended questions (O) is the opposite of closed-ended questions, or questions that only require a one-word response. Closed-ended questions are not seen as beneficial in MI because clients may not elaborate on their answers and the counsellor fails to encourage the client to take an active role in the conversation. Affirmations (A) are used to highlight something positive about the client, whether it is an action they took, positive traits, or an idea. Using affirmations communicates support to the client, can increase self-efficacy for making changes, and can lessen the chances of a client becoming defensive. Affirmations differ from praise, in that praise implies that the counsellor is deciding what is good or bad behaviour, e.g., “I like the progress that you are making.” An affirming statement instead may be “Your consistent efforts are showing progress”. Reflective statements (R) allow the client to hear their thoughts and feelings back and can provide clarity of what the client is communicating. Reflections can be categorized as either simple or complex reflections. Simple reflections involve repeating or slightly rephrasing the client’s statements. Complex reflections are statements that add meaning to the client’s statements or take a guess as to what the client has left unspoken. Reflections are crucial to help clients verbalize what they are thinking. They invite the client to further explore, to provide the opportunity for the counsellor to show empathy, and to communicate to the client that they are trying to understand. Finally, summaries (S) tie in several points that a client has shared. They allow a client to hear various aspects of their own experience in one statement. Summaries can be used to highlight change or to effectively transition into a new topic or wrap up a session. OARS can be effectively used to resolve ambivalence. The communications skills within MI accomplish this by eliciting the client to engage in change talk. Change talk refers to a client’s arguments 5 for making change (Rollnick & Miller, 2013). When used appropriately, OARS can also weaken sustain talk – arguments against making change (Rollnick & Miller, 2013). Skilled counsellors are able to hear and respond appropriately to both change and sustain talk. The aim is to weaken sustain talk and strengthen change talk as the conversation and therapeutic relationship progresses, helping resolve the client’s ambivalence and build their motivation to change (Magill et al., 2017). MI also includes a relational aspect in addition to the technical and micro-communication skills presented above. The spirit of MI refers to building a strong relationship with the client through four processes that form the acronym CAPE, or compassion, acceptance, partnership, and evoking (Rollnick & Miller, 2013). Compassion and empathy (C), genuinely caring about what is important to the client and feeling motivated to help, are key to the spirit of MI. Accepting (A) the client and respecting that they have the right to change or not change is important in MI. To accept the client’s behaviours is not necessarily to approve of their actions, but to allow them to choose their own path through the use of autonomy-supportive language and emphasizing personal choice. Partnering (P) with the client to work together as equals fosters a collaborative setting in which the client is their own expert, and the counsellor is there to help apply everything and act as a key consultant in the journey. The counsellor is there to guide a client from a state of ambivalence to one of change, without forcing, and allowing the client to explore their thoughts on why they are ambivalent and what reasons they have to make change. Evocation (E) is when a counsellor brings forth the client’s ideas, strengths, and knowledge about themselves and situations. Encouraging the client to explore and working together with the counsellor allows room for discovery. CAPE helps build a strong client-counsellor relationship, which is the first key step needed for the client to make behaviour changes. 1.5 Why is Motivational Interviewing Important? MI was born in the context of addiction treatment in the 1980s (Miller, 1983), and has since been effectively used in a variety of health behaviour change settings (Rollnick, Miller, & Butler, 2008). MI’s approach and effectiveness are credited to encouraging the client’s openness instead of defensiveness, as 6 a result of the partnership established between the client and the counsellor. Client satisfaction (as assessed by the 8-item CSQ (Larsen, Attkisson, Hargreaves, & Nguyen, 1979)) has been demonstrated to be higher when counselling with MI relative to other counselling styles (Young, Gutierrez, & Hagedorn, 2013). Below is a summary of the research to date where MI has been used to help individuals make health-related behaviour changes. 1.6 Motivational Interviewing in Health Behaviour Change Research MI has been used in a wide spectrum of health behaviour change research, including addiction treatment, and the management of chronic diseases. MI, or adaptations of MI, have been shown to be significantly better than no treatment or placebo controls in a variety of health-related areas including alcohol and drug addiction, diet and physical activity, dental and medical problems, and social impact (Burke, Arkowitz, & Menchola, 2003; DiClemente, Corno, Graydon, Wiprovnick, & Knoblach, 2017; Martins & McNeil, 2009; O'Halloran et al., 2014; Rubak, Sandbæk, Lauritzen, & Christensen, 2005; Schaefer & Kavookjian, 2017). MI is effective in decreasing alcohol consumption compared to no treatment based on measures of blood alcohol concentration and standard ethanol content (Burke et al., 2003; DiClemente et al., 2017; Morton et al., 2015; Rubak et al., 2005). A large effect size for interventions that used MI on reducing alcohol consumption was shown in a meta-analysis that included 15 controlled clinical trials (Burke et al., 2003). More specifically, on average, those who received MI reduced their number of standard drinks per week from 36 to 16, a reduction of 56% (Burke et al., 2003). Studies show similar findings on the effects of MI for tobacco cessation and reducing cannabis use (DiClemente et al., 2017). For example, a Cochrane review examined 23 randomized controlled trials on cannabis use (Gates, Sabioni, Copeland, Le Foll, & Gowing, 2016). Compared to those in the control condition, those receiving an MI intervention used cannabis 5.67 days less during a 30-day period (Gates et al., 2016). 7 The use of MI in chronic disease prevention and management has also been examined. MI has shown to be promising for better oral care of infants and children when the mother receives an MI intervention, as well as for adolescents and adults who go through an oral hygiene intervention for their own behaviours (Martins & McNeil, 2009). For example, children with mothers in the MI intervention group of one study had significantly fewer cavities than children of mothers in the control group, with 46% less cavities (Harrison, Benton, Everson-Stewart, & Weinstein, 2007). The use of MI has also been shown to be effective in weight loss studies. In a review of 11 obesity trials by Armstrong et al. (2011), the weighted mean difference (WMD) for decreased body weight between those receiving MI and those in a control condition was -1.47kg (p<0.01), and the WMD for BMI was -0.25kg/m2 (p=0.058). Generally, MI alone or in combination with other treatments shows moderate to large effect sizes for decreasing BMI and body weight (Armstrong et al., 2011; Carels et al., 2007; Rubak et al., 2005). It is important to note that oral health and weight loss are not behaviours, but behavioural outcomes in which a number of behaviours (i.e., teeth brushing, diet and physical activity) can be targeted for change. Next, a number of interventions that target physical activity and dietary behaviours are summarized. 1.7 Physical Activity and Dietary Behaviour Change Interventions Regular physical activity and a healthy diet are necessary for a long and healthy life and reducing the risk of many chronic diseases (World Health Organization, 2003). Many interventions aimed at reducing the risk of chronic disease therefore target changing physical activity and dietary behaviours. The majority of behaviour change interventions involving diet and physical activity do not solely focus on one behaviour or the other, but both in combination. Some studies and reviews, however, have separated physical activity from diet and they are presented below, followed by a summary of some multi-modal approaches. 8 A systematic review looking at the effects of MI on increasing physical activity in individuals with chronic health conditions, including but not limited to, obesity, fibromyalgia, and hypertension was conducted (O'Halloran et al., 2014). MI was delivered as the primary intervention in six of the eleven trials, and MI was delivered in combination with educational materials, a weight loss program, or supervised exercise in four trials (O'Halloran et al., 2014). MI had a small but significant effect on increasing levels of physical activity in populations with chronic health conditions immediately following the intervention (Cohen’s d = 0.19). The small effect size was suggested to be due, at least in part, to varying levels of treatment fidelity (O'Halloran et al., 2014). Most of the studies reviewed with a physical activity outcome did not monitor treatment fidelity, which could mean participants in these trials did not in fact receive MI as intended. In a subsequent analysis, studies that did not assess treatment fidelity of MI were removed, and the effect size of MI on increasing levels of physical activity went from Cohen’s d = 0.19 to 0.30 (O'Halloran et al., 2014). When studies do not assess fidelity, researchers risk committing a type III error. A type III error is measuring something that does not exist (Dobson & Cook, 1980). For example, researchers would be committing a type III error if they measured the effectiveness of MI when MI was not delivered as intended. The increase in effect size with the removal of studies lacking fidelity assessments demonstrates that the initial small effect size could have been a result of low-quality delivery of MI, or even the absence of MI. Another possible explanation for the small effect size is that physical activity was not the sole behaviour targeted in these interventions. It is possible that if the interventions targeted only physical activity that the effect size may have been larger. MI significantly improved individuals’ physical activity more than those in control conditions in two randomized controlled trials not included in the O'Halloran et al. (2014) systematic review (Bennett, Young, Nail, Winters-Stone, & Hanson, 2008; Harland et al., 1999). A medium effect size of d = 0.55 was found when the effect of MI on physical activity and fitness in cancer survivors was examined, which is a stronger effect size then what was found in the review conducted by O'Halloran et al. (2014). Sessions in this intervention were recorded, and the MI trainer ensured that the counsellor was using MI-consistent skills and strategies (Bennett, Lyons, Winters-Stone, Nail, & Scherer, 2007). One explanation for why this study had a larger 9 effect size than the O'Halloran et al. (2014) review is that there were fidelity checks, resulting in a greater investment by the researchers to ensure that the intervention was implemented as intended. MI has been used in dietary effectiveness interventions for a variety of populations (Fuemmeler et al., 2006; Resnicow et al., 2004; Richards, Kattelmann, & Ren, 2006). Individuals who received MI reported a significantly greater intake of fruit and vegetables, and a reduced percentage of calories from fat compared to those in the control condition (Fuemmeler et al., 2006; Resnicow et al., 2004; Richards et al., 2006). Small-to-medium effect sizes were found for the different measures, ranging from d = 0.18 to 0.46 (Resnicow et al., 2004). Significant increases in motivation, social support, and self-efficacy regarding eating an increased amount of fruit and vegetables were reported by the MI group along with the significant changes in food consumption behaviour (Resnicow et al., 2004). Small-to-medium effect sizes were found for changes in the psychosocial measures with a range of d = 0.21 to 0.39 (Resnicow et al., 2004). There is a large extent of research examining the effects of MI on health behaviour looking at both diet and physical activity combined. MI interventions focusing on diet and physical activity have been shown to be effective and yield a moderate effect size (Burke et al., 2003). Reviews and individual studies have supported its utility for eliciting behaviour changes in alcohol and marijuana use, diet, physical activity, and overall weight loss. It is important to note the effectiveness of MI on behaviours such as physical activity and diet because both have been demonstrated to be effective in helping with the management and prevention of T2D (Knowler et al., 2002; Lindström et al., 2003; Pan et al., 1997). On average, per 1kg body weight loss the risk of developing T2D decreases by 16% (Hamman et al., 2006). It is thus evident why interventionists have started using MI in adults at risk for developing T2D given the effectiveness of MI at eliciting changes in diet and physical activity that could result in such clinically meaningful changes. 10 1.8 Motivational Interviewing in Prediabetes and Type 2 Diabetes Research MI is effective in assisting individuals with prediabetes and T2D to control glucose levels, increase physical activity, decrease weight, engage in dietary changes, both alone and in combination with other interventions (Chen, Creedy, Lin, & Wollin, 2012; Chlebowy et al., 2015; Christie & Channon, 2013; Clark, Hampson, Avery, & Simpson, 2004; Martins & McNeil, 2009; Smith, Heckemeyer, Kratt, & Mason, 1997; Thepwongsa, Muthukumar, & Kessomboon, 2017; West, DiLillo, Bursac, Gore, & Greene, 2007). MI further leads to increases in self-efficacy in measuring blood glucose, diet and exercise, and a sense of control over diabetes (Christie & Channon, 2013; Martins & McNeil, 2009). In 1997, a pilot study was conducted by Smith et al. (1997) to examine whether the addition of MI to a standard behavioural weight-control program helped to enhance adherence to the intervention, and glycemic control outcome measures. A total of 16 women with T2D were randomized to an MI intervention group or a control condition. The MI group had significantly better adherence to the program as measured by attendance, the number of diaries turned in, and how often they monitored their blood glucose. Individuals in the MI group had better glycemic control (9.8  1.3) than those in the control (Smith et al., 1997). This pilot data showed that adding MI sessions to a standard behavioural weight-control program may yield better results than just solely the behavioural weight-control program. This inspired a number of other research teams to explore the MI approach specifically in this population. Since that seminal 1997 study by Smith and colleagues, a number of studies have used MI for individuals with T2D and showed positive effects on the management of, and outcomes related to, T2D. Significant differences between MI and control groups were discovered for a variety of outcomes including HbA1c, self-management, self-efficacy of diet and physical activity, quality of life, and self-reported physical activity (Chen et al., 2012; Christie & Channon, 2013; Martins & McNeil, 2009). In a randomized controlled trial, individuals in the MI condition significantly reduced their HbA1c from 8.97  2.17 to 8.16  1.73 from baseline to 3-month follow-up, while those in the control group did not (Chen et al., 2012). Reduction in HbA1c in interventions for those with, and those at risk for developing T2D 11 using MI has been replicated numerous times (Chlebowy et al., 2015; Phillips & Guarnaccia, 2017; Thepwongsa et al., 2017; West et al., 2007). A number of diabetes management studies have targeted physical activity as a behaviour to change to improve health. MI has been shown to increase physical activity among individuals with T2D and those at risk of developing T2D as demonstrated by physical activity monitoring devices (Chlebowy et al., 2015), physical activity questionnaires, and diaries (Phillips & Guarnaccia, 2017; Soderlund, 2018). MI interventions have also been shown to be effective in helping individuals with prediabetes or T2D lose weight, reduce waist circumference and BMI (Chlebowy et al., 2015; Clark et al., 2004; Thepwongsa et al., 2017; West et al., 2007). One review evaluating the effect of MI on individuals with T2D noted that two of the six studies examined did not discuss training methods used to teach the general practitioners MI. Similarly, none of the studies included discussed treatment fidelity on the implementation of MI (Thepwongsa et al., 2017). The randomized controlled trial (Chen et al., 2012) noted above also failed to mention the MI training methods and whether fidelity of delivery of MI was monitored. Greaves et al. (2008) designed a randomized controlled trial to assess whether an MI-based intervention delivered by individuals without any healthcare provider experience could have a similar effect on weight loss and an increase in physical activity as some of the larger landmark diabetes prevention programs (Knowler et al., 2002; Lindström et al., 2003; Pan et al., 1997) wherein experienced healthcare professionals were employed. This is different than a number of studies that have highly trained and costly professional counsellors or health care practitioners delivering the MI interventions. Participants identified as being at a high risk of developing T2D based on BMI took part in the study and were either randomized to receive MI or the ‘information only’ in addition to usual care control group. This intervention, similar to the Diabetes Prevention Program (Knowler et al., 2002), consisted of a combination of one-on-one sessions with the health-promotion coach and phone check-ins, where topics such as diet, physical activity and self-monitoring were discussed. Among those who received MI from these non-specialized coaches, 24% achieved at least 5% weight loss six months after their initial 12 consultation session, as compared to only 7% of those individuals in the usual care control (Greaves et al., 2008). Of those in the MI group, 46% achieved the physical activity target of 150 minutes of moderate-to-vigorous physical activity per week, compared to 34% of those in the control group. This study is important in that it shows that individuals not working as health care practitioners can help individuals achieve weight loss, thereby reducing their risk of T2D, through the use of MI. Lack of fidelity assessment appears just as prevalent in MI research in T2D and prediabetes populations as in other populations. A number of MI studies within diabetes populations failed to assess treatment fidelity, and the studies that did assess fidelity tended to be higher quality studies (Phillips & Guarnaccia, 2017). Higher levels of MI skills are thought to have a greater effect on physical activity outcomes. This cannot be said with certainty, however, as there was a lack of fidelity measured and reported (Soderlund, 2018). 1.9 Fidelity It is critical to monitor and report fidelity of intervention components within studies. Fidelity can be broken down into two components: a) treatment integrity: the extent to which the core components of an intervention are delivered as intended by protocol (Bellg et al., 2004; O’Shea, McCormick, Bradley, & O’Neill, 2016), and b) treatment differentiation: the degree to which studies differ from one another in the crucial dimensions (Borrelli, 2011). Fidelity is imperative in all stages and phases of research, implementation and design. 1.9.1 Fidelity in Motivational Interviewing Research Unfortunately, as previously discussed, lack of monitoring treatment fidelity is a reoccurring theme in the literature of MI, specifically in health behaviour change. In a systematic review that examined the effect of MI on increasing physical activity levels in populations with chronic health conditions, a small effect size increased to a moderate effect size when studies that did not assess fidelity were removed from analysis (O'Halloran et al., 2014). It is critical for studies to monitor treatment fidelity as it provides a clear picture of what is happening in the intervention and helps researchers avoid making 13 a type III error. When treatment fidelity is not assessed, it is not possible to make conclusions about the efficacy of treatment, type III errors are more likely, and a study cannot be replicated. Assessing fidelity ensures that counsellors are actually providing MI in an MI-based intervention. It allows one to better understand the elements for an intervention’s success or failure. A number of papers detailing interventions using MI lack information on whether fidelity was measured, how it is measured, when it is measured, and how often it is measured. With these imperative pieces missing from the literature, the real impact of MI is unknown (O'Halloran et al., 2014). The addition of resources needed to assess fidelity may be a reason why researchers often poorly attend to it (O’Shea et al., 2016), although the counter-argument is difficult to ignore. Substantial amounts of resources are put into interventions, and firm conclusions cannot be made on the effectiveness of interventions without knowing whether the intervention protocol was followed. 1.9.2 The Importance of Assessing Fidelity Many researchers have agreed that there are four main areas where fidelity should be assessed: 1) study design; 2) provider training; 3) treatment delivery; and 4) treatment receipt (Bellg et al., 2004; Gearing et al., 2011). Borrelli (2011) argues that there is a fifth area where fidelity should be assessed, which is in treatment enactment. In relation to training new coaches to deliver MI, these five areas can be thought of as: 1) design and protocols of training MI coaches; 2) training coaches in MI; 3) monitoring coaches’ use of MI with clients to ensure MI is being used; 4) monitoring client satisfaction and perception of MI; and 5) monitoring whether clients are using the skills and education that they learned in the intervention. Measuring fidelity allows for confidence in results, improved statistical power (confidence that any observed changed from an intervention were due to the intended delivery of MI), implementation of interventions into community settings, theory development, and comparison and application (Bellg et al., 2004). Further, assessing fidelity provides the opportunity to facilitate skill development by providing ongoing feedback about the program implementation. 14 Implementing fidelity in all steps of the research can be done in a number of different ways. For an MI-based intervention it is crucial to assess fidelity of the MI training process, from the design of the MI workshop to the final piece of treatment enactment by the clients. A model has been designed specifically to assess educational programs such as an MI workshop (Kirkpatrick, 1998). The Kirkpatrick Model is a four-level model developed to evaluate training programs: 1) reaction; 2) learning; 3) behaviour; and, 4) results. Reaction (level 1) is the level that measures how those who take part in training react to it. This can also be thought of as satisfaction with the initial training for counsellors. Learning (level 2) is the extent to which individuals in training change their attitudes, improve knowledge, and/or increase skill as a result of being enrolled in the program. It is imperative that at least one of these change for behaviour to change to occur (Kirkpatrick, 1998). Behaviour (level 3) assesses if there has actually been a behaviour change made as a result from learning. With regards to learning MI, level 3 examines whether counsellors are using MI post-training. Finally, results (level 4) are the final outcomes as a result from taking part in training, which would examine, for example, whether clients’ level of satisfaction with the counselling differ based on MI counsellors’ degree of skill acquisition. 1.10 How to Assess Motivational Interviewing Fidelity Fidelity can be assessed in a number of ways, including checklists, standardized intervention manuals, and coding interactions between provider and participant (Bellg et al., 2004). Coding or evaluating sessions according to a priori criteria is considered to be the gold standard of assessing treatment delivery (Bellg et al., 2004). The field of MI has a few different coding manuals available to assess fidelity and monitor MI skills. The two coding manuals that have most commonly been cited for assessing the quality of MI in health research are the Motivational Interviewing Skill Code (Miller, Moyers, Ernst, & Amrhein, 2008) and the Motivational Interviewing Treatment Integrity (Moyers, Manuel, & Ernst, 2014). Recently, another coding manual, the Motivational Interviewing Competency Assessment (Jackson, Butterworth, Hall, & Gilbert, 2015) was developed to simplify the coding process and to be used as a means to provide 15 feedback to counsellors. All three coding manuals require extensive training to ensure that the manuals are being used appropriately and that coding will be valid and reliable according to each manual’s standards. 1.10.1 Motivational Interviewing Skill Code The MISC was created to be a tool to evaluate the quality of MI in counselling sessions. The most recent MISC manual (version 2.1) has been used in numerous studies for evaluation of MI (Baer et al., 2004; Miller & Mount, 2001; Miller, Yahne, Moyers, Martinez, & Pirritano, 2004). The MISC 2.1 requires two coders to complete three “passes” of each tape (Miller et al., 2008). A “pass” is when the coder listens to the full segment of the audio recording. This means that each of the coders is required to listen to the audio segment three times, with each pass having a different focus. The first pass is for global ratings of both the counsellor and the client. Global ratings are scored on a seven-point Likert-scale. Global ratings for the counsellor assess three dimensions: acceptance, empathy and MI spirit. Global ratings for the client assess only one dimension: self-exploration. The second pass is intended for counting the frequency of 15 separate counsellor behaviour categories: advise, affirm, confront, direct, emphasize control, facilitate, filler, giving information, question (closed or open), raise concern (with or without permission), reflect (complex or simple), reframe, support, structure, warn. The third and final pass codes client’s behaviours. Codes are assigned to client utterances for the following dimensions: reasons (which can be further subdivided into desire, ability or need), other (utterances dealing with types of change talk that are not easily categorized as reasons, such as recognition of problems), commitment language, taking steps toward behaviour change, or follow/neutral (statements that do not move towards or away from behaviour change). The MISC 2.1 provides summary scores based on the codes from the second pass for ratios of reflections to questions, percent of open-ended questions, percent of complex reflections, MI-consistent responses, MI-inconsistent responses, percent MI-consistent responses, and percent client change talk. These are used to provide an overall summary of the quality of the MI in a session. 16 The MISC has several strengths. It is useful for breaking down the counsellor-client interactions. The MISC can be useful in initial training of MI to evaluate skill acquisition because 15 counsellor behaviours are coded, which is more than the number of behaviours coded in the MITI or MICA. The MISC can also be helpful in MI training for a supervisor to provide structured feedback to counsellors based on their scores for each behaviour, however this feedback would likely be extensive due to the number of behaviours that are coded. Finally, the MISC can be used to assess treatment fidelity of MI used in interventions. The MISC also has some weaknesses. The largest weakness of the MISC is that it is time-consuming as it can take more than 60 minutes to code one 20-minute session (Martins & McNeil, 2009). Due to the large number of codes that can be assigned to utterances, the training to use the MISC takes a long time. This may make the MISC less desirable than other coding manuals for the use of providing feedback and monitoring treatment fidelity in interventions, unless feedback is intended to be extremely detailed. 1.10.2 Motivational Interviewing Treatment Integrity The MITI was created with the intention to be used as a tool for monitoring treatment fidelity in interventions, and as a way to provide structured feedback to those using MI (Moyers et al., 2014). The most up-to-date version of the MITI was published in 2015 (version 4.2.1). A random 20-minute segment of a session is selected for coding using the MITI. The MITI suggests that coders use two passes until they are proficient in the coding system, and at that point one pass may be used to capture all the codes. When two passes are being used, the first aims to assess global scores and the second pass is used to capture behaviour counts. Behaviour counts are coded to capture eight specific counsellor behaviours: giving information, persuasion (with or without permission), question, reflection (simple or complex), affirm, seeking collaboration, emphasizing autonomy, and confrontation. One way that the MITI significantly differs from other coding manuals is that it focuses on a particular change goal (e.g., increasing daily physical activity) and keeping on a specific direction 17 towards that goal. Coders should be informed what the change goal of the interaction was prior to beginning coding the session. This allows the coder to more easily be able to determine whether the counsellor is maintaining the focus toward the goal throughout the session. Four global dimensions are coded on a 5-point Likert-scale: cultivating change talk, softening sustain talk, partnership and empathy. The global scores are intended to provide an overall impression of the counsellor. Summary scores can be calculated following the coding of the session to provide an overall impression of the session. The MITI has several strengths. It is considered to be much simpler to use than the MISC, as there are fewer codes to be assigned. The MITI is more time-efficient than the MISC, as it uses only one or two passes (compared to three for the MISC). The MITI can be useful in providing structured feedback on the different global dimensions and specific behaviours. It is diverse in that it can be used to code both novice and experienced counsellors. The MITI also comes with some weaknesses. Unlike the MISC, the MITI only looks at the counsellor’s behaviour and not the behaviour of the client, therefore ignoring the context of the session. The MITI lacks the capability to capture the intentions and strategies of MI, such as evocation and the use of compassion (Moyers, Martin, Manuel, Hendrickson, & Miller, 2005). 1.10.3 Motivational Interviewing Competency Assessment As MI evolved, there became an increasing demand for a coding tool that could be used to provide practical feedback to MI providers working in any service field to help enhance their MI skills. The MICA was developed as a coding manual to be used primarily for providing structured and specific feedback to professionals in any field of work on how to build and improve their MI skills (Jackson et al., 2015). The MICA can help professionals move from a level of MI-competency to MI-proficiency. Similar to the MITI, the MICA codes a 20-minute segment of a counselling session. The MICA uses only one pass of the segment (coders only need to listen to each segment one time to code it). In this pass, MI strategies, namely responding to change and sustain talk are coded, and MI intentions are coded. The five MI intentions aim to capture the overall MI spirit, which include supporting autonomy and activation, 18 guiding, expressing empathy, partnering, and evoking. In addition, frequency scores are generated for two MI microskills. The two microskills are questions and reflections. The MI strategies and intentions are all coded on a scale from 1 (fundamentally inconsistent with MI) to 5 (proficient MI), with half scores being allowed (e.g., 2.5, 4.5). Reliability and validity testing were conducted by researchers at Washington State University (Vossen, Burduli, & Barbosa-Leiker, 2018). Results demonstrated that the MI intentions and strategies in the MICA have good internal consistency, that the MICA and MITI measures were highly related and had good convergent validity, and the MICA has excellent interrater reliability. The MICA has a number of strengths. The primary focus of the MICA is to provide practical feedback to professionals in any field, not just professional counsellors, on how to improve on their MI skills. The MICA can be used on brief sessions/conversations that are as short as 10-minutes, which is a unique feature compared to the MISC and MITI. The MICA recommends scoring each MI intention and strategy starting with a baseline marker of whether the counsellor is operating from a client-centered approach (rating of 3/5), and then either scoring it above or below using the manual. Although a client-centered approach does not necessarily mean the counsellor is operating at a high level of MI-proficiency, it is a good indicator to counsellors and those providing feedback that they are still client-oriented and naturally, intentionally, or unintentionally, achieving crucial elements of MI (Jackson et al., 2015). One of the weaknesses of the MICA is similar to one of the weaknesses of the MITI; that is, the MICA does not specifically code the behaviours of the client. The authors of the MICA explain that the MICA aims to capture an overall impression of how the counsellor uses MI in the session. The MICA scores, therefore, are only based on how the counsellor responds to the client (Jackson et al., 2015). For example, the MICA does not code for client sustain talk, but evaluates the counsellor’s response to client sustain talk. 1.11 Motivational Interviewing Workshop Effectiveness The previous sections of this paper have shown that MI is effective in a variety of settings, administered by a wide array of people with diverse trainings, and for a number of populations. Three 19 coding manuals to assess MI skills and treatment fidelity have also been discussed. This literature review will now detail how MI skills are typically taught to counsellors, and the effectiveness of these training methods. MI workshops that combine didactic instructions and experiential exercises are the most frequently used, and the most effective method for briefly teaching individuals how to use MI (Britt & Blampied, 2010; Madson, Loignon, & Lane, 2009; Miller et al., 2004). MI workshops throughout the literature range in number of days, length (hours), teaching method and who leads the workshop (Madson et al., 2009). A systematic review in 2009 provided an overview of published research on MI training from 1999 to 2007. A total of 28 studies were examined, and length of MI training programs ranged from less than eight hours of training to more than 24 hours of training (Madson et al., 2009). The majority of the studies ranged from 9-16 hours of training. Workshops also vary in the training methods used. The most common form of training is a combination of didactic instruction and experiential practice (Madson et al., 2009). Two-day MI workshops that combine didactic and experiential methods have been shown repeatedly to significantly change the behaviour of counsellors (Baer et al., 2004; Miller & Mount, 2001). Brief two- to three-day workshops are also used in the community to teach MI to different groups of health care practitioners. For example, the Motivational Interviewing Network of Trainers (MINT), an international organization of MI trainers hosts two- to three-day MI introductory workshops. MI skill acquisition post-workshop can be assessed in a variety of ways, such as through coding tools (i.e., the MITI) or the helpful responses questionnaire (HRQ) assessment. The HRQ is a 6-item vignette that provides hypothetical statements and requires the respondent to indicate in one to two sentences how they would respond to the provided scenario. A systematic review of 27 studies in which MI trainings were conducted reports favourable training results. Four of the 27 studies reported an increase in MI skills based on the HRQ. Nine of the 27 studies reported improvements in MI skills as assessed using either the MITI (Moyers et al., 2014) or the MISC (Madson et al., 2009; Miller et al., 2008). Only one of the studies in this review had a non-significant improvement in MI skills using the MITI (Madson et al., 2009). MI 20 skill acquisition post-workshop has also been assessed by coding counselling sessions with standardized patients after two-day workshops have been completed (Baer et al., 2004; Miller & Mount, 2001) using the MISC (Miller et al., 2008). Immediately after a two-day workshop, probation officers had sessions with confederate actors and modest increases were seen in five of six of the global ratings: consistency with overall spirit of MI (ES = 0.27), warmth (ES = 0.28), acceptance (ES = 0.29), empathy (ES = 0.29), and egalitarianism (ES = 0.48), however none of these reached statistical significance, possibly due to small sample size (Miller & Mount, 2001). Statistical significance was reached for pre-post workshop MISC behavioural counts: increased ratio of reflections to questions, increase in reflections, an increase in MI-consistent responses, and an increase in percentage of MI-consistent responses (Miller & Mount, 2001). Two of the global ratings showed significant improvements in a different study for addiction and mental health clinicians: egalitarian and consistency with overall spirit of MI (Baer et al., 2004). Significant increases were also found in the behavioural counts: the ratio reflections to questions, percentage of open-ended questions, and percentage of MI-consistent responses were found pre-post two-day workshop (Baer et al., 2004). Two-day workshops evidently can increase some MI skills from pre- to post-workshop (Baer et al., 2004; Miller & Mount, 2001). There is some research that assesses the impact of having additional training elements after a two-day MI workshop. A randomized controlled trial of MI training methods was conducted to compare five training conditions and MI skill acquisition (Miller et al., 2004). There were 140 participants that were randomized to one of five groups: 1) workshop only – a two-day MI workshop, 2) workshop plus feedback – two-day workshop plus ongoing feedback on practice tapes, 3) workshop plus coaching – two-day workshop and a maximum of six individual phone coaching sessions with a MI training expert, 4) workshop plus feedback and coaching – a combination of groups 2 and 3, and 5) self-training control – a waitlist control condition that was only given a therapist manual and training videos. The self-training control group showed no significant changes in MI skills from baseline to the 4-month mark (Miller et al., 2004). The four conditions that included a workshop all showed significant gains in MI skills from baseline to post-workshop (Miller et al., 2004). The only significant difference between the four 21 conditions that received the workshop was that those who attended the workshop only had lower ratings of MI spirit compared to the other three workshop groups that received training enhancements (i.e., feedback or coaching). The effectiveness of adding supervision and feedback post-two-day MI workshop was also demonstrated in a pilot study with two Diabetes Nurse Educators (Britt & Blampied, 2010). After the workshop, the nurses submitted audio recordings of their counselling sessions with patients over eight weeks to be coded using the MISC behavioural counts (Miller et al., 2008). After the workshop, one nurse reached a level of beginning proficiency in using open-ended questions (50-70% of questions were open-ended) (Moyers, Martin, Manuel, Miller, & Ernst, 2007). The other nurse was below beginning proficiency in using open-ended questions after the workshop (less than 50% of questions were open-ended) (Moyers et al., 2007), but with feedback and supervised practice she reached a level of beginning proficiency for her last four weeks of counselling (Britt & Blampied, 2010). For the behavioural count of the reflections to questions ratio, both nurses were at a low skill level pre-workshop (below a 1:1 ratio) (Moyers et al., 2007). Post-workshop, they still were at a level below beginning proficiency for the reflections to questions ratio. Through the use of feedback and supervised practice they eventually reached a level of beginning proficiency for reflections to questions (Britt & Blampied, 2010). Both nurses reached a level of beginning proficiency in percent of MI-adherent responses immediately post-training (90% of responses were MI-adherent) (Moyers et al., 2007), with one nurse reaching a level of competence in one of her sessions (Britt & Blampied, 2010). A level of competence was reached by both nurses for complex reflections post-workshop (at least 50% of reflections were complex) (Moyers et al., 2007), and competence was maintained over the course of the eight weeks (Britt & Blampied, 2010). This study adds to the information gained from the research of Miller et al. (2004). Namely, feedback and supervised practice enhance the learning acquired from a two-day workshop. A major shortcoming of this research is that the authors did not describe the amount of feedback and supervision provided or how it was provided. 22 It is evident that a two-day MI workshop is sufficient in teaching some MI skills (Baer et al., 2004; Miller & Mount, 2001), and learning is enhanced with the addition of supervised practice and feedback (Britt & Blampied, 2010; Miller et al., 2004). Skill-level may not consistently be at a level of competency but appears to approach the early level of proficiency (Baer et al., 2004; Madson et al., 2009; Miller & Mount, 2001). The next section covers how long one can expect these skills to last post-workshop completion based on existing literature. 1.11.1 Drift in Motivational Interviewing Skills A study conducted by Miller and Mount (2001) examined a two-day MI workshop delivered to 22 probation officers. The MISC (Miller et al., 2008) was used to code officer sessions with a standardized client pre- and post-workshop. Four months post-workshop, the officers were asked to submit an audio recording of one counselling session with a client to be coded using the MISC (Miller et al., 2008). An increase in percent of open-ended questions were found from pre- to immediately post-workshop when behavioural counts were coded. At the 4-month timepoint, officers were back to near-baseline level (Miller & Mount, 2001). A very similar pattern was also found in the percentage of complex reflections, with skills returning to a level similar to that observed at baseline (Miller & Mount, 2001). Other counsellor behaviours and skills increased immediately post-workshop and were maintained (Miller & Mount, 2001). A two-day MI workshop for addiction and mental health counsellors showed a drift in MI skills from baseline to one-week post-workshop to two months follow-up (Baer et al., 2004). Findings from the HRQ assessment showed significant increase from baseline to both one-week post-workshop and two months post-workshop. However, the findings show a significant decline in MI skills from one week post-workshop and to two months post-workshop (Baer et al., 2004). Counsellor’s MI skills were also assessed at each of the three time points in a simulated session with one of two confederate actors. These sessions were coded, and there was a significant increase in the reflections to questions ratio from baseline to one-week post-workshop. This increase in the reflections to questions ratio was maintained at 23 the two-month follow-up (Baer et al., 2004). Significant increases in percentage of open-ended questions and MI-consistent behaviour were found from baseline to one-week post-workshop. At the two-month follow-up, both percentage of open-ended questions and MI-consistent behaviour had declined to a level that no longer significantly differed from the respective baseline level (Baer et al., 2004). A meta-analysis was conducted to provide an overall impression of MI skill drift post-workshops (Schwalbe, Oh, & Zweben, 2014). The meta-analysis included 21 studies, which examined MI skill retention of 987 service providers (Schwalbe et al., 2014). The majority of studies included in this article used two-day MI workshops that consisted of a mix of didactic and experiential learning. An effect size of d = 0.76 was found when MI skills were assessed immediately post-workshop. For studies that only provide counsellors with a workshop, skills began to decline at three months post-workshop (d = -0.17) (Schwalbe et al., 2014). Providing post-workshop enhancements, such as feedback, at follow-up time points appear to slow down the decline of MI skills in counsellors compared to studies that only offer counsellors a workshop without additional feedback (Schwalbe et al., 2014). When enhancements to the workshops were provided, post-workshop counsellors appeared to maintain skills over a six month period (Schwalbe et al., 2014). This meta-analysis also examined the effect of the length of time of the post-workshop enhancements on the decline of MI skills. This provides one final important finding; post-workshop training enhancements that were 5-12 contact hours or more showed greater MI skills at 6-month follow-up (d = 0.19), compared to enhancements that were less than five hours (Schwalbe et al., 2014). Drift in MI skills can and does occur post-workshops. Skill drift can be minimized through the addition of post-workshop enhancements, such as feedback and supervised practice. Review of the previous literature does not give a conclusive overview of exactly which skills decline, nor the exact timeline of when the skills decline begins. This thesis addressed these important gaps in the literature by examining the MI skill acquisition and decline of newly trained counsellors who delivered a diabetes prevention program called Small Steps for Big Changes (SSBC). 24 1.12 Small Steps for Big Changes 1.12.1 What is Small Steps for Big Changes? SSBC is a community-based lifestyle program for individuals with prediabetes. The primary aim of SSBC is to help empower individuals with prediabetes to make long-lasting exercise and dietary changes to decrease their risk of developing T2D. Findings from a pilot feasibility study (Jung, Bourne, Beauchamp, Robinson, & Little, 2015; Locke et al., 2018) and a randomized controlled trial (Bourne, Ivanova, Gainforth, & Jung, 2019; Bourne, Little, et al., 2019) informed the development of the community-based intervention. The SSBC pilot study demonstrated increases with large effect sizes from preintervention to the 24-week follow-up in task self-efficacy and self-regulatory efficacy (Locke et al., 2018). There was a small-to-moderate effect size for increase in relative VO2peak from the pre-intervention to 24-week follow-up, as well as a significant increase in moderate-to-vigorous physical activity both one- and six- months post-program (Jung et al., 2015; Locke et al., 2018). Through the process of translating SSBC into the community, slight changes were made from the randomized controlled trial to increase reach and to make it a more sustainable program. The revised SSBC model includes the addition of MI used in the counselling sessions as there was a call from the trainers in the RCT to implement a more personalized and client-centered approach. The current model of SSBC, the community-based intervention, began in June 2017 and is operated out of the YMCA downtown Kelowna. There are two phases of the SSBC program. First, clients attend six sessions with an MI-trained coach over the course of three weeks (note: staff delivering SSBC are referred to as “coaches”, to highlight their lack of professional experience as a health care professionals, and to remind the reader that they do not have formal training as a professional counsellor). During the six sessions, coaches utilize evidence-based techniques, including MI and a workbook, to discuss topics on diet and exercise that can help decrease the risk of developing T2D (i.e., reducing the consumption of added sugar, physical sensations during exercise, and strategies to maintain diet and physical activity changes over time). Sessions last approximately 35-50 minutes each. Subsequently, 25 clients transition into the one-year follow-up phase, where clients are contacted by their coach one-month post-program for a follow-up phone call, and then asked to come back to the YMCA at six- and 12-months post-program for follow-up testing. Clients are also asked to come in before any of their six sessions for baseline testing at the YMCA for anthropometric measurements, questionnaires, and a 6-minute walk test. The program is structured in a way that approximately every four weeks new clients begin the program. This means that about once a month each coach begins sessions with one (or more) new clients. Approximately 12 clients join SSBC each month. 1.12.2 Motivational Interviewing Training for Small Steps for Big Changes Coaches The MI training for new SSBC coaches followed a similar format to other two-day MI workshops found in the literature (Baer et al., 2004; Ivanova, Davis, Cranston, & Jung, in preparation; Miller & Mount, 2001). There were three phases to the MI training for SSBC coaches: 1) a two-day workshop; 2) shadowing an experienced MI coach; and 3) being shadowed by the MI instructor and receiving feedback. The workshop (phase one) was an intensive 12-hour workshop that spanned over two days. The MI instructor was a registered clinical psychologist with knowledge in MI and other counselling styles. The workshop was a mixture of didactic and experiential learning. Topics such as the spirit of MI (compassion, acceptance, partnership, and evocation), the four processes of MI (engaging, focusing, evoking, and planning), and the four micro-skills of MI (open-ended questions, affirmations, reflections and summaries) were covered. Coaches also learned how to listen to and respond to change talk, ambivalence and sustain talk. Videos and role-playing were two of the techniques used in the workshop to teach coaches MI. Following the workshop phase, new coaches shadowed the workshop instructor or an experienced SSBC coach for six counselling sessions with a client (phase two). The next month, the new coaches led six counselling sessions with a client while the MI instructor observed (phase three). At the end of each of these six sessions, new coaches had a conversation with the MI instructor where both positive and 26 negative feedback are provided, and the new coaches had the chance to discuss missed opportunities or what they could do differently. All sessions with clients were audio-recorded with consent. The purpose of the recordings was for quality assurance and fidelity checks. After phase three of the MI training, coaches were on their own to meet with SSBC clients independently. Taken together, all new coaches received about 24 to 28 hours of MI-informed training when all three phases of training were combined. 1.13 Objective The objective of the study was to examine the MI skills of newly trained coaches delivering SSBC in the community up to six months after their initial three-phase MI-training. MI-informed counselling has demonstrated effectiveness for changing lifestyle behaviours. The fidelity of delivering MI over time has received less attention in health care research. It is imperative that the fidelity of MI skills over time be monitored and examined to ensure that interventions and programs are truly using MI as stated in protocols. This study evaluated level three of the Kirkpatrick Model and assessed whether SSBC coaches were applying the MI skills that were taught in the MI training workshop and through the supervised feedback. 1.14 Hypothesis The objective of this thesis was exploratory. Previous studies have shown that MI skills begin to decline post training, but it is difficult to know the extent and cause of the decline due to lack of fidelity checks in the literature. There is no gold standard established for MI training workshops, so it was unknown whether after our three-phase training drift in skills will occur and if it did at what time point post-training the coaches would fall below competency (Baer et al., 2004; Miller et al., 2004; Schwalbe et al., 2014). 27 Chapter 2: Manuscript 2.1 Overview More than 6 million Canadians are currently living with prediabetes (Diabetes Canada, 2017). Prediabetes is a condition that is characterized by elevated fasting glucose and/or impaired glucose tolerance that increase the risk of developing type 2 diabetes (T2D) (Tabák et al., 2012). Untreated prediabetes can develop into T2D within five years (Centers for Disease Control and Prevention, 2017; Ramachandran & Snehalatha, 2011). Diabetes and its related complications costs the Canadian health care system more than $3 billion annually, and it is projected that the costs will increase by 25% by 2025 (Diabetes Canada, 2017). It is important to prevent the progression of prediabetes to T2D to reduce morbidity, mortality, and burden on the health care system. Individuals with prediabetes can reduce their risk by increasing physical activity and adhering to a healthy diet, as shown in three landmark intervention trials, the Diabetes Prevention Program (Knowler et al., 2002), the Finnish Diabetes Prevention Study (Lindström et al., 2003), and the Da Qing IGT and Diabetes Study (Pan et al., 1997). The aforementioned lifestyle interventions, however, were highly controlled, time intensive for both highly qualified health care professionals and participants, and very costly to administer (Hernan et al., 2003). Such programs and similar interventions are not sustainable in community settings due to the required the time and resources. Programs that can be offered outside of the laboratory (i.e., in the community) and delivered by individuals without extensive training or a high level of education are needed because this would make programs more sustainable and affordable. Motivational interviewing (MI) is one communication style that has been shown to be an effective mode of delivery to deliver such programs to help elicit clients’ own motivations to make lifestyle changes. MI is a counselling style that has been used effectively in a wide spectrum of health behaviour change research, including the management of chronic diseases (Burke et al., 2003; DiClemente et al., 2017; Martins & McNeil, 2009; O'Halloran et al., 2014; Rubak et al., 2005; Schaefer & Kavookjian, 2017). MI is a client-centered collaborative counselling style that aims to help clients strengthen their motivation and commitment to change (Rollnick & Miller, 2013). Initially 28 born in the context of addiction treatment in the 1980s (Miller, 1983), MI has since been effectively used in helping individuals with prediabetes and T2D control their glucose levels (Chen et al., 2012; Chlebowy et al., 2015; Phillips & Guarnaccia, 2017; Smith et al., 1997; Thepwongsa et al., 2017; West et al., 2007), increase physical activity (Chlebowy et al., 2015; Phillips & Guarnaccia, 2017; Soderlund, 2018; Thepwongsa et al., 2017), reduce body mass index (BMI) and waist circumference (Chlebowy et al., 2015; Clark et al., 2004; Thepwongsa et al., 2017; West et al., 2007) and engage in dietary changes, both alone and in combination with other interventions. (Clark et al., 2004). Diabetes prevention studies using MI delivered by individuals not working as healthcare practitioners have also been shown to be effective in participants’ weight loss and increased physical activity results (Greaves et al., 2008). This demonstrates that MI can possibly be learned and delivered by individuals without extensive backgrounds in healthcare or psychology. MI centers around the quality of the counsellor-client interaction (Morton et al., 2015) and broadly includes four processes and four communication skills. During an interaction using MI the following processes occur: 1) engaging the client, 2) focusing the conversation towards a specific goal, 3) evoking a client’s reasons and motivations for change, and 4) planning specific actions to take towards reaching their goals. Communication skills that are emphasized in MI include: 1) open-ended questions, 2) affirmations, 3) reflections, and 4) summaries. These skills are used to help clients explore the changes that they want to make and their motivation for making these changes. High-quality MI interactions generally consist of more reflections than questions to help clients verbalize and further explore what they are thinking, which provides the counsellor an opportunity to show empathy (Rollnick & Miller, 2013). These communication skills can be used by counsellors to elicit change talk – a client’s arguments for making change (Rollnick & Miller, 2013). Similarly, appropriate use of these communication skills can weaken sustain talk or arguments against making change (Rollnick & Miller, 2013). In addition to the technical and communication skills, MI also includes a relational aspect – the spirit of MI. The spirit of MI refers to building a strong counsellor-client relationship using four processes: 1) compassion and empathy, 2) acceptance, 3) partnership, and 4) evocation. A strong counsellor-client relationship helps a 29 client to begin to make behaviour changes that they are ambivalent, or on the fence about making. Counsellors using MI are there to help guide clients to make the changes that they want to make. Treatment fidelity is the extent to which an intervention is delivered as intended. Treatment fidelity is often left unreported in studies using MI for health behaviour change. This is no different in the T2D prevention and management literature, where few studies using MI have reported any measure of MI delivery fidelity, so conclusions cannot be drawn. Measuring fidelity allows for confidence that any observed changed from an intervention were due to the intended delivery of MI. Assessing fidelity also prevents researchers from measuring the effects of MI on a behaviour change when MI was not in fact delivered (type III error), and increases the likelihood that researchers will detect an effect of MI when that effect is present. Finally, the measurement of fidelity allows for researchers to be confident in implementation of interventions into community settings (Bellg et al., 2004). Further, assessing fidelity provides the opportunity to facilitate skill development by providing ongoing feedback about the program implementation. Unfortunately, lack of monitoring of treatment fidelity is a common in the MI literature, specifically in health behaviour change. In a meta-analysis by O'Halloran et al. (2014) a small effect size was found for studies that examined the effect of MI on increasing physical activity levels in populations with chronic health conditions, however this small effect size increased to a moderate effect size when studies that did not assess fidelity were removed from analysis. Similarly, studies that assess fidelity of MI in populations with T2D tend to be of higher quality than those that do not assess fidelity (Phillips & Guarnaccia, 2017; Thepwongsa et al., 2017). Assessing treatment fidelity ensures that counsellors are actually providing MI in an MI-based intervention. The assessment of treatment fidelity allows one to better understand the elements for an intervention’s success or failure. Of the few studies that have assessed MI fidelity, assessments often include coding manuals that assess specific factors according to a priori criteria, which is considered to be the gold standard of assessing treatment fidelity. Coding manuals allow for skills and processes associated with MI to be scored and counted to ensure that MI is being used when it is intended to be used. Fidelity of MI workshops to assess whether counsellors are improving skills from pre- to post-workshop is also 30 important to consider. MI workshops have often been assessed by coding sessions where counsellors meet with a standardized patient once prior to the workshop and then again after the workshop. Another way workshop fidelity is assessed is through the helpful responses questionnaire (HRQ), a 6-item vignette that provides hypothetical statements and requires the respondent to indicate in 1-2 sentences how they would respond to the provided scenario. In order to test whether MI is being used in an intervention, first individuals must learn the MI counselling skills and processes. Two-day MI workshops that combine didactic and experiential methods have repeatedly shown significant changes in counsellors’ behaviour, specifically to increase behaviours consistent with MI: reflections to questions ratio, number of reflections, number of MI-consistent responses, and consistency with overall spirit of MI (Baer et al., 2004; Miller & Mount, 2001). Furthermore, it has been demonstrated that the addition of supervision and feedback following two-day MI workshops is more effective than a two-day workshop alone (Britt & Blampied, 2010; Miller et al., 2004). Although MI workshops have been shown to be effective, it is important to note how long these skills are maintained for. It appears that skills such as percentage of open-ended questions, percentage of complex reflections, MI-consistent responses may decline between two and four months post-workshop (Baer et al., 2004; Miller & Mount, 2001). However, the decline of MI skills slowed and were found to be maintained over a 6-month period post-workshop when post-workshop enhancements (i.e., feedback and supervision) were provided (Schwalbe et al., 2014). Specifically, post-workshop training enhancements that were 5-12 contact hours or more showed greater MI skills at 6-month follow-up compared to enhancements that were less than five hours (Schwalbe et al., 2014). Review of previous literature does not give a conclusive overview of exactly which skills decline, nor the exact timeline of when the skills begin to decline. This paper aimed to address these important gaps in the literature by examining the MI skill acquisition and decline of newly trained counsellors who delivered a diabetes prevention program called Small Steps for Big Changes. Small Steps for Big Changes (SSBC) is a community-based lifestyle program for individuals with prediabetes. The primary aim of SSBC is to help empower individuals with prediabetes to make long- 31 lasting exercise and dietary changes to decrease their risk of T2D. SSBC clients attend six sessions with an MI-trained coach over the course of three weeks. Coaches deliver sessions using MI-informed techniques to discuss topics on diet and exercise (i.e., reducing consumption of added sugar, physical sensations during exercise, and strategies to maintain diet and exercise changes over time). Approximately every four weeks new SSBC clients begin the program, which means that each coach begins sessions with one (or more) new clients each month. The MI training for new SSBC coaches followed a similar format to other two-day MI workshops found in the literature (Baer et al., 2004; Ivanova et al., in preparation; Miller & Mount, 2001). The MI-informed three phase training protocol and results for new SSBC coaches is published elsewhere and will not be discussed in full (Ivanova et al., in preparation). Briefly, all SSBC coaches attended a two-day MI-informed workshop (phase one) in which they learned the skills and processes needed to deliver the SSBC content using MI. The workshop was a mixture of didactic and experiential learning, with topics covered such as the spirit of MI (compassion, acceptance, partnership, and evocation), the four processes of MI (engaging, focusing, evoking, and planning), and the four micro-skills of MI (open-ended questions, affirmations, reflections, and summaries). Coaches also learned how to listen to and respond to change talk, ambivalence, and sustain talk. Following the workshop, coaches shadowed an expert in delivering SSBC (phase two), and then they were reverse shadowed by the MI instructor who also provided feedback to ensure their understanding and comfort in delivering SSBC in an MI-informed manner (phase three). Following this three-phase MI training, coaches worked independently with clients. The objective of this study was to examine the MI skills of newly trained coaches delivering SSBC up to six months after their initial three-phase MI-training. It is imperative that the fidelity of MI skills over time be monitored and examined to ensure that interventions and programs are truly using MI as stated in protocols and methods. 32 2.2 Methods Study design All SSBC sessions between client and coach were audio-recorded. One session per client was coded within coaches’ first six months delivering the SSBC intervention post-training. An online random numbers generator was used to randomly select sessions to be coded. The two coders (K.C. and E.I.) were also randomly assigned to independently code approximately half of the selected sessions. About one-quarter of the coded sessions were randomly assigned to be double-coded by both coders. Each month, the coders would code the most recent sessions from coaches and discuss the scores on the double-coded sessions to minimize coder drift. Recruitment Participants were recruited through word of mouth from previous coaches and the principal investigator, the university job board, and advertising to undergraduate students about the opportunity during classes and emails offering practicum and research placement opportunities. Eligible participants were naïve to MI and agreed to be coaches in SSBC. There were no specific educational backgrounds required. Participants were informed about the evaluation and consented to participating. Measures Demographics. Participants self-reported their age, self-identified gender, ethnicity, highest education level completed, area of degree completed (if applicable), years of counselling experience, and if they had ever received MI training. Motivational Interviewing Competency Assessment. The Motivational Interviewing Competency Assessment (MICA) (Jackson et al., 2015) is a coding tool developed to evaluate a practitioner’s MI competency from a quality assurance perspective, and to help provide feedback to practitioners on how they can improve their MI skills. In the MICA, MI micro-skills, strategies and intentions are coded. The two micro-skills that are counted are the number of reflections and questions made. Miller and Rollnick (2002) established that those skilled in MI should have a ratio of reflections to questions (R:Q) 3:1. The MICA codes R:Q  2:1 as MI-competent. In the present study, it was not expected for coaches to reach 33 this 2:1 ratio, as SSBC coaches were instructed to deliver specific SSBC intervention content, which requires a number of questions specifically for brief action planning and goal setting. The MICA also codes two MI strategies: 1) strategically responding to change and 2) strategically responding to sustain talk; and five MI intentions: supporting autonomy and activation, guiding, expressing empathy, partnering, and evoking. Each strategy and intention is scored out of five, with a score of three out of five considered being a level of client-centered care and four out of five or higher designating MI-competent or MI-proficient (see Table 1 for full scoring rubric). The MICA scoring rubric permits half scores. In the case of sustain talk or change talk being absent from the coded session, the MICA instructs coders to give a score of 3/5. A total MICA score is generated by summing the average score of the two MI strategies with the average of the five MI intentions. The MICA R:Q and frequency of MI strategies and intentions are all reported in Table 2. Training to Use the MICA The MICA was chosen because it was designed to provide practitioners with practical feedback that can assist in building MI skills. Importantly, the MICA was also chosen because it has real-world applicability in that it is less time-intensive to learn and to use for coding a large number of sessions. This coding tool could continue to be used when SSBC is scaled-up. To ensure appropriate use of this coding tool, two coders (K.C. and E.I.) received training on using the MICA through the Centre of Collaboration, Motivation and Innovation (CCMI, 2018). Training was delivered by one of the MICA authors (A.H.) and consisted of six hours of webinars with other MI specialists. The webinar covered information topics including why the MICA was developed, how to code each skill and intention, coder agreement standards, and coding practice along with discussion on how/why certain scores were given. The coders (K.C. and E.I) also received extra practice with an MI expert (C.D.) to ensure that they were able to reach MICA agreement standards with one another and with the MI expert. Both the second coder (E.I.) and myself were members of the Diabetes Prevention Research Group, which is the research lab that developed and delivers SSBC. 34 MICA Coding and Analysis In the context of SSBC, coders listened to 20-minute segments (according to MICA standards) of each coach-client session audio recording – the first 15 minutes and the last five minutes. These segments of sessions were chosen to be coded as we predicted that they would cover the most similar content. The first 15 minutes generally consisted of coaches reviewing the clients’ goals from the previous session and beginning to cover the information topic for the respective session; they were to end a session by creating new goals. Coders completed sentence stem sheets as they listened, capturing the main ideas of both the coaches’ and clients’ statements. In alignment with MICA coding instructions and protocol, coders were not required to transcribe the recorded sessions verbatim, as the coders were listening for questions, reflections, and the overall impression of the session (Jackson et al., 2015). As coders listened, they coded statements as questions, reflections, or no code. After listening to the 20-minute segment, coders counted questions and reflections, and scored each MI intention and strategy out of five. The MICA has specific coder agreement standards when double-coding occurs. The scores of the two coders were required to be within 0.4 of one another for the reflection to question ratio. If coders were not within 0.4 of one another, the sentence stem sheets filled out by each coder were examined and discussed to see if agreement could be reached on the coding of statements as questions or reflections. For each intention and strategy, the two coders must have been within 1 point of each other. Discussion occurred when coders did not meet this agreement standard, and then coders reviewed their notes and sentence stems to explain why certain scores were given. Coders were able to decide on a new score together. The total MICA scores calculated must have been within 0.8 of one another. Similar to above, coders discussed with one another if this agreement standard was not met and resolved any disagreements in coding. The two coders disagreed on five of the total 135 scores given for double-coded sessions, equating to a 96.3% agreement rate. Disagreements were resolved through discussion between the two coders on explanations for scores given. The coders reached agreement through discussion in all five 35 cases. An audit trail for the sentence stem sheets and the original coding scores and scores resolved through discussion exists. 2.3 Results Participants Seven participants completed the MI training, coached clients independently and were included in the current study. The coaches were thee undergraduate- and four graduate-level students. Areas of study included psychology and kinesiology/exercise sciences. The mean age of coaches was 24.71 years old (SD = 2.43), and five of the seven coaches identified as women. Of the seven coaches, two were considered to be “incompleters” of the study, as one only coached for one month post-training, and the other only coached for two months post-training. Both of the “incompleters” completed their undergraduate degrees at approximately the same time that they stopped coaching. The remaining five coaches completed sessions with clients for the entire 6-month duration of the study. Analyses for the MICA in months one and two include averages for all seven coaches, but also show averages for just the five coaches who completed all six months (please see Table 2). Coding A total of 56 sessions were coded for the seven coaches involved in the study. The first two rounds of coded sessions were all double-coded to ensure that both coders were in agreement with scores given. The subsequent rounds of coding consisted of a smaller sample of sessions double-coded each month to prevent coder drift. Of the 56 sessions coded, 15 were double-coded by both coders (K.C. and E.I.). Coder agreement was found to be moderate (ICC=0.67). Each month coaches had between one and three clients. For coaches who had more than one client in a month, their scores for each client were averaged for each strategy and intention to create one score per month per coach. For more information on how many clients each coach had per month see Table 3. 36 MICA scores The means and standard deviations of the R:Q, scores for each strategy and intention, and the total MICA score for each of the six months post-training are provided in Table 2. Generally, coaches who completed the 6-month duration study were operating at a level of client-centered care immediately post-training and maintained that level of care for the entire 6-month duration of the study. No major increases or decreases in any of the strategies or intentions were seen during the six months post-training. Coaches who did not complete the 6-month duration were operating at a level of MI-inconsistency for the majority of the strategies and intentions. Sustain talk was absent from the majority of coded sessions and was therefore given a score of 3/5 by default for these sessions. This explains the lack of variability between coaches’ scores for strategically responding to sustain talk. 37 Table 1. MICA scoring definitions. MICA Score (/5) General definition of score 1 Fundamentally inconsistent with MI. Absence of MI intentions and skills. Missing most elements of MI, and the conversation being coded has no indicators representing a client-centered approach. 2 Generally inconsistent with MI. Attempts toward MI are missing the underlying intentions and skills. May naturally, intentionally, or unintentionally hit elements of MI, yet the conversation coded does not represent a client-centered approach. 3 Consistencies and inconsistencies with notable attempts to align with MI intentions and skills at a ‘do no harm’ level. Naturally, intentionally, or unintentionally hits elements of MI, yet the conversation being coded represents a client-centered approach. 4 Competent MI. Primarily consistent with MI intentions and skills. Intentionally and purposefully focuses on elements of MI, which is solidly a client-centered approach. 5 Proficient MI. Adept and consistent with MI intentions and skills. Deftly orchestrates elements of MI, and the conversation coded embodies a client-centered approach. Note. Definitions of scores as directly worded from the MICA (Jackson et al., 2015). 38 Table 2. Average MICA scores of Small Steps for Big Changes coaches each month post-training. Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Full sample a Completers b Full sample c Completers Completers Completers Completers Completers Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) R:Q .55(.28) .57(.32) .78(.61) .87(.65) 1.37(.99) .75(.34) .76(.23) 1.40(1.45) ST 3.03(.09) 3.00(.00) 3.08(.37) 3.16(.35) 3.20(.33) 3.10(.24) 3.05(.16) 3.07(.19) CT 2.91(.67) 3.21(.29) 3.08(.60) 3.34(.23) 3.25(.30) 3.28(.42) 3.23(.25) 3.21(.39) Autonomy 3.09(.77) 3.46(.40) 3.15(.54) 3.31(.40) 3.45(.60) 3.40(.61) 3.33(.50) 3.50(.58) Guiding 3.00(.69) 3.29(.51) 3.43(.67) 3.53(.71) 3.43(.32) 3.55(.50) 3.53(.42) 3.29(.76) Empathy 2.84(.50) 3.08(.26) 3.10(.46) 3.25(.38) 3.32(.34) 3.35(.43) 3.30(.48) 3.29(.49) Partnership 3.00(.67) 3.33(.30) 3.10(.91) 3.50(.40) 3.64(.45) 3.53(.53) 3.33(.50) 3.36(.63) Evoking 2.97(.62) 3.25(.39) 3.13(.52) 3.34(.23) 3.30(.53) 3.35(.39) 3.25(.42) 3.21(.57) Total 5.95(.89) 6.39(.35) 6.26(.93 6.64(.52) 6.65(.56) 6.62(.65) 6.47(.55) 6.47(.68) Note. R:Q is the reflections to questions ratio; ST is sustain talk, and CT is change talk a Full sample means in Month 1 are based on seven coaches b Completers means are based on the five coaches that took on clients for all six months c Full sample means in Month 2 are based on six coaches 39 Table 3. Number of clients each coach had per month. Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Coach 1 1 1 2 2 3 1 Coach 2 1 2 2 3 2 1 Coach 3 2 2 3 1 1 2 Coach 4 1 2 n/a n/a n/a n/a Coach 5 1 1 3 2 2 1 Coach 6 1 n/a n/a n/a n/a n/a Coach 7 1 2 1 2 2 2 Note. n/a for months after a coach stopped taking on clients. 40 Figure 1. Coaches’ Strategically Responding to Sustain Talk scores post-training. 0123451 2 3 4 5 6MICA scoreMonth post-trainingCoach 1Coach 2Coach 3Coach 4Coach 5Coach 6Coach 7 41 Figure 2. Coaches’ Strategically Responding to Change Talk scores post-training. 123451 2 3 4 5 6MICA scoreMonth post-trainingCoach 1Coach 2Coach 3Coach 4Coach 5Coach 6Coach 7 42 Figure 3. Coaches’ Supporting Autonomy and Activation scores post-training. 123451 2 3 4 5 6MICA scoreMonth post-trainingCoach 1Coach 2Coach 3Coach 4Coach 5Coach 6Coach 7 43 Figure 4. Coaches’ Guiding scores post-training. 123451 2 3 4 5 6MICA scoreMonth post-trainingCoach 1Coach 2Coach 3Coach 4Coach 5Coach 6Coach 7 44 Figure 5. Coaches’ Expressing Empathy scores post-training. 123451 2 3 4 5 6MICA scoreMonth post-trainingCoach 1Coach 2Coach 3Coach 4Coach 5Coach 6Coach 7 45 Figure 6. Coaches’ Partnering scores post-training. 123451 2 3 4 5 6MICA scoreMonth post-trainingCoach 1Coach 2Coach 3Coach 4Coach 5Coach 6Coach 7 46 Figure 7. Coaches’ Evoking scores post-training. 123451 2 3 4 5 6MICA scoreMonth post-trainingCoach 1Coach 2Coach 3Coach 4Coach 5Coach 6Coach 7 47 Figure 8. Coaches’ total scores post-training. 2468101 2 3 4 5 6MICA ScoreMonth post-trainingCoach 1Coach 2Coach 3Coach 4Coach 5Coach 6Coach 7 48 2.4 Discussion Fidelity is an often overlooked yet crucial aspect of research. Understanding the degree to which an intervention is implemented as intended allows for accurate interpretation of results, appropriate conclusions to be drawn, and replicability (Bellg et al., 2004). The objective of this study was to monitor the MI skills of newly trained SSBC coaches for the six months following their three-phase MI-training. Immediately post-MI training, the majority of coaches were operating at a level of client-centered care, a skill level that was maintained for the 6-month duration of the study. The five coaches that completed the study and independently trained clients for up to six months were able to deliver the SSBC intervention in a client-centered approach. No decline in any of the MI strategies or intentions were seen, and conversely, no increases were seen. Even though coaches were operating at a level one step below that of “MI competence”, as defined by the MICA scoring rubric, providing client-centered care has been emphasized as an important clinician skill. The idea of client-centered practice first appeared in psychology (Rogers, 1959) and has since been adopted by rehabilitation clinicians (Bright, Boland, Rutherford, Kayes, & McPherson, 2012). Specifically, a client-centered approach is foundational in the field of occupational therapy (Townsend, Polatajko, & Canadian Association of Occupational Therapists, 2013), and has been shown to improve health outcomes (Black, 2005; Sumsion, 2005). A client-centered approach “embraces a philosophy of respect for, and partnership with, people receiving services” (p. 253 in (Law, Baptiste, & Mills, 1995)). Client-centered care closely aligns with many of the core ideas of MI such as compassion, empathy, and active listening, all of which have been shown to enhance positive outcomes associated with care (Halstead, 2001; Thorne, Harris, Mahoney, Con, & McGuinness, 2004). In contrast, Jackson et al. (2015) define MI competence as operating at a level that is intentionally and purposefully focused on MI intentions and skills, which differs slightly from their definition of client-centered care: operating at a level that “naturally, intentionally, or unintentionally hits elements of MI”. Because of the novelty of the measure, we are not aware of any studies that have reported the frequency in which novice coaches reach either of these categories, or what effect either category has on client outcomes. The SSBC coaches 49 reached and maintained a level of client-centered care which may be effective at helping individuals make health behaviour changes. It is difficult to speculate if there was anything unique about the two coaches who were at an MI-inconsistent level of coaching, thus we can only speculate as to why these coaches were MI-inconsistent and non-completers. Both of these individuals completed their undergraduate degrees during this study and one moved away while the other accepted full-time employment unrelated to this study. No qualitative data or exit-interviews were conducted to ask these individuals about their perception of their MI skills. Contrary to previous literature demonstrating a decline in MI skills over time (Baer et al., 2004; Miller & Mount, 2001), there was no decline in skills observed among SSBC coaches. This maintenance of skills may be due to several reasons. First, the second and third phase of the training (i.e., shadowing and reverse-shadowing) may have improved coaches’ understanding of these skills and processes allowing them to maintain skills for longer periods of time, as also demonstrated in previous work (Schwalbe et al., 2014). Second, the five coaches that participated in the full duration of this study were all involved in other areas of research within SSBC. Perhaps these coaches were more invested in their clients’ outcomes due to the implications on their own research projects (i.e., adherence to physical activity, evaluation of SSBC). As well, these coaches self-selected to be SSBC coaches that would go through MI training. Individuals who choose to take part in the MI training might be interested in this counselling style or see it as aligning with their own personality (e.g., an individual high in empathy might be more keen to learn a client-centered counselling style compared to an individual who enjoys telling people what to do). Third, it is possible that by auditing the coaches through audio recordings, the coaches were more cognisant of the skills and processes they were being judged on and were therefore more likely to use those skills learned in the MI-workshop. It might also be the case that client-centered communication might be easier to maintain when compared to MI. It is possible that no drift in skills was seen because none of the SSBC coaches started at a level of MI-competence. 50 2.4.1 Strengths and Limitations By assessing MI skills of coaches over the six months post-MI training, it can be concluded that the SSBC was delivered in a client-centered manner informed by MI techniques. This study also adds to the literature that this three-phase MI training style (two-day workshop, shadowing and reverse shadowing) is effective at teaching coaches a client-centered style of counselling that can be maintained for at least six months without the use of any booster training session. None of the coaches had previous counselling experience and were all university students (ranging from less than a bachelor’s degree to less than a PhD), and yet were able to learn MI-informed techniques and operate at an effective level of counselling after a two-day workshop plus shadowing time. Lastly, the method of assessing fidelity was minimal compared to other options of using a more time-intensive coding tool or other methods of assessment (i.e., MISC (Miller et al., 2008), MITI (Moyers et al., 2014)). Despite these strengths, this study is not without limitations. First, the lack of a control group limits the conclusions that can be drawn on which aspects of the training led to the maintenance of skills for six months (the workshop, shadowing, or reverse-shadowing). The sample of coaches is also a limitation. This sample might not be an accurate representation of other individuals who would be working within a diabetes prevention program, such as diabetes educators or dietitians. The small sample size and lack of variability between coaches did not allow for statistical analyses to be conducted. With a larger sample size and more variability between coaches’ scores, it may have been possible to analyze whether clients with coaches who were operating at a higher level of MI had better outcomes (i.e., physical activity adherence, decreased HbA1c, BMI reduction) than those who had coaches operating at a level below client-centered care. Another limitation was that SSBC coaches were providing a very specific intervention and had topics that they aimed to discuss with clients within each session. Therefore, given the structured nature of the content, it is possible that this is why coaches were unable to provide an MI-competent level of care. 51 2.4.2 Future Directions In order to address this study’s limitations, future research should focus on aspects of the post-workshop enhancements to determine what is driving the maintenance of skills while also including a larger and more variable sample of coaches. Additionally, studies should address whether this three-phase MI training is effective in other client and coach populations. Within SSBC, future research regarding coaches’ skills can examine if and how skills can improve from client-centered to MI-competent. Perhaps additional training via a booster session would be impactful in increasing coaches’ skills to a level of MI competence. 2.4.3 Findings This study can be used to inform other researchers on how to monitor fidelity of delivery of MI, which in turn allows for conclusions to be made on the effectiveness of MI within health behaviour change interventions. By assessing the fidelity of how SSBC coaches provided the intervention content, we are better equipped to make more accurate conclusions on why the program is or is not effective at eliciting changes in health behaviours. Through this study we were able to accurately conclude that SSBC coaches were providing consistent client-centered care; a level of care which has been shown to improve health outcomes. 52 Chapter 3: Conclusion This thesis aimed to assess fidelity by examining and monitoring the MI skills of SSBC coaches for the first six-months following their MI training. Post-MI training, 71% of SSBC coaches (five of the seven) were demonstrating a level of client-centered care in their sessions. Those five coaches generally maintained that level of client-centered care over the next six months. A maintenance of MI skills (i.e., no major increases or decreases) was observed in all of the SSBC coaches that independently met with clients over the six-month duration of this study. The two coaches who only met with clients for one- or two-months post-training were both operating at a level inconsistent with MI (below client-centered care). No qualitative information or exit-interviews were collected from these two coaches; however, we can speculate as to what happened. Both of these individuals stopped coaching around the time that they finished their undergraduate degrees; one moved away, while the other found full-time employment. One possible explanation why these coaches were operating at a level inconsistent with MI is that perhaps they knew they would not be continuing to meet with clients after graduation and were therefore less invested in learning and practicing the skills that were taught and practiced in the three-phase training. MI is not a natural communication style for most people and does take practice. Another possibility is that these coaches decided to move away and look for full-time work because they knew that their skills were not at a client-centered or MI-consistent level. A final possibility is that these coaches were less invested in client outcomes as they were the only two coaches not involved in other research within the SSBC program. Maybe they did not reach the same level as the other five coaches because the outcomes of SSBC would not directly affect their research or work. These are a few possibilities as to why MI skills were lower in the non-completers; however, we are unable to determine what caused this difference without further research. Although none of the SSBC reached a consistent level of MI-competency after the MI-training or over the course of this study, they were able to achieve and maintain a client-centered level of care which may still be considered successful. Client-centered care was introduced in the field of psychology (Rogers, 1959) and has become a guiding principle within rehabilitation professions, such as occupational 53 therapy (Bright et al., 2012; Townsend et al., 2013). Client-centered care is an approach that fosters a respectful partnership between counsellor and client (Law et al., 1995), and has been shown to improve health outcomes and client satisfaction among different populations in the health care field (Black, 2005; McMillan et al., 2013; Sumsion, 2005). MI and client-centered care have many overlapping processes and skills. An accepting client-counsellor relationship that involves partnership is both a core component of MI and client-centered care (Rogers, 1951; Rollnick & Miller, 2013). It is possible that the level of client-centered care that the SSBC coaches reached was sufficient in helping the clients make the long-term behaviour changes (i.e., reduction in HbA1c, weight, waist circumference, and increase in physical activity) that preliminary analyses are showing. MI has been shown to be effective at helping individuals make health behaviour changes (Burke et al., 2003; DiClemente et al., 2017; Martins & McNeil, 2009; O'Halloran et al., 2014; Rubak et al., 2005; Schaefer & Kavookjian, 2017), although this thesis has drawn attention to the fact that this can’t be concluded in studies that do not assess fidelity. Further research needs to examine whether client-centered care is effective in helping individuals at risk of, or with, T2D decrease HbA1c, weight reduction, increased PA, etc. Unfortunately, this was not possible to examine in this study due to the small variability between coaches’ scores. 3.1 Fidelity This study adds to the research on fidelity of MI implementation. As previously discussed, it is important to assess fidelity of MI in interventions to help draw conclusions, avoid type III errors, and to proceed with subsequent phases of implementation. Research on the use of MI in health behaviour changes is lacking on assessment of fidelity, and this study helps to address this issue by demonstrating what happens to MI skills post-training. As more literature emerges about studies that monitor fidelity, the more confident the field may become on the effectiveness or ineffectiveness of MI on health behaviour changes that clients are making. Previous systematic reviews (O'Halloran et al., 2014; Phillips & Guarnaccia, 2017; Thepwongsa et al., 2017) have been unable to conclude on the effectiveness of MI 54 on clients making health behaviour changes and the effectiveness of MI training workshops and post-workshop enhancements. The work in this thesis calls into question whether the studies discussed in Chapter 1 that did not assess fidelity should even be considered ‘MI’ studies. Without the assessment of MI fidelity in research, it cannot be concluded that MI was delivered in such interventions, and therefore the effectiveness of MI cannot be determined. In contrast, this thesis demonstrates rigorous methodology and taking the correct steps in ensuring the treatment fidelity. We can confirm that SSBC was delivered using a client-centered level of MI. This will allow future research to relate this level of MI to client outcomes. This study can be confidently classified as MI-informed, but we caution other researchers to only say they use MI if in fact that they have assessed fidelity and have shown that MI is reaching appropriate levels. The two-day MI-informed workshop covered the main aspects of MI, such as the OARS communication skills, the spirit of MI, and the four processes of MI, but did not cover all details of MI. It would not have been feasible for coaches to learn all aspects of MI within a two-day workshop. The topics that the workshop did cover however, are all captured by the MICA coding tool. The use of the MICA in this study allowed for coaches to be scored on skills and strategies that they were taught and able to use while delivering the SSBC intervention according to protocol. The MICA was also deemed appropriate as it was developed to be used for educational purposes to aid coaches in improving their skills. In the future, providing feedback to coaches at the end of each month may help improve their skills further and possibly aid in their achievement of an MI-competence level of care. A decline in MI skills that occurs between two- and four-months post-workshop has been shown to occur (Miller and Mount, 2001; Baer et al., 2004). This decline can be slowed when post-workshop enhancements (i.e., provision of feedback) are provided to coaches, specifically if they consist of 5-12 contact hours or more (Schwalbe et al., 2014). This amelioration or lack of decline was demonstrated in the present study, where no decline over a six-month period post-training was found. It can be contended then that two-day workshops are sufficient in initially teaching MI skills, but that it is the post-workshop 55 enhancements, such as shadowing, reverse-shadowing and feedback in the case of this study, that are required for a maintenance of skills. More research needs to be conducted to strengthen this contention. Further research should examine this three-phase MI-informed training on other populations of coaches to test whether the training is effective on coaches who are not conducting research within the context of SSBC. All seven coaches self-selected to take part in MI training and knew that it was the foundation of the intervention they would be delivering. This may suggest that the coaches in this study were highly interested in learning MI, and therefore more eager to learn and work on their skills. The five coaches who were operating at a level of client-centered care were also very invested in the project and the outcomes of the clients as it affects their research projects. These five coaches were either graduate or undergraduate students conducting research on other aspects of SSBC or helping to coordinate SSBC. This should not affect the level of MI skills as other populations of ‘coaches’ delivering SSBC or a similar intervention in the real world (i.e., personal trainer, diabetes educator) are likely to be invested in their clients’ outcomes as that is likely their job that they get paid for and evaluated on based on their effectiveness with clients. Finally, all sessions were audio-recorded for quality assurance purposes. Coaches were aware that a random selection of their sessions with clients would be coded for this study. It is possible that coaches were hyper-aware of using the skills they learned in the workshop because they knew they were being audio-recorded. It is unlikely that this is the sole reason for the maintenance of coaches’ skills because the delivery of the SSBC intervention required the coaches’ to be focusing on many other factors all at once (i.e., listening and responding to what the clients say). 3.2 Strengths and Limitations A primary strength of this study is that it demonstrated that after a two-day MI workshop, shadowing and being reverse-shadowed, the coaches in this study were able to operate at a client-centered level of care and maintained this level for the six-months post-training. This reinforces that a two-day workshop with shadowing and reverse shadowing is effective at teaching and maintaining a level of client-centered care, which adds to what previous work has shown (Britt & Blampied, 2010; Miller et al., 56 2004). By assessing fidelity, it allows us to confidently state that SSBC is delivered using MI-informed techniques. This strengthens the fidelity of the SSBC intervention as a whole. This study also demonstrated that individuals who were naïve to MI, had no previous counselling experience, and were university students were able to learn an MI-informed counselling style and maintain these skills for at least six months. Most previous literature has looked at a more homogenous population of coaches (i.e., nurses, probation officers) (Britt & Blampied, 2010; Madson et al., 2009; Miller et al., 2004), so this shows us that the workshop is effective for students across varying degree majors and levels. Despite a number of strengths, this study also has some limitations. The small sample size and lack of variability between coaches in this study did not allow for statistical analyses to be conducted to examine whether or not a relationship existed between coaches’ MI skills and client outcomes. There was also no control group, which does not allow conclusions to be made on which aspects of the three-phase training might have played the most integral role in the maintenance of MI skills. Finally, because the SSBC intervention has a number of topics that need to be covered in each of the sessions with clients, coaches are required to ask more questions and be more directive than may be present during a gold-standard MI session. Specifically, each of the six SSBC sessions are assigned a topic that the coach should cover with a client (i.e., consumption of added sugar, exercising at an appropriate intensity). In order for coaches to deliver this information in an MI-consistent style, they should ask clients for permission before introducing new topics and information. This increases the number of questions compared to reflections, and also guide the session in certain directions. Ultimately, this will decrease the R:Q ratio and possibly reduce the score coaches receive for guiding the conversation. 3.3 Future Directions The three-phase MI-informed workshop has been shown to increase learning pre-post workshop (Ivanova et al., in preparation) and to be effective at allowing the coaches to maintain their skills for up to six months post-training. This training can then be continued to be delivered to incoming SSBC coaches and should elicit a level of client-centered care among most coaches. The three-phase training is soon to 57 be pilot tested among YMCA staff to assess whether the same skill development and maintenance is seen among a different population of coaches. After training, the YMCA staff will then be delivering the SSBC intervention, and similar to this study, they will be coded for six months post-training. The current study had highly educated coaches, whereas the YMCA staff will generally have less years of education. Researchers are hopeful that the YMCA staff will show a similar pattern in skill maintenance as the current SSBC coaches, but it is possible that differences will occur as they are less invested in SSBC (i.e., not currently involved in the research), and they have different educational and occupation backgrounds. Ideally, the YMCA staff will be operating at a level of care similar to that of the current coaches who completed the six-month duration of the study. This will show that the three-phase training is effective for teaching individuals of different educational backgrounds. As more coaches complete the three-phase training it is possible that more variance among coaches’ skills will be observed, and then it might be possible to assess the impact of level of MI delivered on client outcomes (i.e., HbA1c, weight loss, physical activity adherence). Another focus should be to examine if and how the coaches’ skills can reach MI competence. Perhaps providing coaches with a booster session a few months after the end of the training, when they are more familiar with delivering the intervention and using the basic MI skills, would help to bring the skills of coaches to one of MI-competence. Alternatively, if coaches were provided with feedback immediately following the completion of a client, they may be able to reflect on how they can improve and incorporate that feedback in their following sessions with a client. Additionally, this three-phase MI-informed training should be tested in other client populations to determine its effectiveness on other health outcomes. Previous literature has shown that MI is effective in helping a variety of populations make health behaviour changes, so this three-phase training model should be tested and used on different client populations. 58 3.4 Conclusion MI-informed client-centered care is a useful style of communication which can result in behaviour change and improved health. This study showed that SSBC coaches are able to achieve and maintain a level of client-centered care for at least six months. Future studies should continue to assess MI fidelity in order to understand ways in which MI skills fluctuate or drift over time and what can be done to improve or maintain coaches’ skills, and what impact any potential drift has on client outcomes. 59 Bibliography Armstrong, M. J., Mottershead, T. A., Ronksley, P. E., Sigal, R. J., Campbell, T. S., & Hemmelgarn, B. R. (2011). Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta-analysis of randomized controlled trials. Obes Rev, 12(9), 709-723. doi:10.1111/j.1467-789X.2011.00892.x Aveyard, P., Begh, R., Parsons, A., & West, R. (2012). Brief opportunistic smoking cessation interventions: a systematic review and meta-analysis to compare advice to quit and offer of assistance. Addiction, 107(6), 1066-1073. doi:10.1111/j.1360-0443.2011.03770.x Baer, J. S., Rosengren, D. B., Dunn, C. W., Wells, E. A., Ogle, R. L., & Hartzler, B. (2004). An evaluation of workshop training in motivational interviewing for addiction and mental health clinicians. Drug and Alcohol Dependence, 73(1), 99-106. doi:10.1016/j.drugalcdep.2003.10.001 Bellg, A. J., Borrelli, B., Resnick, B., Hecht, J., Minicucci, D. S., Ory, M., . . . Treatment Fidelity Workgroup of the, N. I. H. B. C. C. (2004). Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH Behavior Change Consortium. Health Psychol, 23(5), 443-451. doi:10.1037/0278-6133.23.5.443 Bennett, J. A., Lyons, K. S., Winters-Stone, K., Nail, L. M., & Scherer, J. (2007). Motivational interviewing to increase physical activity in long-term cancer survivors. Nursing Research, 56(1), 18-27. Bennett, J. A., Young, H. M., Nail, L. M., Winters-Stone, K., & Hanson, G. (2008). A telephone-only motivational intervention to increase physical activity in rural adults: a randomized contorolled trial. Nursing Research, 57(1), 24-32. Black, R. M. (2005). Intersections of care: An analysis of culturally competent care, client centered care, and the feminist ethic of care. Work, 24(4), 409-422. Boniol, M., Dragomir, M., Autier, P., & Boyle, P. (2017). Physical activity and change in fasting glucose and HbA1c: a quantitative meta-analysis of randomized trials. Acta Diabetol, 54(11), 983-991. doi:10.1007/s00592-017-1037-3 60 Borrelli, B. (2011). The Assessment, Monitoring, and Enhancement of Treatment Fidelity In Public Health Clinical Trials. J Public Health Dent, 71(s1), S52-S63. doi:10.1111/j.1752-7325.2011.00233.x Boulé, N. G., Haddad, E., Kenny, G. P., Wells, G. A., & Sigal, R. J. (2007). Effects of Exercise on Glycemic Control and Body Mass in Type 2 Diabetes Mellitus: A Meta-analysis of Controlled Clinical Trials. JAMA, 286(10), 1218-1227. Bourne, J. E., Ivanova, E., Gainforth, H. L., & Jung, M. E. (2019). Mapping behavior change techniques to characterize a social cognitive theory informed physical activity intervention for adults at risk of type 2 diabetes mellitus. Transitional Behavioral Medicine, 1-8. Bourne, J. E., Little, J. P., Beauchamp, M. R., Barry, J., Singer, J., & Jung, M. E. (2019). Brief exercise counseling and high-intensity interval training on physical activity adherence and cardiometabolic health in individuals at risk of type 2 diabetes: protocol for a randomized controlled trial. JMIR Research Protocols, 8(3), e11226. Bright, F. A., Boland, P., Rutherford, S. J., Kayes, N. M., & McPherson, K. M. (2012). Implementing a client-centred approach in rehabilitation: an autoethnography. Disability and Rehabilitation, 34(12), 997-1004. Britt, E., & Blampied, N. M. (2010). Motivational interviewing training: a pilot study of the effects on practitioner and patient behaviour. Behav Cogn Psychother, 38(2), 239-244. doi:10.1017/S1352465809990531 Bundy, C. (2004). Changing behaviour: using motivational interviewing techniques. Journal of the Royal Society of Medicine, 97(44), 43-47. Burke, B. L., Arkowitz, H., & Menchola, M. (2003). The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. J Consult Clin Psychol, 71(5), 843-861. doi:10.1037/0022-006X.71.5.843 Canadian Society for Exercise Physiology. (2018). Canadian Physical Activity Guidelines. 61 Carels, R. A., Darby, L., Cacciapaglia, H. M., Konrad, K., Coit, C., Harper, J., . . . Versland, A. (2007). Using motivational interviewing as a supplement to obesity treatment: a stepped-care approach. Health Psychol, 26(3), 369-374. doi:10.1037/0278-6133.26.3.369 CCMI. (2018). Centre for Collaboration, Motivation and Innovation. Centers for Disease Control and Prevention. (2017). National Diabetes Statistics Report. Retrieved from Chen, S. M., Creedy, D., Lin, H. S., & Wollin, J. (2012). Effects of motivational interviewing intervention on self-management, psychological and glycemic outcomes in type 2 diabetes: a randomized controlled trial. Int J Nurs Stud, 49(6), 637-644. doi:10.1016/j.ijnurstu.2011.11.011 Chlebowy, D. O., El-Mallakh, P., Myers, J., Kubiak, N., Cloud, R., & Wall, M. P. (2015). Motivational interviewing to improve diabetes outcomes in African Americans adults with diabetes. West J Nurs Res, 37(5), 566-580. doi:10.1177/0193945914530522 Christie, D., & Channon, S. (2013). The potential for motivational interviewing to improve outcomes in the management of diabetes and obesity in paediatric and adult populations: a clinical review. Diabetes Obesity and Metabolism, 16, 381-387. Clark, M., Hampson, S. E., Avery, L., & Simpson, R. (2004). Effects of a tailored lifestyle self-management intervention in patients with type 2 diabetes. British Journal of Health Psychology, 9, 365-379. Diabetes Canada. (2017). CDA. DiClemente, C. C., Corno, C. M., Graydon, M. M., Wiprovnick, A. E., & Knoblach, D. J. (2017). Motivational interviewing, enhancement, and brief interventions over the last decade: A review of reviews of efficacy and effectiveness. Psychol Addict Behav, 31(8), 862-887. doi:10.1037/adb0000318 Dobson, D., & Cook, T. J. (1980). Avoiding type III error in program evaluation: results from a field experiment. Evaluation and Program Planning, 3, 269-276. 62 Fuemmeler, B. F., Masse, L. C., Yaroch, A. L., Resnicow, K., Campbell, M. K., Carr, C., . . . Williams, A. (2006). Psychosocial mediation of fruit and vegetable consumption in the body and soul effectiveness trial. Health Psychol, 25(4), 474-483. doi:10.1037/0278-6133.25.4.474 Gates, P. J., Sabioni, P., Copeland, J., Le Foll, B., & Gowing, L. (2016). Psychosocial interventions for cannabis use disorder. Cochrane Database Syst Rev(5), CD005336. doi:10.1002/14651858.CD005336.pub4 Gearing, R. E., El-Bassel, N., Ghesquiere, A., Baldwin, S., Gillies, J., & Ngeow, E. (2011). Major ingredients of fidelity: a review and scientific guide to improving quality of intervention research implementation. Clin Psychol Rev, 31(1), 79-88. doi:10.1016/j.cpr.2010.09.007 Greaves, C. J., Middlebrooke, A., O'Loughlin, L., Holland, S., Piper, J., Steele, A., . . . Daly, M. (2008). Motivational interviewing for modifying diabetes risk: a randomised controlled trial. Br J Gen Pract, 58(553), 535-540. doi:10.3399/bjgp08X319648 Halstead, L. S. (2001). The power of compassion and caring in rehabilitation healing. Archives of Medical Rehabilitation, 82(2), 149-154. Hamman, R. F., Wing, R. R., Edelstein, S. L., Lachin, J. M., Bray, G. A., Delahanty, L., . . . Wylie-Rosett, J. (2006). Effect of weight loss with lifestyle intervention on risk of diabetes. Diabetes Care, 29(9), 2102-2107. doi:10.2337/dc06-0560 Harland, J., White, M., Drinkwater, C., Chinn, D., Farr, L., & Howel, D. (1999). The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ, 319, 828-832. Harrison, R., Benton, T., Everson-Stewart, S., & Weinstein, P. (2007). Effect of Motivational Interviewing on Rates of Early Childhood Caries: A Randomized Trial. Pediatric Dentistry, 29(1), 16-22. Hawkins, S. Y. (2010). Improving Glycemic Control in Older Adults Using a Videophone Motivational Diabetes Self-Management Intervention. Research and Theory for Nursing Practice, 24(4), 217-232. doi:10.1891/1541-6577.24.4.217 63 Heianza, Y., Arase, Y., Fujihara, K., Tsuji, H., Saito, K., Hsieh, S. D., . . . Sone, H. (2012). Screening for pre-diabetes to predict future diabetes using various cut-off points for HbA(1c) and impaired fasting glucose: the Toranomon Hospital Health Management Center Study 4 (TOPICS 4). Diabet Med, 29(9), e279-285. doi:10.1111/j.1464-5491.2012.03686.x Hernan, W. H., Brandle, M., Zhang, P., Williamson, D. F., Matulik, M. J., Ratner, R. E., . . . Engelgau, M. M. (2003). Costs Associated With the Primary Prevention of Type 2 Diabetes Mellitus in the Diabetes Prevention Program. Diabetes Care, 26(1), 36-47. Ivanova, E., Davis, C., Cranston, K. D., & Jung, M. E. (in preparation). Train-the-trainer workshop informed by motivational interviewing to deliver a diabetes prevention program in the community. Jackson, C., Butterworth, S., Hall, A., & Gilbert, J. (2015). Motivational Interviewing Competency Assessment (MICA). Jadhav, R. A., Hazari, A., Monterio, A., Kumar, S., & Maiya, A. G. (2017). Effect of Physical Activity Intervention in Prediabetes: A Systematic Review With Meta-analysis. J Phys Act Health, 14(9), 745-755. doi:10.1123/jpah.2016-0632 Jung, M. E., Bourne, J. E., Beauchamp, M. R., Robinson, E., & Little, J. P. (2015). High-intensity interval training as an efficacious alternative to moderate-intensity continuous training for adults with prediabetes. J Diabetes Res, 2015, 191595. doi:10.1155/2015/191595 Kelly, M. P., & Barker, M. (2016). Why is changing health-related behaviour so difficult? Public Health, 136, 109-116. doi:10.1016/j.puhe.2016.03.030 Kirkpatrick, D. L. (1998). Evaluating Training Programs: The Four Levels. San Francisco: Berrett-Koehler Publishers, Inc. Knowler, W. C., Barrett-Connor, E., Fowler, S. E., Hamman, R. F., Lachin, J. M., Walker, E. A., & Nathan, D. M. (2002). Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin. N Engl J Med, 346(6), 393-403. 64 Larsen, D. L., Attkisson, C. C., Hargreaves, W. A., & Nguyen, T. D. (1979). Assessment of client/patient satisfaction: development of a general scale. Evaluation and Program Planning, 2, 233-237. Law, M., Baptiste, S., & Mills, J. (1995). Client-centred practice: What does it mean and does it make a difference? Canadian Journal of Occupational Therapy, 62(5), 250-257. Lindström, J., Louheranta, A., Mannelin, M., Rastas, M., Salminen, v., Eriksson, J., . . . Tuomlehto, J. (2003). The Finnish Diabetes Prevention Study. Diabetes Care, 26(12), 3230-3236. Locke, S. R., Bourne, J. E., Beauchamp, M. R., Little, J. P., Barry, J., Singer, J., & Jung, M. E. (2018). High-Intensity Interval or Continuous Moderate Exercise: A 24-Week Pilot Trial. Med Sci Sports Exerc, 50(10), 2067-2075. doi:10.1249/MSS.0000000000001668 Madson, M. B., Loignon, A. C., & Lane, C. (2009). Training in motivational interviewing: a systematic review. J Subst Abuse Treat, 36(1), 101-109. doi:10.1016/j.jsat.2008.05.005 Magill, M., Apodaca, T. R., Borsari, B., Gaume, J., Hoadley, A., Gordon, R. E. F., . . . Moyers, T. (2017). A meta-analysis of motivational interviewing process: Technical, relational, and conditional process models of change. J Consult Clin Psychol, 86(2), 140-157. doi:10.1037/ccp0000250 Martins, R. K., & McNeil, D. W. (2009). Review of Motivational Interviewing in promoting health behaviors. Clin Psychol Rev, 29(4), 283-293. doi:10.1016/j.cpr.2009.02.001 McMillan, S. S., Kendall, E., Sav, A., King, M. A., Witty, J. A., Kelly, F., & Wheeler, A. J. (2013). Patient-Centered Approaches to Health Care: A Systematic Review of Randomized Controlled Trials. Medical Care Research and Review, 70(6), 567-596. Miller, W. R. (1983). Motivational Interviewing with Problem Drinkers. Behavioural Pscyhotherapy, 11, 147-172. Miller, W. R., & Mount, K. A. (2001). A small study of training in motivational interviewing: does one workshop change clinician and client behavior? Behavioural and Cognitive Psychotherapy, 29, 457-471. Miller, W. R., Moyers, T. B., Ernst, D., & Amrhein, P. (2008). Manual for the Motivational Interviewing Skill Code (MISC). 65 Miller, W. R., & Rollnick, S. (2009). Ten things that motivational interviewing is not. Behav Cogn Psychother, 37(2), 129-140. doi:10.1017/S1352465809005128 Miller, W. R., Yahne, C. E., Moyers, T. B., Martinez, J., & Pirritano, M. (2004). A randomized trial of methods to help clinicians learn motivational interviewing. J Consult Clin Psychol, 72(6), 1050-1062. doi:10.1037/0022-006X.72.6.1050 Morrato, E. H., Hill, J. O., Wyatt, H. R., Ghushchyan, V., & Sullivan, P. W. (2007). Physical activity in U.S. adults with diabetes and at risk for developing diabetes, 2003. Diabetes Care, 30(2), 203-209. doi:10.2337/dc06-1128 Morton, K., Beauchamp, M., Prothero, A., Joyce, L., Saunders, L., Spencer-Bowdage, S., . . . Pedlar, C. (2015). The effectiveness of motivational interviewing for health behaviour change in primary care settings: a systematic review. Health Psychol Rev, 9(2), 205-223. doi:10.1080/17437199.2014.882006 Moyers, T. B., Manuel, J. K., & Ernst, D. (2014). Motivational Interviewing Treatment Integrity Coding Manual 4.2. Moyers, T. B., Martin, T., Manuel, J. K., Hendrickson, S. M., & Miller, W. R. (2005). Assessing competence in the use of motivational interviewing. J Subst Abuse Treat, 28(1), 19-26. doi:10.1016/j.jsat.2004.11.001 Moyers, T. B., Martin, T., Manuel, J. K., Miller, W. R., & Ernst, D. (2007). Revised Global Scales: Motivational interviewing treatment integrity 3.0 (MITI 3.0). O'Halloran, P. D., Blackstock, F., Shields, N., Holland, A., Iles, R., Kingsley, M., . . . Taylor, N. F. (2014). Motivational interviewing to increase physical activity in people with chronic health conditions: a systematic review and meta-analysis. Clin Rehabil, 28(12), 1159-1171. doi:10.1177/0269215514536210 O’Shea, O., McCormick, R., Bradley, J. M., & O’Neill, B. (2016). Fidelity review: a scoping review of the methods used to evaluate treatment fidelity in behavioural change interventions. Physical Therapy Reviews, 21(3-6), 207-214. doi:10.1080/10833196.2016.1261237 66 Pan, X., Li, G., Hu, Y., Wang, J., Yang, W., An, Z., . . . Howard, B. V. (1997). Effects of Diet and Exercise in Preventing NIDDM in People With Impaired Glucose Tolerance. Diabetes Care, 20(4), 537-544. Phillips, A. S., & Guarnaccia, C. A. (2017). Self-determination theory and motivational interviewing interventions for type 2 diabetes prevention and treatment: a systematic review. Journal of Health Psychology, 1-23. Ramachandran, A., & Snehalatha, C. (2011). Diabetes prevention programs. Med Clin North Am, 95(2), 353-372, viii. doi:10.1016/j.mcna.2010.11.006 Resnicow, K., Campbell, M., Carr, C., McCarty, F., Wang, T., Periasamy, S., . . . Stables, G. (2004). Body and soul. A dietary intervention conducted through African-American churches. Am J Prev Med, 27(2), 97-105. doi:10.1016/j.amepre.2004.04.009 Richards, A., Kattelmann, K. K., & Ren, C. (2006). Motivating 18- to 24-year-olds to increase their fruit and vegetable consumption. J Am Diet Assoc, 106(9), 1405-1411. doi:10.1016/j.jada.2006.06.005 Robbins, L. B., Pfeiffer, K. A., Maier, K. S., Ladrig, S. M., & Berg-Smith, S. M. (2012). Treatment fidelity of motivational interviewing delivered by a school nurse to increase girls' physical activity. J Sch Nurs, 28(1), 70-78. doi:10.1177/1059840511424507 Rogers, C. R. (1951). Client-centered therapy. Boston: Houghton-Mifflin. Rogers, C. R. (1959). Client-centered therapy: It’s current practice, implications, and theory. Boston: Houghton, Mifflin. Rollnick, S., & Miller, W. R. (2013). Motivational Interviewing. New York, NY: The Guilford Press. Rollnick, S., Miller, W. R., & Butler, C. (2008). Motivational Interviewing in Healthcare: Helping Patients Change Behaviour. London: Guilford Press. Rubak, S., Sandbæk, A., Lauritzen, T., & Christensen, B. (2005). Motivational interviewing: a systematic review and meta-analysis. British Journal of General Practice, 305-312. 67 Schaefer, M. R., & Kavookjian, J. (2017). The impact of motivational interviewing on adherence and symptom severity in adolescents and young adults with chronic illness: A systematic review. Patient Educ Couns, 100(12), 2190-2199. doi:10.1016/j.pec.2017.05.037 Schwalbe, C. S., Oh, H. Y., & Zweben, A. (2014). Sustaining motivational interviewing: a meta-analysis of training studies. Addiction, 109(8), 1287-1294. doi:10.1111/add.12558 Smith, D. E., Heckemeyer, C. M., Kratt, P. P., & Mason, D. A. (1997). Motivational interviewing to improve adherence to a behavioral weight-control program for older obese women with NIDDM. Diabetes Care, 20(1), 52-54. Soderlund, P. D. (2018). Effectiveness of motivational interviewing for improving physical activity self-management for adults with type 2 diabetes: A review. Chronic Illn, 14(1), 54-68. doi:10.1177/1742395317699449 Statistics Canada. (2017). Canadian Health Measures Survey: Activity monitor data. Ottawa: Statistics Canada Catalogue. Sumsion, T. (2005). Facilitating client-centred practice: Insights from clients. Canadian Journal of Occupational Therapy, 72(1), 13-20. Tabák, A. G., Herder, C., Rathmann, W., Brunner, E. J., & Kivimäki, M. (2012). Prediabetes: a high-risk state for diabetes development. The Lancet, 379(9833), 2279-2290. doi:10.1016/s0140-6736(12)60283-9 Thepwongsa, I., Muthukumar, R., & Kessomboon, P. (2017). Motivational interviewing by general practitioners for Type 2 diabetes patients: a systematic review. Fam Pract, 34(4), 376-383. doi:10.1093/fampra/cmx045 Thorne, S. E., Harris, S. R., Mahoney, K., Con, A., & McGuinness, L. (2004). The context of health care communication in chronic illness. Patient Education and counselling, 54(3), 299-306. Townsend, E. A., Polatajko, H. J., & Canadian Association of Occupational Therapists. (2013). Enabling occupation II: Adnaving an occupational therapy vision for health, well-being, and justice through occupation. Ottawa: Canadian Association of Occupational Therapists. 68 Vossen, J., Burduli, E., & Barbosa-Leiker, C. (2018). MICA Reliability and Validity Testing. West, D. S., DiLillo, V., Bursac, Z., Gore, S. A., & Greene, P. G. (2007). Motivational interviewing improves weight loss in women with type 2 diabetes. Diabetes Care, 30(5), 1081-1087. doi:10.2337/dc06-1966 World Health Organization. (2003). Diet, Nutritioni and the Prevention of Chronic Diseases. Retrieved from Young, T. L., Gutierrez, D., & Hagedorn, W. B. (2013). Does Motivational Interviewing (MI) Work With Nonaddicted Clients? A Controlled Study Measuring the Effects of a Brief Training in MI on Client Outcomes. Journal of Counseling & Development, 91(3), 313-320. doi:10.1002/j.1556-6676.2013.00099.x Zhao, G., Ford, E. S., Li, C., & Mokdad, A. H. (2008). Compliance with physical activity recommendations in US adults with diabetes. Diabet Med, 25(2), 221-227. doi:10.1111/j.1464-5491.2007.02332.x 69 Appendices Appendix A MICA Coding w/ Sentence Stems Interviewer: Coder: Behavior: No. Code Sentence Stems 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Codes Q: Question R: Reflection NC: No Code 70 18 19 20 Continued on Next Page No. Code Sentence Stems 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 71 42 43 44 45 Continued on Next Page 72 No. Code Sentence Stems 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 73 70 Continued on Next Page 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 74 95 96 97 98 99 100 75 Appendix B Pre-_MI_Workshop Start of Block: Default Question Block Q1 Thank you counsellors Q2 Dear counsellor, thank you for taking part in the Motivational Interviewing workshop. The following survey will take about 5 minutes to complete. This information is collected for the purpose to evaluate the workshop. In this regard, it is important that you are aware that there is a post-workshop survey as well. The purpose of the current survey is to collect demographic information, and your understanding of and past experiences with Motivational Interviewing. Q3 Please write in your favourite number in the space below. It is important to remember this number because we will ask you to enter it again in two days. This number will be used to link the responses from this survey and the one that you will be asked to complete in two days from today. 76 Q4 Please enter today's date: ________________________________________________________________ Q5 What gender do you identify with? o Woman (1) o Man (2) o Choose not to answer (3) o Other (4) Q6 How old are you? (in years) ________________________________________________________________ 77 Q7 How do you define your ethnicity? (select as many as apply) ▢ South Asian (1) ▢ East Asian and Southeast (2) ▢ Middle Eastern or North Africa (3) ▢ African (4) ▢ Caribbean (5) ▢ British and/or Irish (6) ▢ Mediterranean (7) ▢ Eastern European (or Russian) (8) ▢ Hispanic/Latino/a (9) ▢ First Nation (10) ▢ Métis (11) ▢ Inuk (12) ▢ Choose not to answer (13) 78 ▢ Other, please specify (14) ________________________________________________ Q8 What is your highest degree of school you have completed? o No schooling completed (1) o Some high school, no diploma (2) o High school graduate, diploma or the equivalent (e.g., GED) (3) o Some college credits, no degree (4) o Trade/technical/vocational training (5) o Bachelor's degree (6) o Maaster's degree (7) o Professional degree (e.g., Medical Degree) (8) o Doctorate degree (e.g., Ph.D.) (9) o Prefer not to answer (10) 79 Q9 What did you complete this degree in? o Exercise Science/Kinesiology (1) o Psychology (2) o Nursing (3) o Occupational therapy (4) o Other, please specify (5) ________________________________________________ End of Block: Default Question Block Start of Block: School history Q11 IF you are currently in school, what is your discipline? o Exercise Science/Kinesiology (1) o Psychology (2) o Nursing (3) o Occupational therapy (4) o Other, please specify (5) ________________________________________________ 80 Q12 How many years of counselling experience do you have? (if not applicable, please write "not applicable") ________________________________________________________________ Q13 Have you received Motivational Interviewing training in the past? o Yes (1) o No (2) Display This Question: If Have you received Motivational Interviewing training in the past? = Yes Q14 Please describe the nature of your previous Motivational Interviewing training/s? (e.g., number of sessions, duration, etc). ________________________________________________________________ End of Block: School history Start of Block: 4 81 Q15 Have you read the following book?: Motivational Interviewing: Helping People Change (3rd Ed) authors: William Miller and Stephen Rollnick o Yes (1) o No (2) End of Block: 4 Start of Block: MI_knowledge Q16 The following quesioning ask about your MI knowledge. Q17 1. I know how to 'engage' with clients. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) 82 Q18 2. I know how to 'focus' the session together with my client. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) Q19 3. I know how to 'evoke change talk' with my client. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) 83 Q20 4. I know how to engage in 'planning' with my client. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) Q21 5. I know how to ask open-ended questions. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) 84 Q22 6. I know how to do affirmations. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) Q23 7. I know how to do reflections. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) 85 Q24 8. I know how to do summaries. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) End of Block: MI_knowledge Start of Block: MI_knowledge_2 Q25 9. I know how to be compassionate with my clients. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) 86 Q26 10. I know how to support my client's autonomy. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) Q27 11. I know how to facilitate partnership with my client. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) 87 Q28 12. I know how to encourage my clients to explore more (or evoke). o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) Q29 13. I know how to provide information in an MI supportive way. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) 88 Q30 14. I know how to do brief action planning. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) End of Block: MI_knowledge_2 Start of Block: MI_confidence Q32 The following questions ask about your confidence in using MI for counselling. 89 Q31 1. I am confident I can 'engage' with clients. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) Q33 2. I am confident I can 'focus' the session together with my client. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) 90 Q34 3. I am confident I can 'evoke change talk' from my client. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) Q35 4. I am confident I can engage in 'planning' with my client. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) 91 Q36 5. I am confident I can ask open-ended questions. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) Q37 6. I am confident I can do affirmations. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) 92 Q38 7. I am confident I can do reflections. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) Q39 8. I am confident I can do summaries. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) End of Block: MI_confidence Start of Block: MI_confidence_2 93 Q40 9. I am confident that I can be compassionate with my clients. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) Q41 10. I am confident that I can be autonomy supportive. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) 94 Q42 11. I am confident that I can facilitate partnership with my client. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) Q43 12. I am confident that I can encourage my clients to explore more (to evoke). o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) 95 Q44 13. I am confident that I can provide information in an MI supportive way. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) Q45 14. I am confident that I can engage in brief action planning. o 1 - Totally Disagree (1) o 2 (2) o 3 (3) o 4 (4) o 5 - Totally Agree (5) End of Block: MI_confidence_2 Start of Block: Thank you 96 Q46 Thank you for taking the time to complete this survey! End of Block: Thank you 97 Appendix C Faculty of Health and Social Development School of Health and Exercise Sciences Reichwald Health Sciences Centre 3333 University Way Okanagan Campus Kelowna, B. C., Canada, V1V 1V7 INFORMED CONSENT Small Steps for Big Changes: A lifestyle program to reduce the risk of developing type 2 diabetes 1. INVITATION AND PURPOSE The purpose of this evaluation is to obtain information on how to improve the content and the training/delivery of the Small Steps for Big Changes program. You are invited to take part in this evaluation survey because you may be the coach/facilitator for Small Steps for Big Changes research program. 2. YOUR PARTICIPATION IS VOLUNTARY Your participation in this evaluation for the Small Steps for Big Changes program is entirely voluntary and it is your decision whether or not to take part in the evaluation survey and/or interview. 3. SPECIFIC PROCEDURES If you wish to participate you will be asked to: 98 - participate and receive training based on the Train-the-Trainer manual - provide verbal and written feedback - provide verbal and written feedback on the delivery and training of the Train-the-Trainer manual. Feedback will be one-on-one with one of the study investigators (Elena Ivanova Ph.D.) and in a group setting with other facilitators for the Small Steps for Big Changes (i.e. focus group). - Participate in an interview with one of two study investigators (Corliss Bean, PhD or Tineke Dineen, MSc) to provide your insight on the content of the training processes and Small Steps for Big Changes program delivery - consent to be audio recorded during the feedback sessions, when you facilitate the Small Steps for Big Changes program in the community and when you participate in an interview 4. CONFIDENTIALITY You will be assigned a unique number that will be associated with your audio files and your feedback. This number will not include any personal information that could identify you. The list that matches your name to the unique number will not be removed or released without your consent unless required by law. Your rights to privacy are legally protected by federal and provincial laws that require safeguards to ensure that your privacy is respected. 5. WHO DO I CONTACT IF I HAVE QUESTIONS? If you have any questions or desire further information, you may contact Drs. Mary Jung (250) 807-9670 or Jonathan Little at (250) 807-9876. 6. WHO DO I CONTACT IF I HAVE ANY QUESTIONS OR CONCERNS ABOUT MY RIGHTS? If you have any concerns or complaints about your or your experiences while participating in this study, contact the Research Participant Complaint Line in the University of British Columbia Office of Research Ethics by e-mail at RSIL@ors.ubc.ca or by phone at 604-822-8598 (Toll Free: 1-877-822-8598). Please reference the study number (H16-02028) when calling so the Complaint Line staff can better assist you. 7. SIGNATURES Study title: Small Steps for Big Changes: A lifestyle program to reduce the risk of developing type 2 diabetes 99 Participant Consent: • I have been informed that a recording device is being used during the above mentioned interactions, for the purposes of ensuring that my feedback on the content and the delivery of the Small Steps for Big Changes program is obtained. • I understand these are voluntary procedures and that I am free to withdraw at any time by requesting that the recording be stopped. • I also understand that my name will not be revealed to anyone and that recording will be kept confidential. • The audio files are electronically stored by number only and will be password protected • I understand that confidentiality will be respected and that the audio records will be for professional use only. • I consent to the audio-recording of the intervention I will receive a signed copy of this consent form for my own records. I consent to participate in this evaluation. ____ Subject’s Signature Printed name Date Signature of Person Obtaining Consent Signature of person Obtaining consent Printed Name Study Role Date 100 Investigator Signature ____________________ ______________ _____________ Investigator Signature Printed name Date My signature above signifies that the study has been reviewed with the study subject by me and/or by my delegated staff. My signature may have been added at a later date, as I may not have been present at the time the subject’s signature was obtained.
Thesis/Dissertation
eng
Health and Exercise Sciences
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Sustainability of motivational interviewing skills in new Small Steps for Big Changes coaches
Text