|Year : 2021 | Volume
| Issue : 1 | Page : 51-55
The nescience of the art of conversing and making the shift happen
Gowri Pendyala1, Sourabh Ramesh Joshi2, Ameet Mani1, Viddyasagar Mopagar2, Preeti Kale1
1 Department of Pediatric Dentistry, Rural Dental College, Ahmednagar, Maharashtra, India
2 Department of Pedodontics, Rural Dental College, Ahmednagar, Maharashtra, India
|Date of Submission||16-Dec-2020|
|Date of Decision||04-Jan-2021|
|Date of Acceptance||19-Jan-2021|
|Date of Web Publication||29-Jun-2021|
Sourabh Ramesh Joshi
Rural Dental college, Pravara Institute of Medical Sciences, Loni - 413 736, Ahmednagar, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Motivational interviewing (MI), a patient-centered therapeutic approach, has demonstrated to be effective for a wide range of health behaviors including dentistry. It resolves patient's ambivalence by evoking their own motivation to change, thereby improving clinical outcomes and enhancing clinician patient relationship. Objective: The aim of this study is to evaluate the knowledge and awareness of dental clinicians about MI and predict the likelihood of their use of the MI approach. Methodology: A cross-sectional survey was used to collect data. In total, a purposive sample of 600 dentists including dental professionals, postgraduate students, and interns inclusive of both genders participated in the study. Results: The results of this study indicated that dentists had inadequate knowledge about MI and also their practical implication was less. Conclusion: The results of this study may contribute to positive social change by supporting the development of effective training for dental clinicians as MI is helpful in enhancing patient awareness and obedience leading to better therapy outcomes.
Keywords: Behavior change, effectiveness, motivational interviewing, oral health-care professionals, training
|How to cite this article:|
Pendyala G, Joshi SR, Mani A, Mopagar V, Kale P. The nescience of the art of conversing and making the shift happen. J Head Neck Physicians Surg 2021;9:51-5
|How to cite this URL:|
Pendyala G, Joshi SR, Mani A, Mopagar V, Kale P. The nescience of the art of conversing and making the shift happen. J Head Neck Physicians Surg [serial online] 2021 [cited 2021 Sep 25];9:51-5. Available from: https://www.jhnps.org/text.asp?2021/9/1/51/319749
| Introduction|| |
Behavior change refers to any transformation or modification of human behavior in a broad range of activities and approaches which focus on the individual, community, and environmental influences on behavior. The transtheoretical model of behavior change also known as stages of change model proposed by Prochaska and DiClemente, states that the pros and cons associated with process of change creates ambivalence.
Ambivalence refers to a conflicted state where the individual is stuck simultaneously between wanting to change and not wanting to change. Motivational interviewing (MI), a new form of psychological intervention is an effective client-centered counseling method which enhances motivation by helping people explore and resolve their ambivalence and begin to make positive changes. It was first developed by Miller in his work with alcoholics who later collaborated with Rollnick(1991) to develop research based practice of MI.
MI, an evidence-based intervention, engenders a collaborative relationship between the client and therapist in a safe, nonjudgmental, and supportive environment to enable patients take control of their behavior. It grew out of stage of change model and involves enhancing a patient's motivation to change by means of four guiding principles, represented by the acronym RULE: Resist the righting reflex, Understand patient's own motivations, Listen with empathy, and Empower the patient.
MI, an effective, versatile behavior change method, can be utilized in the dental practice as a brief intervention to motivate patients improve their oral hygiene behaviors.
Traditionally applied with addictions, it is more recently related to health behavior change and health promotion which are relevant to dental clinicians. Behavioral risk factors are common in several oral diseases. Therefore, it is important for dental clinicians to have the clinical competencies to deal with these behavioral risk factors and be able to promote good oral health practices which is challenging for both the clinician and patient.
Evidence from research suggests that the potential of MI in improving oral health care is less well understood and is still considered controversial. A recent evidence-based national clinical guidelines states that “oral health promotion interventions should be based on recognised health theory behaviour and models such as MI.
There is a paucity of studies evaluating the knowledge and awareness of dental clinicians about MI, and hence, this study is an attempt to evaluate the knowledge and predict the likelihood of their use of the MI approach.
| Methodology|| |
This cross-sectional survey was conducted among the dental professionals of Ahmednagar district to evaluate their knowledge and awareness about MI. This study comprised about 600 dentists which included dental professionals, postgraduate students, and interns inclusive of both genders. The study protocol was approved by the Ethical Review Committee of Pravara Institute of Medical Sciences, Loni, prior to commencement of the project.
A questionnaire about MI was developed by carrying out a literature search in English using keywords “Motivational Interviewing,” “Change Talk,” “dentistry,” and “dental treatment.” Then, a questionnaire, consisting of 9 questions inclusive of both open- and closed-ended questions, was compiled from the relevant sources. Google forms were used to create the questionnaire. Subjects were requested to complete an anonymous, self-administered, structured one-page questionnaire.
The validity, content adequacy, consistency with the conceptual framework, and understandability of the questionnaire was examined by experts prior to the main study. The validity was examined by evaluating whether the questions in the questionnaire were correct. Reliability was tested by asking the sample to complete the questionnaire on two separate occasions 2 weeks apart. The acceptability of the questionnaire was evaluated by asking the subjects how they found answering the questionnaire and how long it took them to complete the questionnaire.
The final online questionnaire was sent to all dentists in Ahmednagar district whose contact information had been provided by E-mail, WhatsApp, and private social networking platforms, such as Facebook and Instagram.
The results were subjected to statistical analysis. The descriptive statistics have been used for this study. A percentage-wise distribution of the responses to various questions was used. The percentage of all variables has been recorded and compared. Graphical representations for the same have been shown in the annexures.
| Results|| |
The present survey gives us information about the knowledge and awareness of dental professionals about MI. Of the 600 dental professionals who participated in the study, 76% were MDS, 21% were BDS, and 3% were PhD [Figure 1]. When questioned about the awareness, 82% were aware of MI while the rest 18% were unaware. Seventy-nine percent of the dental professionals implemented MI in their practice while 21% denied the implementation. Among those who implemented, 48% practiced evidence-based MI and the rest 52% practiced circumstantial MI, with 100% of them supporting implementation of MI in dental curriculum.
|Figure 1: Questions regarding qualification, type of patients, and length of time|
Click here to view
MI was conducted on patients who were not ready for change by 13% of dentists, 15% conducted on those who were ambivalent, 8% on those who were ready to change, and 64% of them on all the above categories of patients. The session was conducted for about 15 min by 61% of dentists, 34% of them for 15–20 min, and 5% conducted for 20–30 min [Figure 2].
|Figure 2: Questions regarding awareness, practice, evidence-based practice, and implementation|
Click here to view
The various techniques adopted by dental professionals were by asking open-ended questions (37%), affirmations (8%), reflective listening (29%), and by empathizing (26%). The benefit of using MI in clinical practice as answered in the questionnaire was to increase participation rate during any treatment program(47%), increases the willingness to get help and fight through addiction(26%), triggers change in high-risk lifestyle behaviors (13%) and lowers the chance of future relapse. The reasons for their limitations of practicing MI were lack of time (37%), lack of training (42%), lack of financial incentives (2%), and concern about upsetting dentist–patient relationship (19%) [Figure 3].
|Figure 3: Questions regarding technique adopted, benefit, and limitations of practicing motivational interviewing|
Click here to view
| Discussion|| |
Oral health, being an important component of general health and well-being, enables an individual to speak and socialize without active disease. Most oral diseases are chronic, with the etiologies being modifiable. Evidence suggests that oral health can be maintained by adequate behaviors such as regular oral hygiene, avoidance of tobacco, and consumption of healthy diet.
Oral health-care professionals are presented with a unique combination of patient care scenarios and are regularly involved in activities designed to help individuals handle psychological and social challenges that impact oral health. They should gain an understanding of health effects of inappropriate behaviors in order to successfully target prevention and control disease.
MI offers particular techniques that can be incorporated into counseling interactions to help patients change behavior. Patients seeking dental treatments are often counseled about oral hygiene, dietary habits, and smoking cessation, and their adherence to clinician's recommendations remains central to effective treatment outcomes.
In the present study, most of the dentists (82%) were aware of MI, but only 79% of them implemented it in their practice of which only 48% of dentists practiced evidence-based MI by conducting the sessions for about 15 min (61%). This suggests that oral health-care professionals not only had inadequate knowledge about MI but also their practical implementation was less. The respondents in our study reported lack of training (42%), lack of time (37%), concern about upsetting relationship (19%), and lack of financial incentives (2%) as barriers for its implementation.
MI playing a pivotal role in health professional – patient communication has proven to be effective and has helped numerous people on their path toward recovery. Examining the efficacy of MI among mothers of young children with high risk of developing caries, Weinstein et al. concluded that addition of MI session led to significantly fewer new dental caries among children.,
In a controlled clinical trial, Almomani et al. concluded that the use of MI significantly improved oral hygiene status over a period of 8 weeks in individuals with severe mental illness.
Jonsson et al. stated that significant improvement in oral hygiene and gingival inflammation occurred which was maintained over an observation period of 2 years using MI-based counseling approach. In a systematic review assessing the effects of MI as an adjunct to periodontal therapy, two out of four studies showed promising results in relation to clinical periodontal parameters (Kopp et al.).
In dental practices, brief interventions are more feasible as time constraints are inherent to daily practice. Various health-care settings have adopted MI to provide brief interventions ranging from 5 to 20 min. A 5–10-min smoking intervention was developed by Butler et al. which focused on quitting and the confidence to succeed. Assessing the effectiveness of MI in a systematic review on improving range of oral health behaviors and clinical outcomes such as caries and periodontal outcomes, the authors concluded that MI had a positive effect on parents who were advised to take their children to dentist for fluoride varnish. In the studies, selected 1 to 7 MI sessions were conducted with a duration of 15–45 min.
According to the philosophy of MI, a flexible approach must be utilized instead of prescribed program of sessions as the readiness to change differs among patients. Patients may be not ready for change, ambivalent, or ready to change.,
Various strategies need to be adopted by tailoring the intervention according to the patient's readiness. In patients who are not ready to change, the clinician should respect the patient's autonomy and acknowledge their unpreparedness to change. The clinician can raise awareness about current behaviors and ask the patient if it is acceptable to discuss in the next appointment.
In ambivalent patients, the clinician needs to further explore the opportunities and obstacles of current behavior to build on the motivation and confidence to change. In patients who are ready to change, the clinician's role is to build on the motivation to change by asking the patient to propose feasible steps to make change.
MI has proven to be particularly useful with clients that lack self-efficacy and believe they may be unable to change. In our study, majority of the dentists (64%) conducted on all categories of patients suggesting them to be inerudite about MI.
In the practical application of building motivation, four strategies that can be used are represented by the Acronym OARS(Open ended questions, make Affirmations, use Reflections, and Summarizing). These skills-based, client-centered models of interaction techniques are used “early and often” in the MI approach.
Majority of the respondents (37%) in our study conducted MI by asking open-ended questions with a minor proportion of them (8%) by affirmations. Open-ended questions allow for a richer, deeper conversation that builds empathy with clients providing an opportunity for the patient to craft a response and allows clinicians to better understand the patient's perception by aiming at making the patient aware and responsible for the change. Affirmations are supportive statements made in response to what clients have said by offering encouragement and acknowledgment of patient's strengths. This builds rapport and fosters confidence in the patient's ability to change behavior by directing patient's attention from difficulties to goals.
Reflective listening allows clinicians to display an understanding of patient's perceptions, ambivalence, and efforts. It helps the patient hear his or her thoughts and feelings in a different format, which may support internal motivation to change.
Summary is used to close the MI session by ensuring that the clinician understands the patient's perspective. This helps practitioners connect the information provided by the patient to the individual's specific behavior change goal.
Reflective listening and summarizing require active listening skills from the person conducting MI, and they are considered to be of great significance as they provide the most positive content for patients to encourage them to introduce change. Only 29% of our participants applied reflective listening and 26% of them conducted by summarizing reflecting lack of competence to apply integrative methods to change behavior.
Successful embedding of MI in routine patient-centered health care has barriers to its implementation. These include brevity of consultation times, lack of financial support for collaborative practice, the professional development required in order to master patients' overwhelming desire for “quick fix” options to health issues, and concern about upsetting clinician patient relationship. Time limits of therapists during consultation significantly impact the quality of MI. The oral health practitioner may be able to broach the subject of a behavior change, such as flossing or diet modification, but the duration of the session may not be sufficient when coupled with other responsibilities the health practitioner has to the health and well-being of the patient.
Embedding of MI in routine patient-centered oral health care requires awareness of the possible barriers facilitating agreed guidelines and processes that support interprofessional collaborative practice.
While psychologists, mental health counselors, and social workers are generally well trained in delivering MI, oral health-care professionals generally lack training and skills to master the art of dealing with the patient's resistant statements in a collaborative manner. In dentistry active listening skills, effective communication, handling patient emotions sensitively, demonstrating empathy, and awareness are also crucial aspects besides knowledge and technical skills. Dental students need to be given the opportunity to learn about, experiment with, and reflect on their communication strategies early on during their studies, so that they may be able to successfully communicate with patients later. Training in MI for dental personnel could be a very useful addition to the skill set of practitioners and dental teams as agreed by all (100%) oral health professionals in our study. When integrated into the regular curriculum, MI helps the students learn the benefit of planned deliberate communication with patients. It helps the students learn the benefit of planned, deliberate communication with patients. Further research on efficient methods of training dental students to use MI-related strategies and the use of outcome measures is necessary.
| Conclusion|| |
The level of oral health-care professional's knowledge and awareness regarding the potential influence of MI to effectively develop a collaborative rapport with patients to support behavior changes that can enhance oral and systemic health may be drawn from our study. Our study infers that dentists have inadequate knowledge about MI and also there exists a gap between their knowledge and practice. In dentistry, MI plays a pivotal role in oral health-care professional–patient communication as it positively affects both. The patient becomes motivated to take up new health behaviors and becomes responsible for their health condition which translates into better treatment outcomes and higher disease prevention, and for dentists, MI constitutes a good form of communication that provides self-confidence and protection against burnout. As there is a changing zeitgeist in dental health-care practice and training involving a more client/patient-centered approach, we would suggest that there might be positive outcomes in terms of learning potential by training dental clinicians at an undergraduate level. As the dental curricula are limited in their teaching of behavior change methods, MI needs to be implemented as an integral part to enhance and support dental clinicians' role as health-care providers.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
This material has never been published and is not currently under evaluation in any other peer reviewed publication.
The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
| References|| |
Prochaska J, DiClemente C. Towards a comprehensive model of change. In: Miller WR, Heather N, editors. Treating addictive Behaviours: Process of Change. New York: Pergamon; 1986.
Miller WR, Rollinck S. Motivational Interviewing. Preparing People for Change. 2nd
ed. New York: The Gulliford Press; 2002.
Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care. Helping Patients Change Behavior. New York: The Guilford Press; 2008.
Koerber A, Crawford J, O'Connell K. The effects of teaching dental students brief motivational interviewing for smoking-cessation counselling: A pilot study. J Diabetes Endocrinol 2003;67:439-47.
Gao X, Lo EC, Kot SC, Chan KC. Motivational interviewing in improving oral health: A systematic review of randomized controlled trials. J Periodontol 2014;85:426-37.
Scottish Intercollegiate Guideline Network (SIGN). Dental Interventions to Prevent Caries in Children. Edinburgh: Healthcare Improvement Scotland; 2014.
Cascaes AM, Bielemann RM, Clark VL, Barros AJ. Effectiveness of motivational interviewing at improving oral health: A systematic review. Rev Saude Publica 2014;48:142-53.
Weinstein P, Harrison R, Benton T. Motivating parents to prevent caries in their young children, one year findings. J Am Dent Assoc 2004;135:731-8.
Weinstein P, Harrison R, Benton T. Motivating mothers to prevent caries confirming the beneficial effect of counseling. J Am Dent Assoc 2006;137:789-93.
Almomani F, Williams K, Catley D, Brown C. Effects of an oral health promotion program in people with mental illness. J Dent Res 2009;88:648-52.
Jönsson B, Ohrn K, Lindberg P, Oscarson N. The effectiveness of an individually tailored oral health educational programme on oral hygiene behaviour in patients with periodontal disease: A blinded randomized-controlled clinical trial (one-year follow-up). J Clin Periodontol 2009;36:1025.
Kopp SL, Ramseier CA, Ratka-Kruger P, Woelber JP. Motivational interviewing as an adjunct to periodontal therapy – A systematic review. Front Psychol 2017;8:279.
Butler CC, Rollnick S, Cohen D, Bachmann M, Russell I, Stott N. Motivational consulting versus brief advice for smokers in general practice: A randomized trial. Br J Gen Pract 1999;49:611-16.
Berg-Smith SM, Stevens VJ, Brown KM, van HL, Gernhofer N, Peters E, et al
. A brief motivational intervention to improve dietary adherence in adolescents. Health Educ Res 1999;14:399-410.
Szczekala1 K, Wiktor K, Kanadys K, Wiktor H. Benefits of motivational interviewing application for patients and healthcare professionals. Pol J Public Health 2018;128:170-73.
Resnicow K, DiIorio C, Soet JE, Borrelli B, Hecht J, Ernst D. Motivational interviewing in health promotion: It sounds like something is changing. Health Psychol 2002;21: 444-51.
Schoo A, Kumar K. The clinical educator and complexity: A review. Clin Teach 2018;15:287-93.
Velasquez MM, Hecht J, Quinn VP, Emmons KM, DiClemente CC, Dolan-Mullen P. Application of motivational interviewing to prenatal smoking cessation: Training and implementation issues. Tob Control 2000;9 Suppl 3:III36-40.
Flocke SA, Miller WL, Crabtree BF. Relationships between physician practice style, patient satisfaction, and attributes of primary care. J Fam Pract 2002;51:835-40.
Alvarez S, Schultz JH. A communication-focused curriculum for dental students - An experiential training approach. BMC Med Educ 2018;18:55.
Hinz JG. Teaching dental students motivational interviewing techniques: Analysis of a third-year class assignment. J Dent Educ 2010;74:1351-6.
[Figure 1], [Figure 2], [Figure 3]