Health Promotion: Planning & Strategies
Jamaica
Motivational interviewing: Health promotion strategy for systems change for HIV prevention and control in Jamaica
Antoinette Barton-Gooden, University of the West Indies
Joy Crawford, Eve For Life Organization
Donnahae Rhoden-Salmon, University of the West Indies
Keywords: Motivational interviewing, self-efficacy, HIV/AIDS, communication
Summary
Restrictive laws, stigma and discrimination are barriers to care for persons living with HIV/AIDS in Jamaica. These challenges threaten the goal of universal healthcare and the prevention and control of HIV nationally. However, healthcare workers can positively influence behaviour change with the right skillset. Motivational interviewing is an efficacious tool that can assist clients with ambivalence towards behaviour change that contributes in positive health outcomes. This health promotion strategy combines effective communication, modelling, and vicarious reinforcement to build self-efficacy among healthcare workers to enhance systems change in HIV care in Jamaica.
Setting and context
Jamaica implemented universal access to highly active antiretroviral therapy (HAART) since 2004; despite this, access and medication adherence remains problematic (Allen, Simon, Edwards, & Simeon, 2011; Figueroa et al., 2008; Harvey et al., 2008; Williams, Clarke, Williams, & Barton, 2007). Figueroa (2008) argued that the lack of access resulted from stigma and discrimination against persons living with HIV/AIDS (PLWHA). There are several major challenges impacting the prevention and control of HIV in Jamaica, including cultural and lifestyle factors such as early sexual activity and multiple sexual partners (JRHS, 2008; JNFPB: 2014; 2017; Wilks, Younger, Tulloch-Reid, McFarlane, & Francis, 2008). Risk behaviours among adults with AIDS included, multiple sexual partner (80%), a history of sexually transmitted infection (STI) (51.1%) and commercial sex (23.9%) which are continuously driving the epidemic (Figueroa et al., 2008), despite national campaigns. Therefore, it was felt that behaviour change communication (BCC) such as motivational interviewing (MI), is the right approach and needed to be strengthened in future programmes (JNFPB, 2014; 2017). MI is an efficacious scientific method of communicating that outperforms traditional advice giving (Rubak, Sandbæk, Lauritzen, & Christensen, 2005). It can be taught to non-medical personnel, given in brief encounters and integrated into clinical settings effectively at a low cost (Rubak et al., 2005). For this reason, it can be effectively implemented to address stigma and discrimination (JNFPB, 2014, p. 25; JNFBP, 2017, p. 32), through a multiple agency and systems approach to HIV control and prevention in Jamaican.
Aims and objectives of programme/activity
The United States Agency for International Development (USAID) (2014) stated that, by 2020, 90% of all people living with HIV will know their HIV status. By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy. By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression. The overall goal of the activity is to strengthen health care systems that offer care to PLWHA to support the 90-90-90 target to scale-up HIV prevention and control strategies beyond 2015.
This health promotion programme utilized communication, education and organizational change. Participants were given a comprehensive introduction to the transtheoretical model that guides MI during a three-day workshop which covered the processes, principles, and skills of motivational interviewing that will be integrated into their organizations. Contents of the workshop would facilitate the participants effectively communicating with clients using MI to deal with ambivalence and toward change talk.
Description of main features
The programme initiative was designed and is being implemented over an extended period of six months. First, the participants received 24 hours of contact time with a certified Motivational Interviewing Network of Trainer (MINT) and MI practitioner during a three-day workshop. Several teaching and learning strategies were integrated such as lecture/discussions, videos, demonstration, return-demonstration, gaming, quizzes, and reflective activities among others. Modelling and role-modelling was intricately interwoven during the interactions as it was felt that these have a positive effect on behaviour change and self-efficacy (Heslin & Klehe, 2006). These strategies were chosen for the diverse adult audience with various learning styles. Following the workshop, the participants were paired and assigned a mentor who provided coaching either face-to-face or using technological support through Skype or other medium for the remainder of the programme.
Prior to the beginning of the coaching activities, participants were provided with standard patient profiles that will be used to guide each session monthly. Each coaching session, included role-play of counsellor and patient interaction, followed by an evaluation using the MITI Scale (evidence-based coding tool). Peer and self-evaluation was done at the end of the session and will be continued for the remainder. Constructive feedback from the coach using direct and vicarious reinforcement will also be done to enhance self-efficacy. Each participant will also be informed of the areas to work on for the next session.
Three months after the end date of the workshop, the MI mentees will have one booster training session of six hours. At this point, contents will be reinforced, additional role-play will be done along with reflective practice activities. The final evaluation will culminate in one coding for an audio recorded interaction of a real or simulated standard client by the coach. The participants will become certified MI practitioner if they have attend 95 % of sessions and have demonstrated the core competence in MI skills acquisition. The certificate of participation will be co-signed by Head of the Host Agency and MINT Trainer. All new MI practitioners will be invited to join the MINT by completing additional training towards becoming a certified MI trainer-of-trainer. This intervention will strengthen the human capacity in Jamaica for HIV prevention and control.
Application to key principles of health promotion and relevant theory
The intervention was guided by the ecological model of health behaviour. This model takes into consideration both individual and environmental determinants that facilitates behaviour change. It is argued that, “the ultimate purpose of ecological models of health behaviour is to inform the development of comprehensive intervention approaches that can systematically target mechanisms of change at several levels of influence” (Sallis, Owen, & Fisher, 2008, p. 466). This model has five factors that influence health behaviours. These are at the intrapersonal, interpersonal, organizational, community, and public policy levels. Behaviour change is expected to be maximized when environments and policies support healthful choices, when social norms and social support for healthful choices are strong, and when individuals are motivated and educated to make those choices (Sallis et al., 2008, p. 466). However, interventions targeting the organizational level are more likely to be scaled up, sustained and progress to the public policy level.
The target of the intervention was at several levels: intrapersonal, interpersonal, and organizational and community levels. The systems integration of MI is deemed to be a dignifying method of communication that is empowering and may enhance behaviour change for the staff in the health systems through the reduction in stigma and discrimination which may positively impact access and retention in care for PLWHA. See website: http://www.jnfpb.org/assets/HIV-Policy_RevisedOct2017-Website.pdf
References
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Allen, C. F., Simon, Y., Edwards, J., & Simeon, D. (2011). Adherence to antiretroviral therapy by people accessing services from non-governmental HIV support organisations in three Caribbean countries. West Indian Medical Journal, 60(3), 269–275.
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Figueroa, J. P. (2008). The HIV epidemic in the Caribbean meeting the challenges of achieving universal access to prevention, treatment and care. West Indian Medical Journal, 57(3), 195–203.
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Figueroa, J. P., Duncan, J., Byfield, L., Harvey, K., Gebre, Y., Hylton-Kong, T., Hamer, F., Williams, E., Carrington, D., Brathwaite, A. R. (2008). A comprehensive response to the HIV/AIDS epidemic in Jamaica: A review of the past 20 years. West Indian Medical Journal, 57(6), 562–576.
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Heslin, P. A., & Klehe, U. C. (2006). Self-efficacy. Retrieved September 18, 2017 from https://www.researchgate.net/profile/Peter_Heslin/publication/228210952_Self-efficacy/links/09e4150e7a1b51924e000000.pdf
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Harvey, K. M., Carrington, D., Duncan, J., Figueroa, J. P., Hirschorn, L., Manning, D., & Jackson, S. (2008). Evaluation of adherence to highly active antiretroviral therapy in adults in Jamaica. West Indian Medical Journal, 57(3), 293–297.
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Joint United Nations Programme on HIV/AIDS (UNAIDS). (2014). 90-90-90 An ambitious target to help and end the AIDS epidemic. UNAIDS.
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Jamaica National Family Planning Board. (2014). Revised National HIV Policy, Jamaica. Final draft. Retrieved on September 18, 2017 from http://jnfpb.org/assets/Final-Policy-Document_July2015.pdf
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Jamaica National Family Planning Board. (2017). Revised National HIV Policy, Jamaica. Retrieved on January 10, 2019 from http://www.jnfpb.org/assets/HIV-Policy_RevisedOct2017-Website.pdf
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Jamaica reproductive health survey (JHRS) (2008). Jamaica National Family Planning Board. Statistical Institute of Jamaica. Retrieved on September 18, 2017 from http://jnfpb.org/assets/2008%20Final%20Report%20Jamaica.pdf
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Rubak, S., Sandbæk, A., Lauritzen, T., & Christensen, B. (2005). Motivational interviewing: A systematic review and meta-analysis. British Journal of General Practice, 55(513), 305–312.
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Sallis, J. F., Owen, N., & Fisher, E. B. (2008). Ecological models of health behavior. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health behavior and health education: Theory, research, and practice. Chapter 20 (pp. 465–485). San Francisco, CA: Jossey-Bass, Wiley & Sons.
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Wilks, R., Younger, N., Tulloch-Reid, M., McFarlane, S., & Francis, D. (2008). Jamaica health and lifestyle survey 2007-8. Kingston: Tropical Medicine Research Institute, University of the West Indies, Mona.
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Williams, M., Clarke, T., Williams, P., & Barton, E. N. (2007). The mean levels of adherence and factors contributing to non-adherence in patients on highly active antiretroviral therapy. West Indian Medical Journal, 56(3), 270–274.