Abstract
Cardiovascular disease (CVD) is the leading cause of death for women, and disproportionally so for African American and Latina women. CVD is largely preventable and many risks can be attributable to health behaviors, implementing and sustaining positive health behaviors is a challenge. Motivational interviewing is one promising intervention for initiating behavior change. The purpose of this review was to identify, synthesize, and critically analyze the existing literature on the use of motivational interviewing as a behavioral intervention to reduce CVD risk among African American and Latina women. Seven studies were identified that met inclusion criteria. Results of this review suggest that motivational interviewing has mixed results when used to reduce cardiovascular risk factors in African American and Latina women. More research using a standardized motivational interviewing approach is needed to definitively determine if it is an effective behavioral intervention to reduce CVD risk when used in populations of African American and Latina women.
Between 1980 and 2007, there was a reduction in the age-adjusted death rate of women who died due to cardiovascular disease (CVD), which has been attributed to primary and secondary prevention measures (Ford et al., 2007). Primary prevention identifies and targets people at increased risk, but with no evidence of CVD, whereas secondary prevention seeks to reduce risk in individuals with established disease. Over the past decade, there have also been improvements in the rates of awareness among women that CVD is the leading cause of death. In 1997, only 30% of women were aware that CVD was the leading cause of death among women; the rate of awareness has grown to 54% in 2009. However, awareness is not consistent across all segments of the population. African American and Latina women are less likely to recognize that CVD is the leading cause of death for women compared with White women, and each year, 34.2% of African American women and 29.6% of Latina women die from CVD (Go et al., 2013; Mosca et al., 2011; Mosca, Mochari-Greenberger, Dolor, Newby, & Robb, 2010).
The greatest proportion of CVD burden for African American and Latina women are specifically related to diabetes, overweight and obesity, and lower levels of physical activity when compared with White women (Roger et al., 2011). Fortunately, these risk factors for CVD are largely preventable. Behavioral interventions that target these modifiable risk factors are one way to address these risks, and motivational interviewing is one technique that has shown promise to address the modifiable risk factors for CVD.
There is a significant gap in the literature addressing the effectiveness of behavioral interventions for CVD prevention in women, particularly among African American and Latina women. Traditionally, behavior change methods have relied on the approach of “advice giving” with limited success in uptake and maintenance of behavior change (Brodie & Inoue, 2005; Cifuentes et al., 2005; Hillsdon, Thorogood, White, & Foster, 2002). Motivational interviewing has been demonstrated as an effective counseling approach for treatment of a broad range of lifestyle problems and diseases; and it outperformed traditional advice-giving in a systematic review and meta-analysis of 72 randomized controlled trials (Rubak, Sandbaek, Lauritzen, & Christensen, 2005). However, although the review of the efficacy of motivational interviewing was comprehensive, it did not specifically address its use to improve cardiovascular risk behaviors and outcomes in populations of African American and Latina women.
The purpose of this review was to identify, synthesize, and critically analyze the existing literature on the use of motivational interviewing as a behavioral intervention to reduce CVD risks or improving cardiovascular risk-related behaviors among African American and Latina women.
The American Heart Association recommends that all women over the age of 20 undergo a CVD health screening including history of tobacco use, lipid disorders, obesity, hypertension, diabetes, and other nontraditional risk factors (Roger et al., 2011). Health screening initiatives such as the Centers for Disease Control and Prevention (CDC)-funded WISEWOMAN (Well-Integrated Screening and Evaluation for Women Across the Nation) program target minority populations of middle-aged women at risk for developing stroke, heart disease, or other chronic illness (Will, Farris, Sanders, Stockmyer, & Finkelstein, 2004). In 2002, WISEWOMAN screened over 8,000 disadvantaged, multicultural women at 10 sites across the United States and implemented interventions targeting physical activity and nutrition (Will et al., 2004). Developing behavioral interventions to address the modifiable CVD risk factors including nutrition, diabetes, smoking, hypertension, hyperlipidemia, metabolic syndrome, and physical activity are an effective way to reduce CVD prevalence (Grundy, 2007; Roger et al., 2011; Rubak et al., 2005).
Previous studies that have used motivational interviewing to reduce CVD risk factors demonstrated overall favorable outcomes, particularly when the intervention was delivered in person and over an extended period of time. In a systematic review and meta-analysis of motivational interviewing across a broad array of lifestyle behaviors known to improve health and reduce disease risks conducted by Rubak et al. (2005), 80% of studies that were reviewed demonstrated positive motivational interviewing-facilitated behavior change compared with traditional advice-giving. Use of behavioral interventions such as motivational interviewing to address CVD risk factors have shown to have benefit in increasing physical activity (Carels et al., 2007; Hardcastle, Taylor, Bailey, & Castle, 2008; Perry & Bennett, 2006), improvement in diet (Carels et al., 2007; Hardcastle et al., 2008), decreases in diastolic blood pressure (Hardcastle et al., 2008), decreases in body mass index (Hardcastle et al., 2008), and increases in social support (Perry & Bennett, 2006). Moreover, motivational interviewing has not been reported to cause any adverse outcomes or ill effects (Rubak et al., 2005).
Motivational interviewing is a counseling technique that has been used to promote healthy behaviors to prevent or manage disease by eliciting behavior change (Rubak et al.,2005). Motivational interviewing can be described as a nonconfrontational and patient-directed approach, where the counselor engages in empathetic listening and helps guide the patients to recognize their ambivalence about behavior change (Miller & Rollnick, 2002). Motivational interviewing meets people “where they are,” and has been shown to be effective for those who are not ready or less motivated to change (Hettema, Steele, & Miller, 2005).
Motivational interviewing has roots in the patient-centered counseling approach developed by Rogers (1951). Motivational interviewing was not initially informed by a clear theoretical framework; however, it has been proposed that the self-determination theory is one such method that can be useful in framing motivational interviewing (Markland, Ryan, Tobin, & Rollnick, 2005). The self-determination theory emphasizes that the change must originate from within the person, rather than the provider or counselor pressurizing the clients to change their behavior. In addition, motivational interviewing and the self-determination theory are inclined to value the ability of personal growth (Deci & Ryan, 1985). It was originally developed and used in the addiction field (Miller, 1983) and has since been more widely implemented in efforts to address the prevention of chronic illness and promotion of health behaviors (Resnicow et al., 2002).
The focus and goals of motivational interviewing are to encourage clients to consider their reasons for and against changing a behavior, how the behavior in question may interfere with their goals for health, and how this interference of goals will have an effect on lifestyle overall. Instead of persuading the client to make changes, techniques such as reflective listening, agenda or goal setting, rolling with resistance, and eliciting change talk are employed by motivational interviewing counselors (Miller & Rollnick, 2002). There are four key components comprising motivational interviewing: (a) expressing empathy, (b) agenda or goal setting, (c) rolling with resistance, and (d) eliciting change talk and supporting self-efficacy (Figure 1).
Core components of motivational interviewing.
Expressing empathy allows the health care professional to hear and understand the patient’s experiences through the use of reflective listening, engendering an environment where the patient is comfortable sharing his or her experiences. Reflective listening provides an opportunity to help clients develop an awareness of thoughts, feeling, or behaviors that may be interfering with achieving goals. Restating what a client says, in a slightly different manner, can highlight this discrepancy in thoughts and feelings compared with the actual behaviors that are currently occurring.
Agenda or goal setting allows the patient to see the discrepancy between existing behaviors in contrast to where a patient see’s oneself. Asking questions such as “What concerns do you have about your diet?’ or “Do you have any concerns about your exercise regimen?” allow a patient to clarify and affirm goals in a nonjudgmental, supportive environment engendering recognition of existing behaviors in contrast to what the client would like to achieve.
Rolling with resistance is another key component of motivational interviewing (Miller & Rollnick, 2002). As a client struggles with the disconnect and difficulty in moving toward behavior change, the health professional provides support—neither advocating for or against a behavior, rather, reflecting the comments and situation back to the client. Motivational interviewing involves supporting the client and encouraging feelings of self-efficacy.
Eliciting change talk and supporting self-efficacy for positive behavior change is the fourth component of motivational interviewing (Miller & Rollnick, 2002). Health care providers can increase a patient’s self-efficacy by expressing their support and belief that the patient is capable of changing their behavior and by highlighting the patient’s past successes.
Motivational interviewing is a framework that has shown promise in numerous populations to facilitate behavior change (Miller & Rollnick, 2002); however, its application to reduce CVD risk in African American and Latina women is unknown. Therefore, this review was conducted to identify, synthesize, and critically analyze the existing literature on the use of motivational interviewing as a behavioral intervention to reduce CVD risk factors among African American and Latina women. In the review, the following research question was addressed:
Research Question 1: Does the use of motivational interviewing reduce CVD risk factors in African American and Latina women?
Method
Three electronic databases were used for the search (CINAHL, MEDLINE, and PsychINFO), utilizing the keywords cardiovascular disease, women, African American, Hispanic, Latina, and motivational interviewing. Inclusion criteria for this literature review included English, humans, adults, a motivation-based counseling protocol used as the treatment, inclusion of African American women, and inclusion of Latina or Hispanic women. Another inclusion criteria was that the work directly assessed the effects of motivational interviewing on at least one modifiable CVD risk factors including physical activity, diet as measured by fruit and vegetable consumption, body mass index (BMI), systolic blood pressure (SBP), glycemic control, weight loss, and medication adherence. Date limits were set to include literature from 1980 to January 2013. Electronic searches were supplemented by cross-referencing and duplicates were deleted across the database searches. Given the small body of literature, study completion rates did not affect inclusion in this review. There were no limits placed on study design, since few randomized controlled studies for this population and topic were identified. Studies were excluded if <25% of the sample comprised African American or Latina women, if the sample included <50% women, if the target of motivational interviewing was not CVD risk factors, or if motivational interviewing was not the primary behavioral intervention being used.
Results
A total of 40 papers were examined, yielding seven studies that met the inclusion criteria for this systematic review (Befort et al., 2008; Corsino et al., 2012; Ogedegbe et al., 2008; Resnicow et al., 2005; Rocha-Goldberg Mdel et al., 2010; Villablanca et al., 2009; West, DiLillo, Bursac, Gore, & Greene, 2007). The seven papers were individually evaluated in alphabetical order. A structured abstracting form with seven areas of focus was developed to capture the results of the literature reviewed: Author(s) and year of publication, study design and sample, dependent variable, intervention, and results were used to capture the study results (see Table 1).
Use of Motivational Interviewing to Reduce CVD Fisk Factors in African American and Latina Women.
Note. CVD = cardiovascular disease; MI = motivational interviewing; AA = African American; BMI = body mass index; SBP = systolic blood pressure; F & V = fruit and vegetable consumption; PA = physical activity; HTN = hypertension.
Five of the studies included 38% or more African American women (Befort et al., 2008; Ogedegbe et al., 2008; Resnicow et al., 2005; Villablanca et al., 2009; West et al., 2007), and two studies included 58% or more Latina women (Corsino et al., 2012; Rocha-Goldberg Mdel et al., 2010). Among the studies examined, the mean age ranged from 40 to 79 years old (Corsino et al., 2012; Ogedegbe et al., 2008; Resnicow et al., 2005; Rocha-Goldberg Mdel et al., 2010). Research designs included four randomized controlled trials, two pilot studies, and one longitudinal pre–post educational study. All of the studies were conducted in the United States, and included a wide range in sample sizes, from 17 to 1,052 participants. Overall, the number of subjects across all studies comprised 462 men and 2,020 women; the latter were the focus of this paper’s synthesis and analysis. The research question for this review asked whether the use of motivational interviewing was effective in reducing CVD risk factors or improving cardiovascular risk-related behaviors in African American and Latina women. The primary outcomes of interest that were measured were physical activity, weight loss, BMI, SBP, glycemic control, diet as measured by fruit and vegetable consumption, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and medication adherence.
Evidence Regarding Effectiveness of Motivational Interviewing to Reduce CVD Risk
Two studies, conducted by Resnicow et al. (2005) and Villablanca et al. (2009), explored the primary outcome of physical activity following the use of motivational interviewing with African American women delivered through Black churches or faith-based community sites. In these studies, different methods of delivery of the intervention were used. Villablanca et al. delivered motivational interviewing in person, while Resnicow et al. delivered motivational interviewing by phone. There were no significant improvements in measures of physical activity in either study. However, Resnicow et al. reported an increase in fruit and vegetable consumption among those receiving motivational interviewing. Villablanca et al. demonstrated a significant decrease in hypertension, and a significant increase in knowledge of CVD risk modification. Villablanca and colleagues also sought to affect weight loss; however, there was no benefit apparent from motivational interviewing when compared with the control group.
West et al. (2007) implemented an 18-month randomized controlled trial comparing motivational interviewing to an attention control group to explore the outcomes of weight loss and glycemic control with African American and White women. Motivational interviewing was found to have a significant effect on weight loss at 6 and 12 months for those enrolled in the motivational interviewing arm of the study. However, African American women lost significantly less weight than White women at 6, 12, and 18 months. White women continued to lose weight for the duration of the 18-month study, whereas significant weight loss for African American women was not evident beyond 12 months.
Interestingly, Befort and colleagues (2008) reported a postintervention decrease in adherence to health behavior changes among study participants in a 16-week behavioral weight loss program. The study participants also reported a decrease in self-efficacy, defined as ones’ confidence in his or her ability to change a specific behavior under difficult circumstances (Bandura, 1997). The study sample comprised African American women and compared the use of motivational interviewing to health education. Despite the decrease in self-efficacy and motivation, there were significant improvements in fruit and vegetable consumption and weight loss among both groups. However, there were no significant differences when comparing the results of the intervention arm using motivational interviewing to the arm utilizing health education (Befort et al., 2008). Corsino and colleagues (2012) found a similar significant reduction in weight loss in culturally adapted behavioral weight loss intervention for Latino’s using motivational interviewing. The intervention was delivered by Spanish speakers in a local Latino community setting, and the intervention focused on use of foods and physical activities that are familiar to Latinos.
Three studies exploring reduction in SBP had mixed outcomes. Rocha-Goldberg Mdel et al. (2010) conducted a feasibility pilot study that was tailored to Latino males and females enrolled in 6 weekly group sessions incorporating motivational interviewing. In this study, participants had a significant decrease in SBP at the end of the intervention. Another small study conducted with Latino participants found that after 20 weekly group sessions of motivational interviewing, participants demonstrated a significant decrease in SBP (Corsino et al., 2012). This is in contrast to results of a study conducted by Ogedegbe et al. (2008). In the latter study, African Americans received motivational interviewing sessions of 30 to 40 min at 3, 6, 9, and 12 months for blood pressure control. Investigators found a nonsignificant decrease of SBP. However, participants in the motivational interviewing intervention arm demonstrated a statistically significant difference in maintenance of medication adherence compared with the usual care group, whose medication adherence significantly decreased.
Discussion
The studies presented here address a wide variety of motivational interviewing interventions to promote behavior change to reduce CVD risk factors or to improve cardiovascular risk-related behaviors, including improving physical activity, managing weight, improved nutrition, increasing medication adherence, and management of hypertension among African American and Latina women. The studies had resulted in mixed results in improvements to reduce risk for CVD.
The studies comprising this review demonstrate that motivational interviewing can be delivered in a variety of settings, in varying time frames, and via different methods (i.e., in-person individual sessions, in-person group structure, or telephonic motivational interviewing sessions). In the studies reviewed, varying doses of motivational interviewing were used. Across studies, there was no standard amount of time per session, or number of sessions utilized. It is unclear whether the lack of standardization impacted the variability of findings related to the effectiveness of motivational interviewing interventions that was observed across studies.
The lack of standardization may reflect the fact that “best practices” related to the use of motivational interviewing have not been identified. Further questions need to be explored, such as the following: Are in-person motivational interviewing sessions more effective than distance sessions in reducing CVD risk factors? Are group sessions that use motivational interviewing as effective as individual motivational interviewing sessions? Is there a dose-response effect of motivational interviewing, with more sessions producing better outcomes? Might there be cultural preferences related to the acceptability or effectiveness of motivational interviewing? Data need to be sought to address consideration of the method of delivery (e.g., group vs. individual), training of those delivering motivational interviewing, length of individual sessions, and duration of intervention. All are important aspects to be considered when utilizing behavioral interventions such as motivational interviewing, and reports of studies examining the effects of motivational interviewing on outcomes should be explicit in detailing methods of intervention operationalization and delivery.
Addressing the modifiable risk factors for CVD is a crucial step to reduce the prevalence of CVD among populations of African American and Latina women (Roger et al., 2011). This review demonstrated that evidence for the use of motivational interviewing with African American and Latina women to reduce CVD risk in women is sparse, and those studies that employed motivational interviewing have generated mixed results regarding its efficacy. However, the needs for effective behavioral interventions are great in these subgroups of women who remain at higher risk for CVD and CVD-related deaths. Although motivational interviewing results were inconsistent, the positive effects that were attained in increasing fruit and vegetable consumption, decreasing hypertension/lowering SBP, achieving weight loss goals, and improving knowledge of CVD risk modification among those receiving motivational interviewing show some promise for the use of motivational interviewing among African American and Latina women. Findings also highlight the need for effective cultural adaptations of motivational interviewing and to consider how motivational interviewing protocols could be developed to impact behavior over longer periods of time.
In summary, there is an urgent need to further develop, test, and refine behavioral interventions such as motivational interviewing to determine their efficacy to reduce CVD risk factors and to improve CVD-related health behaviors among African American and Latina women. Motivational interviewing has shown some promise in reducing CVD risk factors populations of African American and Latina women. However, more standardization in research methods is essential to generate definitive evidence and for optimal operationalization of the intervention in specific populations.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.