Motivational Interviewing for HIV/AIDS Prevention Programs

1. Welcome to… Motivational Interviewing for HIV/AIDS Prevention Programs For Bringing Hope (BH) and Abstinence & Be Faithful for Youth (ABY) Partners Facilitator: Trisha Long, University of North Carolina - Chapel Hill

2. Task #1: Introduction* • 1a. Think of an object which symbolizes your work (e.g., a tree, a helping hand, etc.). What is it, and why does it symbolize what you do? Share your symbol and something else about yourself with a partner. • Time: 5 minutes • 1b. We will hear everyone’s symbols as a group. • Time: 10 minutes *Introduction exercise from Global Learning Partners

3. Why are we here? • Goal of the BH and ABY programs: preventnew HIV/AIDS infections among youth and families. • Delay sexual debut and increase abstinence in unmarried youth and adults. • Increase faithfulness among married youth and adults. • Build capacity of faith-based and community-based organizations to decrease transmission of HIV/AIDS. • Reduce unhealthy sexual behaviors that increase people’s vulnerability to HIV.* • Motivational Interviewing helps people change their behaviors • It is usefulwhen people are ambivalent about changing their behavior. • It has been shown to be successful in a developing country setting when applied by non-professional counselors. *Goals adapted from the BH and ABY proposals

4. Part A: What is Motivational Interviewing? After completing Part A, you will have: • Categorized people in variousstages of change in Prochaska’s Model and related their situations to factors in Barrier Analysis; • Compared an example of MI to an example of health promotion; • Reviewed evidence of MI’s effectiveness; and • Reflected on the key principles of MI and their relationship to development work, African culture, and your faith’s teaching. What are your questions?

5. Task #2: Identifying Barriers to Change • 2a. The boxes on the next slide show scenarios of people in different stages of change – they are not in the correct order. Match the people in the scenarios with their stage of change. • 2b. Based on your knowledge of Barrier Analysis, what are the determinants of behavior change for each of these people? Type in the determinants on the right, next to each person’s scenario. • Time: 20 minutes • 2c. We will hear a sample of your conclusions. • 2d. At which stages of change do many development actions take place? • Time: 20 minutes

6. Behavior Change Determinants Prudence is 18, and single. “It is such a relief to know that I will not have to worry about HIV. Since last month, when I made the decision to be abstinent until marriage, my heart feels light.” Pre-contemplation Benito is 17 years old and single. He has been having sex for the past three years, and does not see any reason why he should stop. He says, “Yeah, I’ve heard all about getting HIV, but if I am going to get HIV, I probably already have it by now.” Contemplation Samuel is 25 and newly married. “I have decided I must be faithful to my wife. She and our future children mean too much to me to risk their health.” Preparation George is 40 years old, single, and has HIV. “I have just begun using a condom every time I have sex so that I will not infect my partners,” he says. “I hope I will be able to remember to buy them.” Action Jamila is 19 years old, and has been having sex for money in order to feed her younger siblings since age 15. “I would like to ask each man to use a condom so I know I am at less risk for HIV” she says, “but I do not think I could do it. Plus, I fear he will always refuse, and maybe become angry with me and hurt me.” Maintenance

7. Mtume is 20 years old, and married for two years. “If I do not stop sleeping with other women,” he says, “I am sure I will bring HIV home to my family. But what will my friends say? Will they think I am less of a man if I only sleep with my wife?” Hasan is 24 years old. “Since I decided to be abstinent four months ago, I am happy with my decision,” he says. “Sometimes it is hard to wait, but I will be married soon, and my wife and I will be safe from HIV.” Safiya is 14 years old. “I have thought about this a lot,” she says. “I am ready to decide to be abstinent. I just need to know what I should tell my friends.” Amina is a 35, a wife and mother. “I haven’t heard much about HIV, but since I have always been faithful to my husband,” says Amina, “I could never get HIV. Besides, when God wants someone to get HIV, they get it.” Philip is 32, and married. “I don’t want my family to experience the stigma of HIV, even if I am not always faithful to my wife. I have decided to use a condom every time I have sex with another woman.” Behavior Change Determinants Pre-contemplation Contemplation Preparation Action Maintenance

8. Task #3: MI and Health Promotion: How different are they? • 3a. Listen to the following examples of health promotion and motivational interviewing. • Time: 15 minutes • 3b. With a partner, name the differences between the two methods that you hear. • Time: 5 minutes • 3c. We will hear your ideas. • Time: 20 minutes

9. MI and Health Promotion: Some Differences • In MI, the person you are speaking to decides what you will talk about, not you. • There is less direct confrontation or opposition. • Strategies such as “importance scales” are used to enhance conversation • Ask questions in a positive direction • Good example: “Why is it somewhat important for you to change? Why is it more than just a little important?” • Health promotion isn’t wrong or bad. • It is not always the right tool for this situation.

10. Task #4: Evidence for the Effectiveness of MI • 4a.Listen to the following presentations about how Motivational Interviewing has been used in an African context and to prevent HIV. • Time: 15 minutes

11. Motivational Interviewing in Zambia • From 1999-2001, MI was used in two peri-urban communities in Kitwe, Zambia, where diarrhea and clean drinking water had been identified as major concerns. The goal of the intervention was to encourage adoption of safe water storage practices and purchase of disinfectant in the target communities.

12. Health promotion messages were delivered using MI by neighborhood health committee (NHC) volunteers in weekly visits that were 15-30 minutes long. Health Promotion + MI • An Intervention group received Motivational Interviewing along with education. • A Comparison group received education only.

13. How NHC Volunteers Were Trained • Only the volunteers using MI were trained in MI. All volunteers received diarrhea prevention and safe water education. Local nurses received training in MI, and then developed and delivered MI training for the Neighborhood Health Committee (NHC) volunteers. The NHC volunteers received approximately 10 hours of MI training.

14. Zambia MI Study, Field Trial #2: Bottles of Disinfectant Sold/HH (MI vs. Ed. Only), ’98-’99

15. Field Trial #3: Disinfectant Present in Stored Water

16. Field Trial #3: Ever Used Disinfectant

17. Field Trial #3: Know That Contaminated Water Causes Diarrhea

18. Field Trial #3: Believe They Can Avoid Diarrhea

19. Field Trial #3: Know They Can Avoid Diarrhea by Boiling or Treating Water

20. MI & HIV Prevention • Two trials of an MI-based intervention for HIV risk reduction in a high-risk population in the U.S.,conducted through community-based organizations. • Study Population: • Poor, single urban women, motivationally interviewed in groups • Average age: 32 • Education: Most did not complete secondary school • Risky behaviors: Drug use, transactional sex, and multiple partners, already had a sexually-transmitted disease

21. MI & HIV Prevention • The immediate effects that were observed: • Increased knowledge of HIV risk • Stronger intentions to adopt safer sex practices • Intentions communicated to sexual partners • Fewer acts of unprotected sex • These effects were mostly sustained at a three-month follow up. • Effects were partially replicated in a second field trial, by a 4x increase in condom use in the MI Group. • The MI Group women were also more likely to: • Discuss HIV and condom use with partners • Refuse unprotected sex • Get an HIV test

22. Studies Cited • Thevos A, Quick R, and Yanduli V. “Motivational Interviewing enhances the adoption of water disinfection practices in Zambia.” Health Promotion International. 2000; 15(3): 207-214. • Thevos, A.K., Kaona, F. A. D., Siajunza, M.T., & Quick, R.E. “Adoption of safe water behaviors in Zambia: Comparing educational and motivational approaches.” Education for Health. (2000); 13(3): 366 - 376. • Carey, M. and Lewis, B. “Motivational Strategies Can Enhance HIV Risk Reduction Programs.” AIDS and Behavior. 1999; 3(4): 269 – 276.

23. Important Limitations • Few studies are in a developing-country context. • No studies are available in which abstinence and faithfulness-based HIV prevention approaches were used. • Most studies focus on risk reduction through condom use and increased risk awareness. • Studies are often done with high-risk populations, such as commercial sex workers.

24. Why We Think MI Will Be Effective • People are often ambivalent about sexual behaviors like abstinence, faithfulness, and condom use • MI works best with ambivalent people • People expect to be involved in making decisions about their sexual behavior • MI respects this choice • MI is not coercive

25. Other Situations Where MI has been Used to Help Individuals Change • These are just a few examples: • Alcohol and drug abuse in adults and teens • Criminal rehabilitation • Adherence to medication regimen or treatment • Weight control • Dietary changes related to health (example: lowering cholesterol) • General healthcare settings, including emergency rooms at hospitals

26. Task #4: Evidence for the Effectiveness of MI • 4b. What surprises you about the effectiveness of MI in these studies? • 4c. What is different about the context of your project from how MI was used in these studies? • 4d. What about these examples makes youconfident that MI could be effective in your programs? • 4e. How convinced are you of MI’s effectiveness at this point? • Time: 15 minutes

27. 4e. How convinced are you of MI’s effectiveness at this point? • A: Very convinced • B: Somewhat convinced • C: Not sure • D: Somewhat skeptical • E: Not convinced

28. Task # 5:Principles of MI • 5a. Read the following definition of Motivational Interviewing. Motivational Interviewing is a people-centered, directive method for increasing a person’s inner motivation to change by exploring and helping them to resolve ambivalence about a new behavior. • What strikes you when you read this definition? Underline that part. • What do you have questions about? • Time: 15 minutes

29. Task #5 continued… • 5b. Listen to the following presentation on motivational interviewing. • Time: 15 minutes

30. The Guiding Values of MI • Collaborating Together: honors the person’s experience and perspective. MI does not attempt to force someone to change. • Bringing Forth Strength for Change: recognizes that the person already has the resources and motivation to change, and works to enhance them. We help people to “drink from their own wells.” • Free Choice: respects the person’s right to decide what to do for themselves, and helps them make an informed decision.

31. Express Understanding • Ambivalence is normal • Use reflective listening • We’ll practice this in Part B • Accepting the person for who they are facilitates change • This does not mean you must agree with or endorse their attitude or behavior “It is okay to feel confused about this issue.”

32. Develop Difference • Change is motivated by perceived differences between present behavior and personal values or goals • The person you are talking to discovers and presents their own arguments for change “For what I do is not the good I want to do; no, the evil I do not want to do--this I keep on doing.” [Romans 7:19]

33. Roll with Resistance • Avoid arguing for change • Instead, invite a new perspective on the issue • Resistance is a signal to you to respond differently. • We’ll talk more about this in Part B. • “Take what you want and leave the rest.” (Who can argue with that?)

34. Support Self-Efficacy • A person must believe they can change before change is possible. • Self-efficacy: Barrier Analysis! • People draw on hope and faith as personal resources for change Your belief in their ability to change can be a self-fulfilling prophecy.

35. Task #5 continued… • 5c. Divide into three groups and reflect on the relationships between the values of MI, these principles and: • Group 1: Development work • Group 2: African culture • Group 3: Your faith • What examples of development interventions, African cultural beliefs or proverbs, and religious beliefs are supportive of the values and principles of motivational interviewing? • Time: 20 minutes • 5d. We will hear all responses. • Time: 10 minutes

36. Review of Part A • We related the Stages of Change to Barrier Analysis and discussed where MI fits in. • For what stages of change is MI helpful? • We compared MI to Health Promotion. • What differences did you notice? • We reviewed the evidence that MI can be effective in our context. • We discussed the guiding values and principles of MI, and how they relate to development work, to African culture, and to religious faith. • Do think MI is compatible with development work, with African culture, and with your faith? What are your questions?

37. The stories can be from any point in your life (they need not be recent). The story should not be so personal that you would be unwilling to share it with the other participants. Be able to finish telling the story in five minutes. Specifics about the stories: You were trying to change something in your life (not someone else’s), either a behavior or a situation. There were good reasons to change, but also good reasons not to change. It is okay if you did not resolve the situation. Homework: Your Stories • Think of two stories from your life where you were conflicted (ambivalent) about something. • We will tell each other our stories for one of tomorrow’s exercises.

38. Part B: Basic MI Skills After completing Part B, you will have: • Examined an outline of the practice of Motivational Interviewing; • Distinguished between open and closed questions; • Assessed how reflective listening skills can help develop discrepancy between current behavior and personal values; • Experienced, Heard, and Practiced reflective listening; • Compared resistance and change talk as indicators of how the conversation is going; and • Practiced using motivational interviewing skills in role-playing situations. What are your questions?

39. Task #6: The MI Process • 6a. Order the steps in the MI Process on the following diagram. • Time: 10 minutes

40. Task #6: Order the MI Process Set the Agenda Encourage Change Talk Explore Importance/ Values and Build Confidence Reduce Resistance Exchange Information Enhance Motivation to Change (Next: Create Change Plan) Open Questions Affirmation Reflective Listening Summarizing Establish Rapport Assess how important they think change is, and how confident they are that they could change

41. The MI Process: An Overview Establish Rapport Set the Agenda Assess importance and confidence Explore Importance/Values and Build Confidence Exchange Information Reduce Resistance Open Questions Affirmation Reflective Listening Summarizing Encourage Change Talk Enhance Motivation to Change – Move on to Part 2, Creating a Change Plan

42. Task #6 continued… • 6b. Looking at the MI diagram, what MI techniques could you use to increase someone’s feeling that it is important to change their behavior? • 6c. What key determinants in Barrier Analysis affect importance the most? • 6d. Thinking about the values and principles of MI, and OARS, how could you enhance confidence by using MI? • 6e. How would low confidence affect importance of making a change? • 6f. How did Afiya, the health promoter in yesterday’s scenario, assess Imani’s importance and confidence? • Time: 20 minutes

43. Importance & confidence scales • How important is it to you to remain abstinent before marriage? 1 2 3 4 5 Not important Very important • How confident are you that you can remain faithful to your spouse? 1 2 3 4 5 Not confident Very confident

44. Summarize arguments for change/acknowledge reluctance Ask a key question, like “What do you think you will do now?” Provide information and advice Set Goals Consider change options Make a Plan Elicit Commitment to the Plan Support Commitment to the Plan Review and Revise Plan, If Needed Preview of Part 2: Create a Change Plan

45. Task #7: OARS - Open Questions • 7a. Which is an open question? • What do you think about abstaining from sex before marriage? OR • Have you and your girlfriend discussed having sex?

46. Task 7 continued… • 7b. With a partner, divide the following list into open and closed questions. • Time: 5 minutes • 7c. We’ll hear a sample of your responses. • Time: 10 minutes

47. Categorize these questions as either: Open Closed Does your girlfriend ever ask you if you have other partners? What would make it easier for you to be faithful? Who decides whether or not you will use a condom, you or your partner? What are the reasons that you would want to continue having sex with your boyfriend? What consequences of HIV concern you most? Is this an open or a closed question? What are your views on faithfulness in marriage? Have you ever thought about being abstinent? How would being abstinent before marriage be good for you? Where do you go for information about HIV? Have you ever been tested for HIV? Do you believe you can get HIV, even if you are married? Do you want to stay in this relationship? What do you like about being abstinent?

48. What do you like about being abstinent? How would being abstinent before marriage be good for you? What are your views on faithfulness in marriage? Where do you go for information about HIV? What consequences of HIV concern you most? What are the reasons that you would want to continue having sex with your boyfriend? What would make it easier for you to be faithful? Have you ever been tested for HIV? Have you ever thought about being abstinent? Do you want to stay in this relationship? Do you believe you can get HIV, even if you are married? Does your girlfriend ever ask you if you have other partners? Who decides whether or not you will use a condom, you or your partner? Is this an open or a closed question? Correct AnswersOpen Closed

49. Task #8: Recognizing OARS • 8a. Listen to the following dialogue, which shows the use of open questions, affirmation, reflective listening, and summarizing in developing discrepancy. • 8b. Circle or mark the following in your paper copy of the dialogue: • Two examples of reflective listening • One open question • One example of resistance • One example of affirmation • One example of summarizing • 8c. We will hear your responses. • Time: 30 minutes

50. Affirmation • An affirmation is a compliment! • Praise positive behaviors. • Support the person as they describe difficult situations. • Examples: • “You seem to be a very giving person. You are always helping your friends.” • “That situation must have been very painful for you, but you managed to get through it.”