Motivational Interviewing for HIV/AIDS Prevention Programs

1. Welcome to… Motivational Interviewing for HIV/AIDS Prevention Programs For Abstinence & Behavior Change for Youth (ABY) Partners Facilitator: Tom Davis, MPH Director of Health Programs Food for the Hungry Based on the work of: Stephen Rollnick, PhD. & William R. Miller, PhD.

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. Groups to Train on MI • MI Trainers in each country • Community Leaders (for counseling youth, married people) • Religious leadersand workers (for counseling youth and married people, and doing premarital counseling) • Teachers (for counseling youth) • Youth Leaders (for counseling other youth)

4. Behaviors that Can be Promoted through MI • Primary abstinence • Secondary abstinence • VCT • Marital faithfulness • Condom use • Using improved communication techniques • Other steps toward abstinence/ faithfulness (e.g., partner reduction). • Also used to leave behind other problems: alcohol abuse, drug use, prostitution, spousal abuse, poor study habits, etc.

5. 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

6. 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?

7. Task #2: Identifying Barriers to Change • 2a. The cards you have received show scenarios of people in different stages of change – they are not in the correct order. Work in small groups to order the cards according to the Stages of Change model. Then match the people in the scenarios with their stage of change, using the cards, taping them to newsprint. • 2b. Based on your knowledge of Barrier Analysis, what are the determinants of behavior change for each of these people? Write in the determinants on the newsprint, to the right of each person’s scenario card. • Time: 25 minutes • 2c. We will hear a sample of your conclusions. • 2d. At which stages of change do most development actions take place? • Time: 15 minutes

8. Most people are here… ut we usually target people here… Stages of Change Model(Prochaska and DiClemente) Maintenance Action Person is maintaining a change that has already been made. Preparation Person is engaging in actions with the intention of bringing about change. Change is made. Contemplation Person is open to change and preparing for change (often in the next month) Pre-contemplation Ambivalent; Person both considers and rejects change. Person is not ready to consider a change or unaware of the need to change; sometimes demoralized

9. CORRECT ANSWERS 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.” Behavior Change Determinants Pre-contemplation 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.” 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 Maintenance 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.”

10. 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.” Behavior Change Determinants Pre-contemplation 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?” Contemplation 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.” Preparation 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.” Action 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.” Maintenance

11. 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

12. 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.

13. 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

14. 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.

15. 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.

16. 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.

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

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

19. Field Trial #3: Ever Used Disinfectant

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

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

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

23. 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

24. 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

25. 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.

26. 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.

27. 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

28. 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

29. 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

30. 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

31. 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 mixed feelings (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

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

33. 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.

34. 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.” “Like one who takes away a garment on a cold day, or like vinegar poured on soda, is one who sings songs to a heavy heart.” [Prov. 25:20]

35. 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

36. One Example of Developing Difference (Discrepancy) between Values and Actions 2 Sam 12: 4-7: Now there came a traveler to the rich man, and he was loath to take one of his own flock or herd to prepare for the wayfarer who had come to him, but he took the poor man's lamb, and prepared that for the guest who had come to him.“ Then David's anger was greatly kindled against the man. He said to Nathan, "As the LORD lives, the man who has done this deserves to die; he shall restore the lamb fourfold, because he did this thing, and because he had no pity.“ Nathan said to David, "You are the man! Better -- Self-discovery of Discrepancy: "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]

37. 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?) But I tell you, Do not resist an evil person. If someone strikes you on the right cheek, turn to him the other also.” [Mat 5:39]

38. 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. “Preach the Word; be prepared in season and out of season; correct, rebuke and encourage--with great patience and careful instruction.” [2 Tim 4:2]

39. 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

40. 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?

41. 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 reasons not to change / barriers. 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.

42. 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?

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

44. 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

45. The MI Process: An Overview Establish Rapport Set the Agenda This is the uphill part… 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 Two, Creating a Change Plan

46. 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

47. 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

48. 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 Two: Create a Change Plan It’s mostly downhill from here…

49. 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?

50. 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