Motivational interviewing to promote exercise behaviour change: a meta ethnography using perspectives of patients and clinicians
Relevance: Physical inactivity is a key future health challenge. Lack of exercise is a modifiable risk factor contributing to global mortality and morbidity rates. Substantial quantitative evidence suggests motivational interviewing (MI) is effective in helping various lifestyle changes including exercise, but the exact mechanism is unclear and therefore its expansion into mainstream healthcare settings has been limited. Identifying the crucial 'active ingredients' of MI requires the exploration of the human experience. This is the first known qualitative systematic review of users' perceptions of MI for behaviour change. Purpose: To identify, appraise and synthesise qualitative studies of participants' experiences of MI relating to behaviour change including exercise. The synthesis aimed to reveal a new understanding of the phenomenon of MI as an intervention to aid modification of lifestyle risk factors. Methods/analysis: This interpretive systematic review followed the seven phases of the meta ethnography approach by [1] as well as the statement for enhancing transparency in reporting the synthesis of qualitative research (ENTREQ 2012) A systematic search of MEDLINE, EMBASE, AMED, CINAHL, and PsycINFO databases, reference lists and unpublished literature identified 6004 citations of qualitative research studies exploring experiences of MI in relation to behaviour change including exercise. 1745 duplicates were excluded, electronically and then manually. 3329 papers were excluded following title and abstract review, leaving 22 study reports for full text analysis. Six studies were included in the final review; two involving clinicians' perspectives and four focusing on the patients' Two independent reviewers conducted data extraction using a piloted, customised form and critical appraisal employing two complementary tools. The first reviewer performed a meta ethnographic cross case analysis on all six studies to permit a transparent expression of the synthesis. Results: 'Reciprocal translation' of all six studies identified nine categories: self efficacy; taking responsibility; fundamental feedback; support or sabotage; special style; a refreshing change; understanding about relapse; long term commitment and deviation leads to disengagement. The synthesis presented an overarching theme: that the mutualistic symbiosis needed for behaviour change depends on observing the 'spirit' of MI. Discussion and conclusions: This qualitative synthesis relating to MI and behaviour change has integrated the essential and unhelpful elements in behaviour change interactions from the users' perspectives, revealing an inter dependent partnership of mutual respect between patient and clinician. When the 'spirit' of MI is observed truly patient centred behaviour change occurs. This focuses on engagement rather than adherence, thus relieving the burden on both patient and clinician. The small sample and inconsistent study quality reduced the depth of the synthesis, but the findings demonstrate strong convergence in patients' and clinician's impressions of MI, regardless of the lifestyle behaviour in question [2] Impact and implications: The findings provide useful guidance for clinicians about communication approaches to support behaviour change. Clinicians can promote lasting behaviour change by encouraging effective social support. MI trained clinicians require workplace support to optimise behaviour change outcomes. Further high quality research is required to explore the experiences of MI in relation to behaviour change among patients and clinicians, particularly physiotherapists.