Essay: Motivational intervention is efficacious as an intervention to reduce alcohol consumption

Discussion
The research investigated within this review was found to have some limitations: those that are inherent of the behavioural nature of the topic that make it difficult to definitively assess and are therefore difficult to improve on (for example, fidelity of intervention and self-reporting of alcohol use); and those that are a product of methodological weakness, such as potential for bias and absence of important data.
Critical appraisal can highlight discrepancies that make it difficult for the reader to ascertain the validity of the results and therefore come to a decisive conclusion.
Clear and precise research is required to provide unequivocal results from which more accurate and vigorous conclusions can be drawn.
Alternatively, a solution could be the adaptation of the critical appraisal process: for example, to make allowances for the type of behavioural trials where blinding is impossible and therefore grading them high risk for performance bias is possibly unjustified (Grant et al., 2016).
Fidelity of intervention was an interesting limitation of these trials and reviews. It would seem important to assess whether the interventions held and described as MI did indeed adhere to the principle tenets of MI and therefore whether these results attributed to MI are appropriate.
MI is very difficult both to assess and quantify. Its efficacy is reliant on the rapport between clinician and client and daily variations can occur. For this reason, there can also be wide inter- and intra-therapist variability.
The quality and accuracy of patient self-report on their therapist could also be called into question as entirely subjective but, with behavioural studies being so difficult to quantify, it is possibly one of the best possible measures of the clinician-client relationship and therefore the quality of the MI delivered. MI is more than just the learned techniques and its success relies equally on the counsellor evoking the spirit of MI as a way of being with people and understanding the people they are attempting to help (Miller and Rollnick, 2002), therefore a client’s response to their counsellor would appear to be a good intimation of the likelihood of success.
Beyond this, the importance of training in the techniques of MI should not be downplayed but clinicians should be trained in a wide range of strategies and more importantly be able to critically evaluate the evidence for different approaches to behaviour change and be able to assess which to employ in any given circumstance (National Institute of Clinical Excellence, 2007).
The main issue with all the included papers was that of publication bias. Although all papers outlined a thorough search strategy, none included a search of the “grey literature”, a source consisting of: unpublished trials; those reported in non-english journals; and trials reported as meeting abstracts, book chapters and letters (Ahmed et al., 2012). Only two papers discussed the possibility of this bias and investigated its likelihood, with funnel plots finding no evidence of asymmetry (Foxcroft et al., 2016; Kohler and Hofmann, 2015). Vasilaki et al. (2006) selected peer-reviewed papers only, as they considered these to form higher quality evidence, but they only searched two databases and handpicked references from two earlier meta-analyses because they appeared in the bibliography of the MI website, which it might be natural to assume, incorporates the possibility of bias.
Huh et al. (2015) produced an individual participant-level data meta-analysis which is a technique that provides the most reliable approach to evidence synthesis and therefore has the potential to reduce publication bias (Ahmed et al., 2012) but they only used papers whose authors had submitted their original data to project INTEGRATE (Mun et al., 2015) thereby limiting their pool of data and highlighting that this type of meta-analysis is still not guaranteed to be bias-free. Meta-analyses conducted without a thorough search of the literature are judged to be hypotheses-generating only and at major risk of publication bias (Biondi-Zoccai et al., 2011).
While much of the historical research into MI and alcohol misuse has been intended to assess its efficacy as an intervention, there has also been a move towards trying to identify the populations that different adaptations of MI work best for and identifying which components of MI predict the best outcomes. This would be useful to be able to apply within the dental appointment.
The findings of this review support MI for reduction of alcohol consumption and show few contraindications to its use in other areas of behaviour change.
This view is shared by NICE and Public Health England who support its use within their guidelines for behaviour change on both a general and individual level (National Institute of Clinical Excellence, 2014, 2007; Public Health England, 2016b).
Vasilaki et al. (2006) found MIs to be effective compared to other active treatments only in those seeking treatment and it could be argued that the dental population both do and don’t fall into this category. Persons with alcohol misuse concerns usually seek treatment with the knowledge that their alcohol consumption is the behaviour that must change while patients seeking treatment for their dental disease are not always expecting to have to change their behaviour to cure their disease.
It is speculated that age may have a bearing on the efficacy of MI techniques with better results being seen in older populations (Vasilaki et al., 2006) however none of the other included studies covering a wider range of age groups made any investigation into a link between age and success of intervention.
Papers chosen for this review were not selected with regard to age but only four of the ten are concerned with a population over the age of twenty-five (Beckham, 2007; DiClemente et al., 2017; Field et al., 2014; Vasilaki et al., 2006). The remaining papers address either a student population with or without age specified (Appiah-Brempong et al., 2014; Huh et al., 2015; Monti et al., 2007); under 18’s (Arnaud et al., 2017); or young people where the cut off for inclusion was 25 years of age (Foxcroft et al., 2016; Kohler and Hofmann, 2015). These studies varied in their conclusions for the efficacy of MI and did not suggest any significance regarding the age of the subject.
Three of the papers are concerned with a student population where many of the participants will be undergoing mandatory interventions ordered by their institutions. Arnaud et al. (2017) involve caregivers in their intervention for under 18s. Both factors could be said to act against the important tenet of MI that is patient autonomy and could be considered to have influenced the results post-intervention. However, this influence could be exerted positively, the importance of compliance with college dictates to remain in school; or negatively, where the lack of autonomy renders the MI less effective.
Two of the three papers relating to students concluded favourably for MI.
Arnaud et al. (2017)’s study of under 18’s found both interventions reduced alcohol use but did suggest that the negative experience of the paediatric emergency department visit may function as a cuing event that may override the impact of the brief intervention. Support for this hypothesis is given in other studies (de Visser et al., 2013).
Four papers (Arnaud et al., 2017; Field et al., 2014; Kohler and Hofmann, 2015; Monti et al., 2007) have the setting of emergency care departments where the situation itself may be motivational towards change: this may influence the strength of their results and make their population less comparable to a Dental Hygiene/Therapy cohort despite some dental patients having strong motivations of their own.
Two papers, both systematic reviews, did not limit the setting of the interventions and so could offer comparisons. Diclemente et al. (2017) found type of setting comparisons to be non-significant and Foxcroft et al. (2016) stated that there was no discernible subgroup effect for any of the outcomes considered. Field et al. (2014) was a multisite trial, utilising 3 separate trauma centres, and found no significant effects relating to site. They suggested their results inferred that BMIs can have a robust effect across a range of patient populations when adequately standardised.
Dental Hygiene/Therapists are well placed to use MI within their appointments because the frequency of visits by patients lends itself to the cultivation of relationships with them and provides continued opportunities to promote necessary behaviour change. Many studies have shown the effects of MI were not sustainable beyond 12 months (Vasilaki et al., 2006) but it may be that these effects could be extended within the framework of regular dental visits.
Field et al. (2014) found good results for brief motivational interventions that incorporated a follow-up booster by telephone and this could be considered for use in dental practices to further extend the benefits of MI to patients.
While none of the studies included in this review contained interventions as brief as those within a dental hygiene/therapy appointment would be, this is perhaps not necessarily an obstacle to success and may be an advantage – a dripping tap effect – a steady erosion of patient resistance, arrived at by their own insights into their desired objectives for health and well-being.
Time may be considered a barrier to the implementation of these techniques by dental professionals: the time needed to develop MI strategies and then to implement them within the framework of the dental appointment. Married to this is the cost and access to MI training and a possible lack of support for a clinician if there is some variance in staff training and perspectives within an organisation.
Clinicians may feel they lack the expertise or the confidence in their ability to deliver this style of intervention.
From the patient angle, infrequent attendance and cultural and/or language barriers will influence the ability to successfully use MI.
Other barriers to incorporating evidence-based practices such as MI can be the perception of its effectiveness: if this is negative then the motivation to implement will be decreased. It is hoped the findings of this study may encourage the positive fit of this strategy to the dental setting and what the DHT is trying to achieve.
Clinicians need to see a benefit to applying MI and it can require a change to a clinician’s professional identity: a shift from an “expert” role of solving a client’s problems to a position of helping them solve their own.
Regular and good quality training in MI can improve a clinician’s self-efficacy and demonstrate the technique’s relative ease of use and flexibility.
Another important advantage of MI is its cost-effectiveness which is a large part of its appeal as an intervention method. Many sources support this (Beckham, 2007; Public Health England, 2016c; Rollnick et al., 2008) and others call for further research to test this (Monti et al., 2007; Vasilaki et al., 2006). In this respect if often outweighs other active therapies and removes another barrier for implementation.
Future research into the efficacy of MI within the limits of the dental appointment would be constructive and investigation of the most successful or essential components of MI may help to structure its use here. Finally, it might be interesting to further explore the benefits for the clinician of this interaction style: for example, the expected improvements to the therapeutic relationship which result from a less authoritarian approach and the knock-on effects of this enhancement.
Conclusion
From this review it can be concluded that MI is efficacious as an intervention to reduce alcohol consumption in any population with alcohol misuse issues, when compared with alternative treatments, although its results are stronger in comparison to less active control interventions.
Implications for Clinical Practice
This research indicates that MI would be an effective technique within the setting of the dental hygiene/therapy appointment to promote necessary behavioural changes. The evidence for the efficacy of MI provided over short durations, in many healthcare settings and with different age groups, as well as its overall cost-effectiveness, lends itself well to the dental appointment. While MI is something that can work for individual clinicians, a practice-wide approach may be advantageous as this would allow both continuity of care for the patient and added support and alliance for the practitioner. In this way, many barriers to implementation can be overcome if there is a perception of MI as an effective strategy.
The significant impact of a follow up contact to boost the MI intervention within many studies is also one that could be applied within the dental setting although a general dental practice may not consider this to be cost effective.
Improvements to future research
The next step may be to investigate the most effective components of MI and how self-motivational statements from a patient/client, known as “change talk” within the concept of MI, can predict future outcomes and likelihood of successful behaviour change. It is unclear how this could be effectively measured.
There are already many facets, of trials which investigate the efficacy of MI, that could call into question the validity of their results. It is difficult to quantify and measure effects of a behavioural intervention particularly one which relies so heavily on the human relationship between clinician and client.
It has also been suggested that critical appraisal for behavioural trials needs to be modified as the current expectation is towards standards that are impossible for this type of study to realistically achieve.
Future research could investigate the efficacy of MI for behaviour change specifically within the dental setting with randomised control trials using larger populations and with provision of the highest standards of fidelity measurement and statistical calculation to ensure unquestionable validity of results.