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Update review

Brief motivational interviewing as a clinicalstrategy to promote asthma medicationadherence

Belinda Borrelli, PhD,a Kristin A. Riekert, PhD,b Andrew Weinstein, MD,c and Lucille

Rathier, PhDd Providence, RI, Baltimore, Md, and Philadelphia, Pa

1023

Patient-centered approaches are associated with better patient

retention and treatment outcomes, without increased time and

cost. Motivational interviewing (MI) is a patient-centered

counseling approach that can be briefly integrated into patient

encounters and is specifically designed to enhance motivation to

change among patients not ready to change. Existing asthma

management approaches (eg, education and self-management)

increase resistance among patients not ready or willing to

follow medical recommendations. MI helps patients resolve

their ambivalence about behavior change and builds their

intrinsic motivation before providing education. Although MI

overlaps with patient-centered communication, it additionally

includes some concrete motivational strategies that can be

briefly and easily implemented in medical settings (eg, setting

an agenda, assessing motivation and confidence for change,

helping the patient weigh the costs and benefits of change, and

providing medical advice and health feedback). Reflective

listening is used to help patients clarify their ambivalence and

diffuse resistance. MI has been shown to be efficacious across a

wide variety of health behavior change areas. This article will

describe the method and spirit of MI as applied to asthma

management by reviewing the principles of MI, brief MI

strategies to motivate medication adherence, the evidence base

for MI, and the costs and benefits of building MI into clinical

practice. (J Allergy Clin Immunol 2007;120:1023-30.)

Key words: Motivational interviewing, adherence, medicationadherence, brief interventions, health behavior change, asthma

management

From athe Centers for Behavioral and Preventive Medicine, Brown Medical

School and The Miriam Hospital, Providence; bthe Division of Pulmonary

and Critical Care Medicine, The Johns Hopkins School of Medicine,

Baltimore; cthe Division of Allergy and Immunology, Jefferson Medical

College, Philadelphia; and dthe Centers for Behavioral and Preventive

Medicine and The Miriam Hospital, Providence.

Supported in part by grants R01 HL062165-06 (BB) and HL079301 and

HL075344 (KAR).

Disclosure of potential conflict of interest: B. Borrelli has consulting arrange-

ments with and has received grant support from the National Institutes

of Health. A. Weinstein has patent licensing arrangements with Asthma

Management Systems and is employed by Asthma and Allergy Care. The

rest of the authors have declared that they have no conflict of interest.

Received for publication January 22, 2007; revised August 10, 2007; accepted

for publication August 13, 2007.

Available online October 1, 2007.

Reprint requests: Belinda Borrelli, PhD, Centers for Behavioral and Preventive

Medicine, Coro-West, One Hoppin St, Suite 500, Providence, RI 02903.

E-mail: Belinda_Borrelli@Brown.edu.

0091-6749/$32.00

� 2007 American Academy of Allergy, Asthma & Immunology

doi:10.1016/j.jaci.2007.08.017

Successful asthma management requires an array ofpatient behaviors. National asthma guidelines (NationalAsthma Education and Prevention Program)1 suggest thatindividuals with persistent asthma take 1 or more dailycontroller medications, use rescue medication as neededfor symptoms, monitor lung function with peak flow mon-itors, and avoid asthma triggers. Adherence rates for in-haled corticosteroids (ICSs) range from 44% to 72%.2-7

Only 8% to 13% of patients taking ICSs continue to filltheir prescriptions 1 year after the initial prescription.8,9

Nonadherence is associated with increased asthma symp-toms,3,10 frequent emergency department visits,11 hospi-talizations,10 and need for oral steroids.11 Given thenumber of patients seen for asthma each year (13.6 millionvisits in 2004),12 the medical visit is a prime opportunity topromote adherence.

Increasing asthma knowledge through education yieldslittle improvement in patient adherence or asthma out-comes.13 Interventions that encourage patients to monitorsymptoms or peak flow have shown significant butsmall effects on asthma morbidity.14 Self-managementapproaches, including identifying barriers to adherence,self-monitoring medication use, goal setting, and problemsolving, result in fewer urgent care visits,15 short-term im-provements in adherence,16,17 higher asthma managementself-efficacy,17,18 improved quality of life,17,18 reducedasthma symptoms,16,19 and less b-agonist use.16,19

Unfortunately, the majority of self-management studiesinvolve more than 5.5 hours of patient contact.20

An important limitation of both educational and self-management approaches is that they are predicated on theassumption that patients are motivated to accept treatmentrecommendations. These approaches might be effectivefor those who are ready to change but less so for those who

Abbreviations usedHCP: Health care provider

ICS: Inhaled corticosteroid

MI: Motivational interviewing

OARS: Open-ended questions, affirmations, reflective

listening, and summary statements

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are not ready.21,22 Schmaling et al,23 for example, foundthat asthma education resulted in increased knowledgebut decreased motivation to use medication. There is aneed for innovative approaches to promote motivationfor medication adherence that (1) build on previously val-idated interventions, (2) are easily integrated into standardclinical care, and (3) target both those who are ready andthose who are not ready to change.

The goal of this article is to describe motivationalinterviewing (MI), a patient-centered approach specifi-cally designed to enhance motivation to change amongpatients not ready to change.21 A brief version of MI, de-scribed in the current article, was developed for use byhealth care providers (HCPs) and structured for bothhospital bedside and outpatient settings.24 MI is ‘‘patientcentered’’ in that the HCP tries to understand the patient’sexpectations, beliefs, and concerns regarding their healthand treatment recommendations, thereby achieving an un-derstanding of the patient and not just his or her illness.25

Patient-centered communication skills have become astandard part of medical curricula and are required as aspecific competency (eg, the American Board of InternalMedicine). MI overlaps with patient-centered approachesbut additionally includes some concrete motivationalstrategies that can briefly and easily be implemented inpractitioners’offices24 and is based on 25 years of social-psychological research on attitude change.26 This articlewill describe the method and spirit of MI as applied toasthma management, review the evidence base for MI,and discuss building MI into clinical practice.

MI: BASIC PRINCIPLES

MI involves 2 key aims: (1) building patients’ intrinsicmotivation to adopt health recommendations and (2)resolving patients’ ambivalence about behavior change(eg, adherence).21 In MI intrinsic motivation is strength-ened by discussing how change is consistent with the pa-tient’s own values and goals.26 For example, if a patientloves to play basketball, the HCP asks how taking his orher asthma medication can help him or her play better.Intrinsic motivation is also increased by having the patientplay an active role in the consultation. For example, rec-ommendations are presented as a menu of options, andthe patient’s concerns and beliefs about these options areexplored (eg, concerns about ICSs). The HCP becomesa consultant, rather than an educator, in the process ofchoosing among the options. Increasing intrinsic motiva-tion through greater patient involvement enhances thelikelihood of both initial change and sustainedchange.27-30

A second important focus of MI is to help patientsresolve their ambivalence.21 Ambivalence (perceivingboth the pros and cons of changing and not changing) isconceptualized in MI as a normal part of the process ofchange. Studies have shown that educating and confront-ing an ambivalent person about change can have a para-doxical effect (eg, the ambivalent person argues more

fervently for not changing).31-34 In one study the numberof alcoholic drinks consumed per week was predicted bythe level of HCP confrontation: the more the HCP con-fronted, the more the patient drank.34 Instead of confront-ing patients about the need for change, the MI HCP asksquestions that elicit patients’ ‘‘change talk’’ (positivestatements about change). Research has shown thatwhen people speak in defense of a new perspective,even one that is opposite to their prior views, their attitudesand behavior shift in the direction of the new perspec-tive.26,35 Thus the more patients hear themselves arguein favor of medication adherence, the more committedthey become to adherence. Verbal commitment is associ-ated with smoking cessation,36 decreased opiate andcocaine use,37 and increased medication adherence inpediatric settings.38,39

In MI change is viewed as a process rather than adiscrete event. This idea was borne out of Prochaska andDiClemente’s stage-of-change model,22 in which peopleare theorized to go through a series of distinct stages be-fore changing their behavior, ranging from not thinkingabout change at all to contemplating change to makingsome initial changes. Problem solving before sufficientlybuilding motivation for change often leads to patient resis-tance (‘‘I’ve tried keeping the medicine by my toothbrush,and it doesn’t work’’). These statements are often reflec-tive of an underlying motivational problem rather than apoor self-management strategy. Educational approachesare therefore an inefficient use of clinical time because un-motivated patients are less likely to initiate and maintaintreatment.21-23,40

PATIENT-PRACTITIONER COMMUNICATIONSTRATEGIES: FOUNDATION OF MI

An important goal of MI is to establish a comfortableand noncoercive atmosphere so that patients feel free todiscuss their feelings about the recommended treatment.This is particularly relevant for asthma medication, aboutwhich patients might falsely self-report adherence.3

Creating a nonjudgmental atmosphere enhances the like-lihood of accurate self-report.30 Four communicationcomponents engender MI spirit: open-ended questions, af-firmations, reflective listening, and summary statements(OARS). OARS has been shown to increase patient col-laboration and satisfaction, treatment adherence, andpatient-physician working alliance.31,32,41 UnderlyingOARS is empathy, or the HCP’s ability to understandthe patient’s thoughts, feelings, and struggles from theirpoint of view. Empathy is a strong predictor of treatmentoutcome.42

Open-ended questions cannot be answered with a yes orno. They produce less biased data because they allowpatients to ‘‘tell their story.’’ Open-ended questions elicitimportant information that otherwise might not be asked.Closed-ended questions often damage rapport, decreaseempathic connections, and paradoxically end up takingmore time.43,44

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Affirmations are statements of appreciation, which areimportant for building and maintaining rapport. Efforts tomake changes are acknowledged, no matter how large orsmall (eg, ‘‘I am impressed by your maintaining a weeklyschedule during the allergy injection build-up phase’’).

Reflective listening involves taking a guess at what thepatient means and reflecting it back, restating theirthoughts or feelings in a slightly different way (Table I).Reflective listening helps to ensure understanding of thepatient’s perspective, emphasizes his or her positive state-ments about change, and diffuses resistance. Resistanceoccurs most often when patients experience a perceivedloss of freedom or choice.45 Reflective responses movethe interaction away from a power struggle and towardchange.46

Summaries are longer than reflections and used totransition to another topic, highlight both sides of apatient’s ambivalence, or provide a recap at strategicpoints to ensure continued understanding (eg, ‘‘You haveseveral reasons for wanting to take your asthma medica-tion consistently; you say that your mom will stop naggingyou about it and you will be able to play basketball moreconsistently. On the other hand, you say they are a hassleto take, and that they taste bad. Is that about right?’’).

BRIEF STRATEGIES FOR ENHANCINGMOTIVATION FOR CHANGE

Beginning the consultation

Setting an agenda. Koning et al47 found that one thirdof patients with asthma or chronic obstructive pulmonarydisease desired greater participation in decision makingabout their treatment. Patients with asthma who reportactive participation in treatment decisions are moreadherent.48 However, patients might be hesitant to voicetheir agendas without being prompted.49 MI provides aframework to actively solicit patients’ agendas. TheHCP provides a menu of options for discussion and letsthe patient decide where to start the conversation (eg,‘‘Would you like to talk about taking your medication,monitoring asthma symptoms, or avoiding asthma trig-gers? What are you most concerned about?’’).50 Havingpatients take initial control of the consultation helpsthem be more active and invested.24 This approach hasshown high acceptability among primary care practi-tioners.24 Although collaborative agenda setting mightincrease consultation time in the short term, patient satis-faction and health outcomes show improvements over thelong term.25

Discussing a typical day. A single open-ended ques-tion inquiring about the patient’s typical day allows theHCP to assess the patient’s social context and adherence ina nonjudgmental framework.52,53 Instead of asking, ‘‘Howmany times did you take your medication this week?,’’which can lead to face-saving answers, the HCP can ask,‘‘What is a typical day like for you, from start to finish,and, if you like, tell me about where taking your medica-tion fits into your day.’’ This technique has been used

successfully in medical populations51,53,54 and is easilyconducted during a physical examination.

Assessing motivation and confidence for change. Bothmotivation and confidence for change have been found tobe strong predictors of asthma treatment adherence.14,39,55

Assessment of motivation and confidence levels helps cli-nicians calibrate their approach to patients. For example,the HCP can ask, ‘‘How motivated are you to take yourmedication? Rate your motivation on a scale of 1-10,where �1� is not at all motivated and �10� is very moti-vated.’’ Confidence in the patient’s ability to adhere canalso be rated. Studies have shown that patients, even thosewho are older and medically ill, do not have difficulty withthis form of numeric assessment.54,56

Using midconsultation strategies to enhancemotivation for change

Using the lower-higher exercise. After motivationis assessed as outlined above, the HCP asks: ‘‘Why nota lower number?’’ This nonjudgmental approach helps toelicit positive statements about change, which have beenshown to be associated with better treatment out-comes.37,57 After the patient provides several reasons,the HCP asks, ‘‘What would it take for you to get to a 9or a 10?’’ This approach helps to identify barriers andfacilitators of adherence. The same exercise can also bedone with confidence levels.

Exploring the costs and benefits of change. Exploringthe costs and benefits of change helps patients to (1) seeboth sides of their ambivalence simultaneously, (2) realizethat the HCP is interested in both sides of their ambiva-lence and not only the ‘‘prochange’’ side, and (3) articulateand think more deeply about their reasons for adherenceand nonadherence. Exploration of ambivalence aboutchange has been successfully used across a wide varietyof health behaviors.54,58 In asthma, studies that included adiscussion of the pros and cons of adherence have been ef-fective in improving adherence and health outcomes.15-17

More benefits and fewer perceived barriers are associatedwith better asthma self-management.7,39,59 In MI the HCPmight start with the ‘‘not so good things’’ about takingmedication to convey a nonjudgmental posture. TheHCP can then ask, ‘‘What about the other side; what aresome �good� things about taking your medication?’’

The HCP encourages detailed answers. For example, inresponse to the ‘‘good things about taking medication,’’ ifthe patient says ‘‘improved asthma,’’ the HCP asks him orher to clarify what that means functionally (eg, reducedsymptoms or better able to perform activities). Aftergathering this information, the HCP provides a summary,an empathic statement, and a query about next steps: ‘‘Onthe one hand, you feel that taking your medication limitsyour freedom. On the other hand, you say that when youdon’t take your medication, you are not free to do thethings that you want to do, like play tennis. This is a toughposition to be in.’’

Providing medical advice and feedback. In MI healthinformation is shared in a manner that increases the

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TABLE I. Types of reflections

1. Repeating Patient HCP

Use to diffuse resistance. ‘‘I don’t want to take my medication.’’ ‘‘You don’t want to take your

medication.’’

2. Rephrasing Patient HCP

Slightly alter what the patient says to

provide the patient with a different

point of view.

‘‘I want to take my medication, but I have

trouble fitting it into my day.’’

‘‘Taking your medication is important to

you.’’

3. Empathic reflection Patient HCP

Provide understanding for the patient’s

situation.

‘‘You’ve probably never had to deal with

anything like this.’’

‘‘It’s hard to imagine how I could

possibly understand.’’

4. Reframing Patient HCP

Help the patient think about his or her

situation differently.

‘‘I’ve tried to take my medication

consistently, but I just can’t seem to

pull it off.’’

‘‘You are persistent, even in the face of

discouragement. Controlling your

asthma is really important to you.’’

5. Feeling reflection Patient HCP

Reflect the emotional undertones of

the conversation.

‘‘I know that not taking medication is bad

for my asthma.’’

‘‘You’re worried about your asthma

getting worse.’’

6. Amplified reflection Patient HCP

Reflect what the client has said in an

exaggerated way. This encourages the

client to argue less and can elicit the

other side of the client’s ambivalence.

‘‘My mom is totally exaggerating my

symptoms. My asthma isn’t that bad.’’

‘‘There’s no reason to be concerned

about your asthma.’’ (said without

sarcasm)

7. Double-sided reflection Patient HCP

Acknowledge both sides of the

patient’s ambivalence.

‘‘Taking medications just takes away my

freedom. It’s such a hassle.’’

‘‘On the one hand, you find that

medication takes away your freedom.

On the other hand, you said that your

asthma symptoms limit your freedom

by preventing you from doing things

you enjoy. What do you make of

this?’’

likelihood that the patient hears, understands, and acceptsthe information. This can be accomplished by using clearand understandable language and reflections that conveyempathy and the patient’s concerns. MI uses the elicit-provide-elicit process to give patients feedback about theirhealth.24 This approach, also called shared decision mak-ing, has received empiric support across a variety of stud-ies,58,60,61 including studies in asthma.62 In one study62

adults with asthma who received shared decision makingwere more adherent to their medication (according topharmacy refill data) versus those who received NationalAsthma Education and Prevention Program guideline–based education.

In MI patients’ perspectives on their condition areelicited (eg, ‘‘What connection, if any, do you see betweenyour taking your medication and your asthma?’’). TheHCP then asks permission to provide education (eg,‘‘Would you like to know more information about howmedication can help your asthma?’’) and then provides theinformation (‘‘What usually happens to some of mypatients who take their medication.’’). The person’sinterpretation of the information is elicited because it is thepatient’s interpretation of the information and not theinformation itself that determines adherence (eg, ‘‘I won-der if we could talk briefly about whether or not this mayapply to you. What do you make of this information?’’).26

Feedback can be given about test results, health care use,medication use and symptoms, or activity limitations.

Advising the patient to change. In MI, advice is givenafter a relationship has been established and the patient’sperspective on the situation has been sufficiently explored.Giving advice has 5 components, creating the acronymRAISE: (1) relationship with the patient; (2) advice tochange; (3) ‘‘I’’ statements; (4) support of patient auton-omy; and (5) empathy. For example, the HCP can say,‘‘As your doctor, I (�I statement�) think the best thing youcan do for your asthma right now is to take yourmedication every day (�advice�). I am not going to pressureyou to do that; the decision to take your medication iscompletely up to you (�support autonomy�). I know thatthese decisions can sometimes be difficult (�empathy�).’’

Asking evocative questions. There are several keyquestions HCPs can ask to evoke optimistic statementsabout adherence from patients: (1) ‘‘If you were to takeyour medication consistently, what might be the bestresults you can imagine?’’ (2) ‘‘What worries you mostabout your asthma?’’ (3) ‘‘How does asthma stop youfrom doing the things you want to do?’’

Ending the consultation

The MI consultation ends with a summary and a queryabout what the patient would like to do next, if anything,

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about managing his or her asthma. Attainable goals arenegotiated if the patient is sufficiently motivated.

THE EFFECTIVENESS OF MI ASA PATIENT-CENTERED METHOD

MI overlaps with patient-centered medicine in thatboth approaches involve patient acceptance, collaboration,open-ended questions, and listening skills. MI uses pa-tient-centered communication but also includes a set ofstrategies to help move patients toward change. Patient-centered approaches improve health outcomes for avariety of conditions, such as asthma,62 diabetes,28,63

obesity,64 and blood pressure.65,66 In asthma managementphysicians trained in patient-centered communicationhave better communication skills, greater patient satisfac-tion, and greater reductions in patient emergency depart-ment visits, hospitalizations, and symptomatic daysversus those seen in control subjects, with no significantincreases in visit time.55,67,68

MI was originally described by Miller in 198340 to ad-dress problem drinkers and has since been applied to avariety of settings (primary care and hospital)25,50,56,60,69

and health behaviors, such as smoking cessation,54 dietarychange,70 medication adherence,23,71,72 exercise,73 HIVrisk reduction,74 drug use,75 gambling,76 eating disor-ders,77 sleep apnea,78 hypertension,79 and obesity.80 Inmedical and public health settings, MI has been used asan opportunistic intervention in which patients receivebehavior change counseling during routine medical care,although they might not be expecting it.54,81 In one studyby Borrelli et al,54 patients receiving Visiting NurseAssociation service who were randomized to receivenurse-delivered MI for smoking cessation were twice aslikely to be continuously quit at a 12-month follow-upthan those who received a standard educational approach.These effects were obtained despite almost 75% of the par-ticipants not being motivated to quit before treatment.

There is evidence for the effectiveness of MI as either aprelude to treatment (eg, motivating treatment entry) or asan intervention itself.82 A meta-analysis found that MI in-terventions result in small effect sizes for smoking cessa-tion, medium effect sizes for both gambling and HIVprevention, and large effect sizes for treatment adherence,diet, and exercise.

With regard to medication adherence, MI plus cognitivestrategies have been shown to be effective in improvingattitudes toward medication adherence in patients withpsychotic disorders, alcohol dependence, and HIV.83-86

Although several studies are underway examining MIto promote asthma medication adherence (C. Rand, PI,National Institutes of Health no. HL079301), only onestudy has been completed.23 In this pilot study 25 adultswith asthma were randomly assigned to receive either asingle session of asthma education or asthma educationplus MI. Although the education condition significantlyincreased knowledge scores, there was a reduction in mo-tivation for medication adherence. Participants in the MI

condition had significant increases in motivation and anincrease in the ratio of advantages to disadvantages fortaking their medication as prescribed versus those in theeducation condition. These medication adherence studiessuggest that MI holds promise as a brief patient-centeredcounseling approach to improve asthma management.Future studies should use objective monitoring of medica-tion adherence,87 long-term follow-up, and monitoring oftreatment fidelity by using established methods.88

BUILDING MI INTO CLINICAL PRACTICE

Although HCPs might be concerned about the time ittakes to integrate MI into a busy clinical practice, studieshave shown minimal time differences (typically no morethan 2 minutes) between delivery of patient-centeredcounseling and delivery of standard approaches.89 Onestudy of primary care physicians found that MI took anaverage of 9.69 minutes.90 The small amount of extracounseling time might be well spent, given that patient-centered approaches are associated with better adherence,better patient retention and satisfaction, greater physiciansatisfaction, lower malpractice, more accurate diagnosis,and better clinical outcomes than usual care.25,91-94

HCPs need not apply the entire arsenal of MI techniquesduring a single visit but rather chose the strategies thatfit best with their own style and with patient readiness tochange. CPT Evaluation and Management codes allowHCPs to be reimbursed for time spent counseling patients.Practices can also be reimbursed by having nurse practi-tioners or physician assistants provide patient-centeredcounseling.

The Accreditation Council of Graduate MedicalEducation mandated that directors of residency programsprovide communication skills training for their residentsand fellows. Trainees must be proficient at (1) demon-strating caring and respectful behaviors, (2) performingcounseling and education, and (3) interpersonal com-munication skills. The MI skills reviewed above fit wellwith the training requests of the Accreditation Councilof Graduate Medical Education. Practitioner-patientcommunication training to improve adherence havebeen provided at state, regional, and national meetings.95

Two health plans (AmeriChoice-Pennsylvania and BlueCross Blue Shield-Delaware) now provide an adherence/communication training CME course for primary carephysicians treating asthmatic patients (Weinstein A;CME course available on request). A series of half-daytraining periods over time combined with self-study (read-ings and viewing training videos) and follow-up trainingbooster sessions are recommended for HCPs.

CONCLUSION

Patient-centered approaches improve the HCP’s per-formance, patient satisfaction, and health outcomeswithout an increased burden of time and cost. MI is a

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patient-centered approach that is effective for promotionof health behavior across a wide variety of areas. MIinvolves fostering practitioner-patient communication andusing brief strategies to help patients resolve their ambiv-alence about change and build intrinsic motivation forchange. MI strategies have been modified such that HCPscan readily incorporate them into regular clinical care.24,54

Although the literature is suggestive of MI as an effectivestrategy to enhance treatment adherence, further researchis needed specifically examining the efficacy of MI in pro-moting asthma management. In 2007, there were 117National Institutes of Health–funded trials on MI, 2 ofwhich were on asthma management, one with low-incomeadults and the other with inner-city teens. Demonstratingto HCPs that patient-centered counseling serves theirneeds by reducing daily frustrations of nonadherent pa-tients, decreasing adverse events, and improving the qual-ity of care with minimal drain on time could motivateHCPs to learn and use these skills.

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