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Table 1 Description of studies included in the realist review for MI and health behavior change for adolescents

From: Realist-informed review of motivational interviewing for adolescent health behaviors

Reference Population characteristics Description of MI intervention Study design Primary outcomes Contextual factors Mechanisms CMO configuration
Ball et al. 2011 [74] (medium) - 13 to 17 years old
- BMI > 85th %
- 46; 40% of these dropped out
- Weight management clinic
- Caucasian majority
- 16 to 20 weeks, 16 sessions total
- MI and CBT delivered by RD and RN with 2 days of training
- Parents invited to attend 3 parent-only sessions on supporting teenagers
- RCT; 2 intervention groups or wait-list control
- Pre/post
- No MI fidelity assessed
- %Δ of BMI z score; body weight; BMI and BMI percentile; improved in the intervention groups only
- No difference with the addition of MI
- Caucasian majority
- Clinical setting
- Lack of relatedness - Lack of parental involvement (C3a) with Caucasian majority (C4), created lack of relatedness (M3), resulting in null results
Bean et al. 2015 [68] (medium) - 11–18 years (M = 13.8)
- African American (73%) females (74%)
- Parent/caregiver willing to participate
- MI (n = 58) or control (n = 41)
- Attrition: 20.6%
- IG: Brief MI sessions on first and last session
- Biweekly dietician and behavioral support visits and 3×/week supervised physical activity.
- 2-day training by MINT trainer and 30 h practice.
- Parental involvement but separate from MI
- RCT; pre, post follow-up at 3 and 6 months
- High MI fidelity
- MI participants had greater 3-month adherence overall and to dietician and behavioral support visits, and result was consistent at 6 months - Majority female, African American - No mechanisms discussed - High MI fidelity by clinician (C2), led to greater adherence to dietician and support visits
- No mechanisms or behavioral change outcomes.
Berg-Smith et al. 1999 [73] (medium) - Ages 13–17
- 50% female
- Previously enrolled in DISC program for 3 years
- N = 127
- MI session held in clinic
- Reported no attrition
- Single session MI
- Increase participant motivation + adherence to DISC dietary guidelines
- Master’s degree level health educators and nutritionists. Interventionists had 18 h of training and ongoing supervision
- Pre/Post design
- No control group
- Follow-up 1–3 months
- Did not report fidelity
- Mean proportion of calories from fat decreased from 27.7–25.6%
- Proportion of calories from fat decreased from 9.5–8.6% of total energy intake
- Clinical setting
- Family engaged for 3 years previous
- Reported that teens liked being treated as adults and wanted to express their own choices about what and how much to eat.
- Relatedness within family
- Majority Caucasian (C4) Families already involved in intervention (C3a), created relatedness (M3) resulting in outcomes
- Participants reported autonomy (M2), resulting in outcomes
Black et al. 2010 [60] (high) - Aged 11–16
- 97% African Americans
- Intervention completion and follow-up n = 91 and 89
- Control completion and follow-up n = 93 and 90
- Challenge program: mentorship + MI
- 12 weekly sessions with mentor
- Mentors received 40 h of training and had weekly supervision during the intervention
- RCT; pre/post design
- Follow-up 24 months after end of intervention
- Attrition 76.2% completed follow-up
- Fidelity not assessed
- Overweight/obese status declined 5% among intervention adolescents and increased 11% in control
- Increase physical activity
- Decreased snack/dessert consumption
- Delivered in home and community
- College-enrolled (or recently graduated) mentor
- African American adolescents
- With a mentor, the adolescent experiences healthy eating and PA and gain confidence to adopt new behaviors - African American adolescents (C5), MI delivered by gender- and race-matched peer (C3b), produced relatedness (M3), resulting in health behavior change
Brennan et al. 2008 [95]; Brennan et al.,  2012 [79]; Brennan, 2016 (medium) - Ages 11–18 and parents
- 46% female
- N: standard interview (SI) 34
- MI: 29
- 81% Australian
- Mid to high income
- CHOOSE HEALTH program: MI + CBT or structured interview + CBT or wait list
- MI session conducted with both adolescent and parent present
- RCT
- Control group: yes
- Attrition: reported none
- No fidelity reported
- MI + CBT and SI + CBT did not differ significantly in terms of fat mass, lean mass and percent body fat, weight, BMI, BMI z score, waist circumference, waist–hip or waist–height ratio - Parental engagement
- At an Australian university
- Delivered by a post-graduate in psychology
- MI session was conducted with both the parent and adolescent present
- Report that the efficacy of MI in the current study may have been influenced by parental involvement in the session - MI not delivered effectively (C2), adolescents could not develop autonomy (M2), leading to null findings
Carcone et al. 2013 [69] (medium) - N = 40, with primary caregivers
- Recruited from pediatric and endocrinology clinics
- Participants were self-identified black adolescents
- 27 females
- M age 14.7
- Mean BMI was 38.5
- Low- to middle-class families
- Identify interventionist motivation patterns and language that are most successful
- Counselors highly trained in MI by the MINT
- Four 60-min sessions of MI
- Change plan was completed and shared with the caregiver at the end of the session
- The counselor met with the caregiver alone (20 min)
- Coded by SCOPE, adapted to capture culturally relevant examples of CT and CM
- Analysis of codes
- 62% of the time, counselors’ open-ended questions elicited CT
- Provider statements emphasizing autonomy were more likely to elicit CT
- Affirming statements not effective
- Parental involvement
- Highly trained professionals
- Met with parent/child separately.
- African American adolescents
- Provider statements emphasizing adolescents’ autonomy or personal choice in making health-related decisions were highly predictive of adolescent CT - Highly trained professionals in MI (C2); provider statements asserting autonomy leads to adolescent change talk (M2).
- No outcomes reported
Carcone, et al. 2016 [70] (medium) - 37 adolescent/parents dyads
- Self-identified as black
- Secondary data analysis
- M age was 14.7 (SD = 1.63) and most were female (n = 27)
- Participants received a single MI session, approximately 60 min long
- Sessions conducted by MI counselors who were members of the MINT
- Counselors met first with adolescents alone, then with caregivers alone and ended with both together
- Extracted phrases assigned the ambivalence code
- A total of 268 statements were extracted from 25 (67.6%) families
- Directed content analysis
- Fidelity not assessed
- Ambivalence is reported at higher rates for caregivers than youth
- Ambivalence is less for nutrition-related changes for caregivers compared to youth
- Greater convergence in ambivalence for nutrition-related changes
- Greater divergence in ambivalence for physical activity-related changes
- Parental involvement
- African American adolescents
- Ambivalence between adolescent and parent - Parental involvement (C3a), divergence in the ambivalence between the dyad (M4), no outcomes reported
Davis et al. 2011 [80] (medium) - N = 45
- Female, (BMI) ≥ 85th percentile
- Latino
- Average age = 15.8
- Participants received circuit training (CT) exercise training 2 times per week for approximately 60–90 min per session for 16 weeks
- Participants were required to attend at least 28 of the 32 sessions.
- MI group received 4 individual MI and 4 group MI sessions
- Interventionist members of MINT
- Randomized to 1 of 3 groups: control (n = 13), circuit training (n = 18), or CT + MI (n = 14)
- Pre/post test
- The average of code was 3.8, with 3.5 being considered proficient
- MI sessions did not significantly improve health outcomes, and CT alone showed more promising results - Trained interventionist
- MI sessions were too frequent (8 sessions for 4 months) and were held before or immediately after the exercise sessions
- Latino adolescents
- Lack of autonomy due to requirement to attend classes
- Perform specific goals that were not their own in the exercise training portion
- MI delivered without fidelity due to goals not being collaborative (C2), lack of autonomy (M2), no significant outcomes
Flattum et al. 2009 [78] (medium) - Girls at risk for becoming overweight or who are overweight
- 41 girls (age M = 17)
- 20 participated in the MI condition
- Majority white (n = 11)
- Attrition, 81% completed all seven sessions
- New Moves: individual sessions with MI, teaching nutrition and social support
- 5 in person (20–25 min) and 2 phone visits (10–15 min) every 2 to 3 weeks
- Registered dietitian and health educator
- 2-day training in MI and also attended weekly case mgmt
- Mix-methods: coaches completed process evaluation forms, about goals, barriers to meeting goals, and setting of an action plan
- No fidelity data
- Set goals 100% of the time
- Achieved goals 75% of the time
- Goals related to physical activity, nutrition, and social support
- No outcomes
- Delivered in community/school setting
- 2-day training in MI and attended weekly case management
- Delivered by a dietician and health educator
- MI phone sessions difficult to schedule
- Goal setting  
Gourlan et al. 2013 [62] (medium) - N = 54 (28 in Standard Weight Loss Program (SWLP); 26 in SWLP + MI) completed interventions
- Attrition rate = 13%
- Recruited from hospital by gen. practitioner due to obesity
- M age = 13 years
- 41% female
- BMI over 90th age and gender-specific percentiles
- Participants randomly assigned to groups
- SWLP group received 2 individual sessions of 30 min at the hospital with a healthcare provider discussing health behavior
- MI condition = plus 6 MI phone sessions
- Doctoral student delivered MI
- MI training including 40 h of reading and 32 h of training with the French Association of MI
- RCT
- MI measured using MITI coding below proficiency for 2/5 ratings (reflection-to-question ratio and percent MI adherent)
- Administered at baseline, 3 months, 6 months
- No difference in BMI
- Significant increase in physical activity for SWLP + MI group
- No difference in intrinsic motivation, perceived competence
- SWLP + MI condition perceived medical staff as more autonomy supportive
- Hospital setting
- MI adherence
- MI group had a significant change in integrated (i.e., engaging in an activity because it is perceived as coherent with his/her values and identity) and identified regulations (i.e., engaging in an activity because it is perceived as personally important and useful) - MI adherence (C2), adolescent perceived staff as more autonomy supportive (C2), developed autonomy, and led to increased health behaviors
Lee and Kim 2015 [63] (high) - Male students from a junior high school in Seoul who had BMI greater than 25 kg/m2. (n = 125)
- Average age = 15.37
- 89.7% completed
- ME sessions 2×/week reinforcement
- 16 weeks total (5 days a week and a total of 80 sessions).
- Behavior-based motivational enhancement intervention applied in this study was based on materials used in previous studies
- Text message sent to participants and parents
- Pre-post design (8 weeks)
- No control group
- No info on training or fidelity of ME
- BMI decreased
- Physical activity increased
- Self-efficacy and perceived benefits of exercise increased
- Perceived barriers decreased
- Significant increases in weight control and “better outlook”
- Physical satisfaction lack of competence and tiredness were significantly reduced
- Intervention conducted in the gym and classroom of a middle school before the school day began
- All male participants
- Self-efficacy
- Increased perceived benefits to weight loss
- Increase in weight control, better outlook, and physical satisfaction
- Decrease in perceived barriers
- Reduced lack of competence and tiredness
- School setting (C1), led to increased self-efficacy, reduced competence (M1), resulting in health behavior change
Love-Osbourne et al. 2014 [96] (low) - Adolescents with a BMI > 85%
- 2 school-based health centers located in public schools
- 87% in the CG and 77 students (94%) in the intervention group completed study
- Both groups received preventive services
- IG had a mean of five visits with the educator (range, 1 to 8).
- IG randomized to receive either weekly text messages or no text messages for the first semester
- Full-day training on MI techniques conducted by a local expert and a follow-up session with the trainer 2 months later
- BMI, demographic questionnaire
- Pre/post
- Record weight weekly and lifestyle behaviors daily on a paper log sheet
- Participants were instructed to turn in log sheets weekly
- No MI fidelity assessed
- CG had more youth who decreased their BMI compared to the IG (40 versus 18%)
- CG had higher sports participation than IG (47 versus 28%)
- Increased visit number not associated with improved BMI outcome.
- No difference for text messaging group
- Age of student impacted outcomes (younger than 15 years had better BMI outcomes)
- Unequal sports participation rate in the control group
- No mechanisms reported  
Lydecker et al., 2015 [97] (medium) - N/A - N/A - Review from book chapter - Interventions based in community settings are more successful
- School-based interventions allow the adolescent to feel more comfortable
- Family interventions are successful to create common goals.
- Community workers are more culturally inclined and aware of the environment
- Book chapter
- Various contexts
- Comparison between community and hospital settings
- Autonomy
- Self-efficacy
- Readiness and willingness to change
 
Macdonnell et al., 2013 [82]  (medium) - N = 49
- Caregiver/adolescent dyads
- Health clinic
- 13–17 years of age
- African American
- Control group—nutritional program
- Intervention group—MI sessions
- Four 60-min sessions
- Met with adolescent first, then dyad together
- Dietician underwent 16 h of training, received weekly supervision from a network of MI trainers
- Pre/post
- No fidelity reported
- Only 27% of the intervention group and 36.4% of the control group received all sessions
- Decrease in fast food consumption
- IG showed increased intrinsic motivation for physical activity but a decrease in activity
- No change in BMI, or motivation for nutrition change, or fruit and vegetable intake
- Hospital setting
- Low engagement
- Family participation
- African American adolescents
- Increased intrinsic motivation for physical activity - African American (C5), family participation (C3a), resulting in low participation, and few outcomes
Mehlenbeck & Wember, 2008 [66] (medium) - Book chapter
- Adolescents + parents
- MI as a major component of the studies reviewed - Review chapter, so varied by study - Increasing physical activity
- Improving nutrition
- Diabetes self-management
- Varied by study
- Family influence must be considered when changing health behaviors
- Role of family members needs to be addressed
- Increased self-efficacy for making changes
- Support self-efficacy by enhancing personal responsibility and ability to carry out behavior change
- Self-confidence in achieving goals
 
Naar-King et al., 2016 [81] (medium) - 12–16 years old.
- 67% (n = 122) female; mean age was 13.75 years
- African American
- Youth and caregiver
- Dyad was randomized to 3 months of home-based versus office-based delivery of MI plus skills building
- After 3 months, nonresponders were rerandomized to continued home-based skills or contingency management
- Sessions to reduce food intake by 500 kcal or to consume a maximum of 1600–2000 kcal per day.
- 80 h of MI training
- RCT
- Measured at baseline, 3 and 7 months
- After 3-month data collection, families were randomized based on response and nonresponse to phase 1 treatment
- MI fidelity computed (not reported)
- Attendance of sessions higher for home-based group
- Greater weight loss for youth with higher executive functioning (no group differences)
- No difference for percent overweight between groups or across time
- No differences between skills or contingency management programs
- Location of program delivery (home versus office) impacts attendance
- Clients with higher executive functioning have greater weight loss (in short term but not long term)
- African American
- Clients were not able to develop a sense of autonomy (M2) because the clinician set the goals (reduction by 500 kcal) - Youth with better decision-making skills (M5) are more likely to lose weight in the short term
Nansel et al. 2015 [67] (medium) - 136 parent-youth dyads (treatment n = 66, control n = 70)
- Aged 8–16 (m = 12.8 ± 2.6)
- 90% Caucasian, high income
- Type 1 diabetes diagnosis ≥ 1 year
- Outpatient diabetes center
- Retention through study completion was 92%
- All participant withdrawals were in the IG
- 9 in-clinic sessions delivered to the child and parent
- Control condition comprised equivalent assessments and number of contacts
- Research assistants who received training in motivational interviewing delivered the intervention
- RCT
- Dietary intake was assessed using diet records at 6 time points
- The Healthy Eating Index 2005 (HEI2005) and Whole Plant Food Density (WPFD) were used for diet quality
- No MI fidelity assessed
- At 18 months, HEI2005 was 7.2 greater and WPFD was 0.5 greater in the intervention group versus control, during which time the intensity of the intervention had decreased
- There was no difference between groups in HbA1c across the study duration
- Parental involvement
- Children with type 1 diabetes
- Caucasian, high-income families
- HEI2005 and WPFD demonstrated improvement from months 12–18, during which time and the intensity of the intervention had decreased.
- Adolescents had the opportunity to use their autonomy
- Caucasian (C4), parental involvement (C3a) leads to relatedness in the dyad (M3) creating improved diet quality
- Outcomes occurred when the intervention intensity decreased, when adolescents could use their autonomy (M2)
Neumark-Sztainer 2008 [98]; Neumark-Stainzer 2010 [64] (high) - 100% female
- Obese or at risk for becoming obese
- Mean age 15.8
- More than 75% racial/ethnic minority
- N = 182 (intervention) and 174 (control)
- Advertised as an alternative to the required physical education class
- Attrition 80.8% completed 5 to 8 MI sessions
- New Moves
- Physical education class
- Nutrition education, empowerment, + individual MI sessions
- MI, 5 to 7 times per year, every 3 to 4 weeks for 15 to 20 min
- New Moves coaches were intervention staff who received training and ongoing support in MI
- Group RCT design
- Control group: yes (inactive treatment)
- Pre/Post/follow-up
- No fidelity assessed
- New Moves did not lead to significant changes in percentage body fat or BMI
- Improvements for sedentary activity, eating patterns, unhealthy weight control behaviors, and body/self-image
- Significant decrease in total sedentary activity
- School setting
- Majority racial/ethnic minority
- IG reported more support for physical activity from friends, teachers, and family members than control
- For healthy eating, significant increases were found for friend and teacher support, but not for parent support
- Intervention increased stage of change for physical activity, physical activity goal-setting behaviors, their self-efficacy to overcome barriers to physical activity, and perceived athletic competence - School setting (C1) supports competence (M1), leading to increased health behaviors
- Ethnic minority (C5) and peer involvement (C3b) led to feeling more supported by those in their life (M3), resulting in outcomes
Olson et al. 2008 [59] (medium) - N = 148 intervention and 136 TAU
- Family medicine practice
- Adolescents
- 50% female
- 96% Caucasian
- Medicaid rates from 10 to 40%
- Attrition: none reported
- Healthy teens = MI + personal digital assistant
- 1 brief MI session
- 3 h of interactive training in MI by psychologists
- Pre/6-month follow-up
- Control group
- Attrition: none reported
- Used self-report to measure diet and exercise
- No fidelity assessed
- Significant changes for milk intake and physical activity
- Specific predictors of improvement in physical activity level after 6 months were the Healthy Teens intervention group and an interest in making a change at baseline
- Clinical practice
- Delivered by clinicians
- Fewer health risks than adolescents screened in schools
- Interest in changing behavior at baseline predicted outcomes (M5)  
Pakpour et al. 2015 [65] (high) - Obese adolescents
- Outpatient pediatric clinic in Qazvin, Iran
- 357 Iranian adolescents (aged 14–18 years)
- Approximately 50% female
- 119 in each treatment group
- 113, 118, and 115 completed the 12-month assessment
- Randomized into MI intervention or an MI intervention with parental involvement (MI + PI) or assessments only (passive control).
- 2 trained interventionists delivered all sessions
- 6 MI sessions with youth
- Parents in MI + PI group (n = 119) received 1 MI session in clinic delivered at the end of the 6 sessions
- RCT; pre/post
- All MI sessions were audiotaped and quality checked by (MITI) instrument. All scores were above proficiency except percent complex reflections, which was slightly below proficiency
- Significant differences in favor of the MI + PI intervention for BMI changes, diet, physical exercise, and self-efficacy for diet
- The MI + PI group was not superior to control for servings of vegetables and milk products per day, waist circumference, or social functioning
- Parental involvement
- Outpatient clinic
- Proficient professionals
- The intervention targeted the adolescents (6 sessions), with only 1 session given to parents; promoted autonomy; and perceived competence of the adolescent - Parental involvement (C3a) promoted relatedness between parent and adolescent (M3) and resulted in changes in outcomes
- High MI fidelity (C2) led to changes in health behaviors
Resnicow et al. 2005 [35] (medium) - N = 123
- Recruited from churches
- Adolescent + parents
- 100% female
- Ages 12–16
- African American
- Overweight or at risk for becoming overweight
- 84% completion
- 73% completed follow-up
- Go Girls = nutrition education + two-way pager + MI + parent outreach
- High-intensity group: 4 to 6 MI phone calls
- Parents met alone for half of the session and then joined daughters for the physical activity and food tasting
- Master’s level counselors received 16 h of MI training plus ongoing supervision
- Group RCT
- Pre/post design
- Control group: yes (6 sessions of education)
- No fidelity assessed; authors state that their MI protocol was not appropriate for adolescents
- Average attendance in the high-intensity group was 13 of 23 (57%) sessions.
- In the high-intensity condition, an average of 4 of 6 MI calls were completed.
- No significant group differences
- Girls who attended more than 75% of sessions had lower percentage body fat and BMI than those who attended fewer
- Delivered in church
- Delivered by a master’s- or doctoral-level psychologists
- Delivered MI over the phone
- Developmentally inappropriate protocol
- African American girls
- Only 45% stated calls helped them think differently about health habits
- 47% agreed their counselor asked too many questions
- The protocol may not have been developmentally appropriate
- MI protocol was inappropriate (C2); girls reported calls were not helpful (M2), resulting in no outcomes
Walpole et al. 2013 [99] (medium) - 40 (females = 23) participants
- Recruited from Toronto East General
Hospital—convenience sample
- M age was 13.9
- N = 20 (treatment condition), n = 22 (control condition)
- Majority Caucasian with 2-parent households
- BMI in obese range at baseline
- Standard care program—Healthy Lifestyles, participants randomly assigned to receive this care combined with either MI or social skills training (control arm)
- 6 therapy sessions over the course of 6 months, at the time of their regularly scheduled Healthy Lifestyles appointments
- Clinical psychology doctoral student
- Training was 60+ h with the MINT
- RCT
- Pre/post test
- Sessions coded using the MITI 3.0 scale
- Fidelity assessed:
- MI treatment scored 2.7 for evocation, 3.1 for collaborative, 3.2 for autonomy supportive, 3.4 for direction, 3.5 for empathy; with an average global score of 3.2
- No significant differences in self-efficacy and eating habits
- Both groups improved
- Clinical psychology doctoral student
- Hospital setting
- MI interventions lacked fidelity
- Therapies were meant to be structured differently
- Both groups implicated tactics in similar ways
- No mechanisms discussed - Intervention lacked fidelity (C2), resulting in no outcomes