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 |