No validated questionnaire was available for evaluating the courses in motivational interviewing and the GP's conception of the methods, adherence to the technique and their actual use of motivational interviewing. The construct of the questionnaire was therefore designed based on: the theoretical knowledge about motivational interviewing; the leading author's knowledge from attending the course; and knowledge from the teacher and head of the course. The content of the questionnaire was divided into themes: GPs reaction in specific patient cases; GPs preferred way of motivating change in patient behaviour; and practicability of motivational interviewing and aspects concerning the GP's use of the technique in their daily clinical work. The questionnaire was evaluated and pilot tested by GPs and lay people within and outside the Department of General Practice, University of Aarhus. The validation process included ensuring that questions were not to be misunderstood, that questions in total covered the themes while at the same time not overlaying each other and that answering categories was sufficient to discriminate between different answers. In order to evaluate the GPs' use of motivational interviewing, the four questions in Boxes 1 and 2 were asked.
Box 1. Questions 1–3: evaluating how GPs used motivational interviewing.
▸ Q1: What do you do, when the patient obviously does not follow your advice?
▸ Q2: What do you do, when you sense that the patient does not want to follow your advice?
▸ Q3: What do you do, when the patient's conception of good health and actual life style are inconsistent?
GPs had to respond on a 5-item Likert scale to each of the following possible reactions:
▸ Explain the plan of treatment and care once again
▸ Explore further the patient's abilities and possibilities for solving the problem
▸ Explain by arguments why it is important to follow the treatment once again
▸ Investigate if the patient believes that the treatment will help
▸ Make the patient tell about advantages and disadvantages of habits in relation to disease
▸ Inform further about the disease and treatment to pursuit the patient to a deal
▸ Tell further about the consequences if the treatment plan is not followed
▸ Make the patient summarise the agreed deal
▸ Ask about the patient's expectations to what you can do in the actual situation of disease
Five-item Likert scale: Fully agree = 1, partly agree = 2, not agree or disagree = 3, partly disagree = 4, totally disagree = 5.
Box 2. Question 4: evaluating how GPs used motivational interviewing.
GP's had to respond on a 5-item Likert scale to each of following possible reactions:
▸ Reflective listening
▸ Preparing the patient of different treatment options before choosing the one
▸ Using accurate arguments for change of lifestyle to emphasise the consequences of sustained lifestyle
▸ Clarifying the treatment strategy in relation to time
▸ Emphasising the patients resources
▸ Clarify what advantaged and disadvantages the patient sees in relation to disease and plan of treatment
▸ Showing patient empathy, support and respect
▸ Focusing on the positive sides of the patients habits in relation to the disease
Five-item Likert scale: always = 1, often = 2, on occasion = 3, seldom = 4, never = 5.
The possible reactions for Q1–4 were related to counselling style, using either motivational interviewing or ‘traditional advice giving’. Traditional advice giving is used as an expression for doctor-centred approach, that is the GP define the patients' problem from a biomedical perspective that usually does not include the patient perspective on the matter, thus giving advice accordingly.17,18
The sum-scores for questions 1–4 were calculated to evaluate whether or not the GPs used the methods of motivational interviewing or traditional advice giving. Questions 1–4 were based on the responses to each possible reaction in Boxes 1 and 2. The responses were first reversed in order to unify the direction of the response to each possible reaction. Then all the responses to the possible reactions to each question were added and divided by the number of items, thereby generating a mean response for each question. The method of sum-scoring questions has been used and validated in different settings.19–23
Questions 1–4 were given to all three groups of GPs, whereas the remaining questions regarding the practicability of motivational interviewing and aspects concerning the GPs' use of the technique in their daily clinical work (Table 2) were given to the GPs in the motivational groups (M/LM group). Questionnaires were mailed to all three groups either 1 year (M and C groups) or 3 years (LM group) after the courses. Reminders were mailed 2 weeks later.
