Disclosures Funded, in part, by a research grant from American - - PDF document

APNA 29th Annual Conference Session 4016: October 31, 2015 Wong-Anuchit 1

Choochart Wong-Anuchit, PhD(Candidate), RN Joanne Kraenzle Schneider, PhD, RN Mary M. Krieger, MLIS, RN

Motivational Interviewing within Compliance/Adherence Therapy to Improve Outcomes of People with Severe Mental Illness: A Meta-Analysis

Disclosures

Funded, in part, by a research grant from American Psychiatric Nursing Foundation Conducted in partial fulfillment of a 3-manuscript, non-traditional doctoral dissertation at Saint Louis University

Presentation Objectives

• Understand the value of meta-analytic

research

• Interpret meta-analytic results to apply

in clinical practice

• Recognize how to implement

motivational interviewing counseling in clinical practice

APNA 29th Annual Conference Session 4016: October 31, 2015 Wong-Anuchit 2

Research Synthesis Defined

• Research synthesis, research review,

systematic review

• No consensus in definition
• Research synthesis – evaluative review
• f research
• Primary focus and goal – Integrate

empirical research to:

• Create generalizations (implies limits)
• Attend to relevant theories, research,

conflicts, and central issues

Meta-Analysis: A Brief Introduction

Primary source: Borenstein, M., Hedges, L. V., Higgins, P. T., & Rothstein,

• H. R. (2009). Introduction to Meta-analysis. West

Sussex, UK: John Wiley & Sons.

Vote Counting

“The process of counting the number of studies that are statistically significant and comparing this with the number that are not statistically significant.” “Vote counting is never a valid approach.”

Borenstein et al. (2009) page 255

APNA 29th Annual Conference Session 4016: October 31, 2015 Wong-Anuchit 3

Logic of Vote Counting

• Significant finding

= effect

• Nonsignificant finding

≠

effect

But

• No statistical significance might mean

low statistical power  Meta-analysis is the quantitative synthesis of primary studies that are essential for informing evidence-based practice and policy.  A meta-analytic study can provide an

• verall effect size, provide insights for

clinical practice related to outcomes, and point to areas for future research.

Meta-Analysis Defined Meta-Analysis Defined

• Used as a synonym for research

synthesis

• Includes quantitative procedures to

statistically combine the results of studies

APNA 29th Annual Conference Session 4016: October 31, 2015 Wong-Anuchit 4

Meta-analysis

• Synthesizes data from a series of

studies

• Can often identify the true effect
• If true effect is substantial and consistent,

nonsignificant findings are due to low power.

• Statistically sound to test the null

hypothesis

• Can assess magnitude of effect and

consistency across primary studies

How Meta-Analysis Works

Individual studies

• Effect size (ES)
• Precision
• Study weight
• p-values

Summary effect

• Effect size (ES)
• Precision
• p-value

Basic points

• Compute ES and variance for each

study; then weighted mean of each ES

• Weighted mean: Assign more weight

to more precise studies

Individual Studies

• Effect size (ES): A value that reflects the

magnitude of the treatment effect; strength of a relationship between 2 variables (square in fig.)

• ES based on ratios – a ratio of 1.0 = no difference

between groups

• ES based on mean difference – 0.0 = no difference
• Precision: Confidence Interval (CI)
• Primarily driven by sample size
• Study weights: Good precision, higher weight
• Solid square sizes reflect weight
• p-value: Under .05 if 95% CI does not include

null value

Adapted from Borenstein et al. (2009) page 4

APNA 29th Annual Conference Session 4016: October 31, 2015 Wong-Anuchit 5

Summary Effect

 Effect size: The weighted mean of the

individual effects (bottom line in figure) – depends on assumptions

 Fixed-effect model: All studies share the same

true effect true effect size, summary is common ES

 Random-effects model: True ES vary from study

to study, summary is estimate of mean of ES distributions.

 Precision: variance, SE, CI: diamond width in fig.

 p-value: Reflects the magnitude of summary

ES and the volume of information on which estimate is based.

Adapted from Borenstein et al, (2009) page 4

Why Meta-analysis?

 Provides context  Provides power  Provides the magnitude of effect

 Summary effect size

 Capable of examining inconsistency

across studies

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Research Background

• Motivational interviewing (MI) is a

popular intervention.

• Therapeutic behavioral change occurs

by engaging individuals to argue for change (Miller & Rollnick, 2013)

• MI is a purposive counseling style to

resolve ambivalence for change.

Research Background

• Motivational interviewing (MI)
• Widely used with compliance/adherence

therapy

• To improve adherence in people with

severe mental illness.

• No published meta-analysis
• Examining MI effectiveness in people with

severe mental illness.

Motivational Interviewing

 Client-centered, directive approach for

enhancing intrinsic motivation to change by exploring and resolving ambivalence

APNA 29th Annual Conference Session 4016: October 31, 2015 Wong-Anuchit 7

Motivational Interviewing

 Client-centered or person-centered-focuses

• n person’s interests and concerns

 Consciously directive—to resolve

ambivalence

 Method of communication—not a set of

techniques

 Elicits intrinsic motivation for change  Exploring and resolving ambivalence—has to

be in person’s inherent interest

Purpose

 To synthesize studies that test the

effects of motivational interviewing interventions on three primary

• utcomes reflecting treatment

adherence:

• Symptoms
• Medication attitude
• Functioning

Method: Literature Search

• Comprehensive database search
• Identify eligible studies
• Publication years: through the end
• f December 2014
• PsycINFO
• Ovid MEDLINE
• SCOPUS, CINAHL
• Web of Science
• Cochrane Library
• Sociological Abstracts (ProQuest)
• Social Work Abstracts (EBSCO Host)
• ProQuest Dissertations and Theses
• Full Text without date restriction

APNA 29th Annual Conference Session 4016: October 31, 2015 Wong-Anuchit 8

Method: Statistics

 Using random-effects models,

summary effect sizes with 95% confidence intervals were computed using Hedges’ g.

 Two-tailed p-values for the Z tests were

used to test the null hypotheses that the mean effects were equal to zero.

Results

 Retrieved and coded primary studies  Studies (s) = 16  Adults with severe mental illness  At least 5 participants per group  Researchers used motivational

interviewing (MI) within compliance/ adherence therapy.

Results

 MI within compliance/adherence therapy

significantly improved psychotic symptoms

 g = –0.353  Confidence interval: –0.662, –0.044;

p = .025

 s = 15, N = 1153

 Global functioning

 g = 0.653  CI: –0.004, 1.310; p = .051  s = 6, N = 385

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Results

 MI within compliance/adherence therapy

significantly improved psychotic symptoms

 No improvement in attitude

 g = 0.175  Confidence interval: –0.046, 0.395; p =.120  s = 14, N = 1058

 All studies were significantly

heterogeneous warranting follow-up moderator analyses.

Conclusion

• Motivational interviewing (MI) within

compliance/adherence therapy

• Improves symptoms and functioning,
• Informs psychiatric-mental health nurses

about using MI in clinical practice to improve treatment adherence outcomes.

Conclusion

• Future research to provide additional

insight

• Moderator analyses of
• Participant
• Design
• Intervention characteristics

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References

Borenstein, M., Hedges, L. V., Higgins, J. P. T., & Rothstein, H. R. (2009). Introduction to meta

• analysis. West Sussex, UK: John Wiley & Sons.

Cooper, H. M. (2010). Research synthesis and mata-analysis: A step-by-step approach (4th ed.). Washington, DC: SAGE Publications. Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd ed.). New York, NY: Guilford Press.

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