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The feasibility of implementing brief motivational interviewing in the context of tuberculosis treatment in South Africa

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dc.contributor.advisor Swartz L, Prof en
dc.contributor.author Allen S en
dc.date.accessioned 2016-09-22T08:35:06Z
dc.date.available 2016-09-22T08:35:06Z
dc.date.submitted 2006 en
dc.identifier.uri http://hdl.handle.net/20.500.11892/31777
dc.description.abstract This thesis explores the feasibility of -implementing an approach called Brief Motivational Interviewing (BMI) in the context of tuberculosis (TB) treatment in South Africa. TB is a serious threat to global health and has not been controlled despite the fact that it is curable. Ever since effective drugs became available, continued spread of the disease has been understood as a problem of poor adherence to treatment. This narrow understanding of the epidemic has been broadened by psychological and social science perspectives among others. There has been much debate around the topic of adherence and the international TB control policy known as Directly Observed Treatment, Short-course (DOTS), as some, suggest that it is an incomplete response to the challenge of improving adherence and controlling TB. The caring aspects of TB treatment seem to be neglected in TB policies and protocols, and some argue that this and the lack of attention to other systemic factors are responsible for poor programme performance. South Africa is an example of this, where the communication between nurses and TB patients has been described as authoritarian, nurse-centred and task-oriented.<br><br> A patient-centred approach (PCA) is a way of improving patient-provider communication and patient satisfaction, and some promote it as a way of improving treatment adherence and health outcomes. The challenge, however, is that the concept of 'patient-centredness' can be inteipreted and implemented in a variety of ways. BMI is a PCA to communication that is designed to promote a spirit of collaboration and resolve people's mixed feelings about behaviour change. An adaptation of Motivational Interviewing, BMI is a menu of concrete skills or tools that health providers can use in consultations about health behaviour change. BMI is based on theories about behaviour change and has been used to address a wide variety of health behaviours, including treatment adherence. Although seldom applied in less developed country settings and never before applied in TB, BMI has been successfully applied in other busy health care settings.<br><br> The design of the present study of the feasibility of BMI in the context of TB treatment in South Africa evolved within the design of a larger study that included other interventions designed for a PCA. The present study aims were to describe the context and what happened during the intervention period and to describe BMI's feasibility. Using elements of participatory action research, BMI communication training was developed and implemented with TB staff based in four urban primary health care facilities. A grounded theory approach was used to describe the dynamics of the implementation process and generate a theory about what made BMI more or less feasible in this context. A multidisciplinary team contributed to the study design, BMI training and data gathering process. Data were gathered largely through participant observation, focus groups and key informant interviews and generated volumes of diverse materials including field notes, training materials, video and audio-taped interactions. The data were analysed using the inductive approach to grounded theory analysis promoted by Glaser (1992) and relied on theoretical sampling and constant comparative analysis. The quality and trustworthiness of the data were ensured through an emphasis on researcher reflexivity and triangulation of the perspectives of different materials, participants and health facilities.<br><br> The study was implemented as a pilot BMI training process at one facility in Port Elizabeth (Eastern Cape Province) followed by expanded training targeting TB staff of three facilities in Cape Town (Western Cape Province). Data analysis resulted in a categorised description of the research settings, the interactions and relationships among patients, providers, managers and researchers, the BMI training interventions and the way participants responded to BMI during each phase of the process. Although seemingly similar at the outset, analysis began to show that dynamics of implementation at each facility were complex and multidimensional. The categories that were generated during each cycle of implementation were used to shape the categories selected for the next. Examining the categories across the four health facilities yielded a grounded theory with seven core categories regarding the role of: (1) the personal qualities of the TB staff involved, (2) the way staff moved in and out of the TB service, (3) the leadership, hierarchy and staff dynamics in the health facilities, (4) the pressurised working conditions of TB staff, (5) the poverty of patients, (6) mismatches between the TB programme's protocols and BMI, and (7) the capacity of staff to innovate and improve care.<br><br> These findings are discussed in terms of the way they respond to the study's research questions and the way the grounded theory categories relate to each other. Their significance is understood from a social constructivist perspective as bound within the context of the study. The findings are also compared to the theoretical perspectives included in the study design and new literature on the diffusion of innovations in service organisations. Inconsistencies between the grounded theory and the concepts behind the intervention design emerge. An overarching model on diffusion of innovations provides a helpful context in which the grounded theory of the feasibility of BMI could be positioned. Recommendations are made for future context-focused research and adherence-related intervention development. If interventions like BMI are to be implemented successfully in contexts such as those included in this thesis, policy-makers and managers need to consider the ways in which working, conditions, policies and protocols and patient poverty may be counter-productive, and focus on the innovative potential of health staff and teams for delivering patient-centred care. en
dc.language English en
dc.subject Clinical psychology en
dc.title The feasibility of implementing brief motivational interviewing in the context of tuberculosis treatment in South Africa en
dc.type Masters degree en
dc.description.degree MA (Psych) en

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