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By Anita Brakman, MS
Senior Director of Education, Research & Training
Physicians for Reproductive Health
New York City
Melanie Gold, DO, FAAP
Medical Director of School-Based Health Centers
New York City
Near the end of September 2014, the American Academy of Pediatrics (AAP) published its policy statement on contraception for adolescents.1 The AAP has been addressing the issue of contraception since 1980, and this policy statement updated the 2007 statement on contraception and adolescents. The policy statement provides a description and rationale for best practices in counseling and prescribing contraception to adolescents and is supported by an accompanying technical report.2 In addition to recommending long-acting reversible contraceptive methods (LARC) as first-line contraceptive choices for adolescents, the policy statement states the following: "Counseling should draw on motivational interviewing approaches, with the focus of the interview on future goals, belief in the adolescents’ capacity to change, and engagement of the adolescent in the process of adopting health-promoting behaviors.3 For an example of motivational interviewing for sexual health counseling, see Ott et al (2007),4 and for a more detailed discussion of counseling approaches, see the accompanying technical report."2
Although motivational interviewing, or MI, emerged from the adult addictions field in the early 1980s, it is becoming a standard of care for counseling adolescents to facilitate health behavior change. Evidence-based research supports this recommendation. In a community-based randomized trial, MI was found to be an effective counseling intervention at reducing rapid repeat pregnancy among teen mothers.5 Researchers found participants who received an MI intervention reported a greater frequency of keeping condoms available.6 Sexually active participants also had a significant increase in self-reported condom use.
In a recent systematic review and meta-analysis of literature comparing MI to control conditions for adolescent health behavior change, Researchers reviewed 697 articles identified from PsycINFO, PubMed/Medline, and ERIC until June 2013.7 To be included in the review, studies were required to (a) compare the efficacy of at least one session of MI intervention with a control condition using a between-groups design and (b) examine a non-substance-use health behavior in adolescents. A total of 15 studies met criteria for inclusion, representing 1,610 participants. Data were described qualitatively and quantitatively. Half of the abstracted studies used an interventionist with master’s level or greater training in a mental health profession, while the other half of the sample included community paraprofessionals, nurses, physicians, and dieticians. A total of eight of 15 studies provided data after the post-treatment assessment and follow-up assessments ranged from four weeks to two years (average 33.6 weeks).
The systematic review found that, compared with controls, MI interventions produced a small, but significant, aggregate effect size for short-term post-intervention effects (g = .16; 95% confidence interval [CI] [.05, .27]). Also, MI produced relatively stable effects over time (n = 8, g = .18; 95% CI [.05, .32]).The authors concluded that MI interventions for adolescent health behaviors appear to be effective and that the magnitude of the aggregate effect size does not appear to differ meaningfully from reports of interventions targeting only substance use in adolescents.
Of note, the average number of intervention sessions for the 15 studies assessed was 5.6, with three interventions producing a positive effect requiring only two sessions. This information is important because it suggests that a relatively small number of counseling sessions can produce meaningful change. Moreover, brief interventions such as MI allow for multiple intervention opportunities across repeated visits with the healthcare providers, which could multiply the effects of a small but reliable change and that could result in larger health behavior changes at a population level over time.
Family planning providers are renowned for their skill and comfort with counseling adolescents about sexual and reproductive health. Routinely incorporating MI style into family planning counseling, especially with adolescents, is a more effective and efficient counseling intervention compared to counseling interventions that are more didactic and directive. For more examples of MI for adolescent contraceptive counseling, see Gold and Delisi 8 and for other health behaviors, see Barnes and Gold.9 (Also look at the resources at the end of this article that will help family planning providers to gain the knowledge and skill necessary to follow the new AAP policy statement recommendations in using MI for counseling adolescents about contraception.) New resources on MI, including a webinar, will be available this month on the New York-based site for adolescent providers, www.nypath.org.
Use these additional general resources on motivational interviewing with adolescents: