Motivational interviewing in health care - worldwide uptake
Submitting InstitutionCardiff University
Unit of AssessmentPublic Health, Health Services and Primary Care
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
Research carried out at Cardiff University refined an addiction
counselling method, motivational interviewing, co-founded
previously by Rollnick, to improve the consultation for changing
health behaviour (e.g. diet, exercise, smoking and drinking). Their
published findings and resulting method are now used in health care
worldwide, with good evidence for effectiveness. The impact of this work
has been described as `immeasurable' and is reflected in industry
guidelines and policy documents, and diverse clinical efforts that include
the treatment of children with HIV-AIDS in Africa.
The research question
Research on the best way to encourage patients to change their lifestyle
or medication use has a long history, with mixed results. People don't
respond uniformly well to being advised to change. This challenge is even
more marked in specialist addiction treatment, where a counselling method
was developed with a different goal - to avoid direct persuasion and
elicit peoples' own motivation to change.
Rollnick was the co-founder of this specialist method, Motivational
Interviewing (MI), defined as a counselling style for helping people
resolve ambivalence about behaviour change. In 1993,
Rollnick (Research Fellow  - current Professor ) and Stott
(Professor  - current retired ) considered this question for a
programme of research: Can MI be simplified for everyday practice in
hospitals and clinics, in which patients clarify for themselves why and
how they might change their behaviour?
20 years of research
Butler (1993, Clinical Fellow — current Professor) joined the team,
and for the first time, a careful study of the consultation on health
behaviour change emerged. All research was conceived and executed
in the Cardiff University's School of Medicine Cochrane Institute of
Primary Care and Public Health (CIPCPH).
There followed 20 years of research on specific brief consultation
- "Pros & Cons" The patient describes the benefits and
drawbacks of change
- "Importance & Confidence" Specific questions to address the
"why" and "how" of change
- "Elicit-Provide-Elicit" A new framework for exchanging
information with patients
- "Agenda-setting" A method for deciding with patients which
behaviour change to focus on
These strategies were developed, tested, and published in papers and
textbooks for clinicians.
Smoking & lifestyle change
Butler & Rollnick (mid-1990s) conceived the "importance
& confidence" strategy in experimental consultations with
smokers [3.1]. Its use by GPs achieved significantly better outcomes when
compared to advice-giving [3.2]. It was integrated into a larger
counselling method, along with "pros and cons" and the "elicit-provide-elicit"
strategy, published in two textbooks for clinicians, and then evaluated in
a MRC-funded, multi-site trial of effectiveness for promoting lifestyle
Diabetes: Agenda-setting & multiple-behaviour consultations
In 1993 Rollnick, Stott & colleagues used a MRC grant
to develop and evaluate "agenda-setting" in adults with poorly
controlled diabetes [3.4]. This strategy for deciding what
behaviour change to focus on was then applied to children with Type 1
diabetes: Gregory (2002, Reader- current Professor), Rollnick,
Channon (2002 Consultant Clinical Psychologist — current, the same)
& Robling (2003 Research Fellow — current Reader) began with a
pilot and successful trial of MI delivered by a psychologist [3.5]; they
then worked with parents and children to develop a child-friendly visual
agenda-setting chart and evaluated its use by doctors and nurses in a
multi-site controlled trial across UK services [3.6].
Integrating the research
This research on brief strategies for helping patients with behaviour
change was not only reported in journals, but integrated into the first
(and only) two MI healthcare textbooks for clinicians, and two subsequent
editions of the parent text of the broader MI method (2002 & 2012).
References to the research
3. Butler C, Simpson SA, Hood K, Cohen D,
Pickles T, Spanou C, McCambridge J, Moore L, Randell
E, Alam FM, Kinnersley P, Edwards A, Smith C, Rollnick
S. Training practitioners to deliver opportunistic multiple
behaviour change counselling in primary care (MRC/NPRI Pre-Empt): a
cluster randomized trial. BMJ 2013;346:f1191 (Published 19 March 2013).
4. Pill R, Stott N, Rollnick S, Rees M. (1998) A
randomized controlled trial of an intervention to improve the care given
in general practice to Type II diabetic patients: patient outcomes and
professional ability to change behaviour. Fam Pract 15: 229-235.
5. Channon S, Huws-Thomas M, Rollnick S, Hood K,
Cannings-John R, Rogers C, Gregory J A Multi-Centre
Randomised Controlled Trial Of Motivational Interviewing In Teenagers With
Diabetes. Diabetes Care 2007; 30:1390-1395. DOI: 10.2337/dc06-2260
6. Robling M, McNamara R, Bennert K, Butler C, Channon
S, Cohen D, Crowne L, Hambly H, Hawthorne C, Hood K,
Longo M, Pickles T, Playle R, Rollnick S, Thomas-Jones
E, Gregory J. The effect of the Talking Diabetes consulting
skills intervention on glycaemic control and quality of life in children
with type 1 diabetes: cluster randomised controlled trial (DEPICTED
study). BMJ 2012; 344, e2359. DOI: 10.1136/bmj.e2359
Preventing disease through opportunistic, rapid engagement by primary
care teams using behaviour change counselling (PRE-EMPT). C
Butler, S Simpson, K Hood, S Rollnick.
£846,667, MRC. Sep 2006 - Sep 2010.
Details of the impact
Between 2008 and December 2012, Motivational Interviewing in Health
Care by Rollnick, Miller & Butler sold 71,748
copies and was translated into 11 languages, prompting the senior
commissioning editor at Guilford Press to note: "Rollnick &
Butler's Cardiff research provided the fuel for a book that has
surpassed all expectations. It continues to find avid readers from
across medicine and related professions, and has established itself as
the primary source for teachers and practitioners wanting to learn about
the application of MI in different health care settings." [5.2]
Specific strategies developed in Cardiff have also been integrated into
the 2nd & 3rd editions of the standard Miller/Rollnick
text on motivational interviewing [5.1]. Between 2008 and December 2012,
these texts sold 77,028 copies and have been translated into over 25
The impact of the above Cardiff research on clinical strategies is very
diverse and widely disseminated worldwide, embracing guidelines and policy
documents in many countries and continents. The following examples have
been selected because they provide precise links between Cardiff research
Example 1: AETNA Health Insurance Organisation: Prof. K. Resnicow
(Michigan, USA, 2010) used Cardiff health care textbooks, and the
agenda-setting and importance-confidence strategies within them, in the
training of trainers within AETNA, a company with over 36 million members.
The focus was on behaviour change among members with a chronic disease.
Between 2010 and September 2012, 83+ trainers in health care MI were
trained, along with 2,210 clinical staff worldwide, with a reported 43%
increase in engagement in the disease management programme and a 55%
decrease in drop-outs [5.3]. Professor Resnicow notes, "The impact of
Rollnick and Butler's seminal research in Cardiff goes beyond the
private sector and is all but immeasurable. Leading US government and
professional bodies, e.g. the American Medical Association, the American
Academy of Pediatrics, and the US Preventive Task Force, have adopted
healthcare MI for the prevention and management of chronic disease"
Example 2: Emergency & Public Health Medicine in USA:
Healthcare strategies evaluated in Cardiff ("pros and cons", "elicit-provide-elicit")
for very brief emergency room consultations with alcohol and drug problems
were used in 1994 by Bernstein (Boston, USA) and Rollnick to
develop a 3-5 minute intervention, Brief Negotiation Interview
(BNI) [5.5]. Bernstein established effectiveness in numerous randomised
trials, and set up a BNI ART Institute. Since 2008 they
have trained 1525 clinicians across North and Central America. Data
obtained by Bernstein from the small Boston-based cohort of 52/1525
clinicians (only 3.4% of the total), reveal that in 2011 alone,
BNI was used with 5,158 patients. For the longer period 2008-2012,
Bernstein estimates that these 52 clinicians saw a total of 44,983
patients, all of whom received BNI, a method of proven effectiveness. The
programme has been endorsed by the National Registry of Evidence-based
Programs [5.6]. Bernstein notes, "Rollnick's research on brief MI has
had a direct and measurable impact on the delivery of brief intervention
in emergency room settings in North America from Bethel Alaska to
Bayamon Puerto Rico to Yale New Haven and Boston Medical Centers. The
benefit to patients emerged from our numerous controlled trials.
Implementation of this respectful and effective intervention now extends
way beyond the boundaries of our work here in Boston to many scores of
thousands of patients across the USA and in other countries." [5.7]
Example 3: Swedish Quitlines for tobacco and alcohol: Dr Astri
Brandell Eklund and colleagues, used a health care text and the strategies
of "agenda-setting" and "importance and confidence" in the training of
staff of these two national telephone services. Between January 2008 and
June 2012 counselling contact was made with 8,066 people on the alcohol
line, and 17,407 on the smoking line, with a reported quit rate of 36% for
the latter [5.8].
Example 4 - UK Family Nurse Partnership Programme [5.9]: The
founder of this intensive home-visiting programme for pregnant teens in
deprived settings bought 2,500 copies of the Rollnick/Miller/Butler Motivational
Interviewing in Health Care book for distribution among its home
visiting nurses tackling a wide range of behavioural issues (alcohol;
drugs; safe sex). Rollnick was contracted to provide training and support
to the UK rollout of this programme. Since 2008, the strategies developed
in Cardiff have been integrated into the training and supervision of 1000+
nurses who have delivered the programme to 9,207 families up to the end of
Example 5: African low resource settings [5.10] Paediatric Aids
Treatment in Africa (PATA —www.teampata.org) brings together HIV-AIDS
treatment teams for training from across the Continent. It covers over 30%
of children in treatment in Africa. Rollnick was a founding member and
currently a Director, and since 2008, he has integrated health care MI for
medication adherence into training provided in Mbabane, Swaziland (40
teams, 20 countries), Kigali. Rwanda (40 teams), Gaborone, Botswana (41
teams; 18 countries; 65,142 children in treatment), Cape Town (South
Africa; 20 teams; 10 countries) [5.10].
Sources to corroborate the impact
- Miller W, Rollnick S. (2012) Motivational Interviewing: Helping People
Change. 3rd Edition. New York: Guilford Press. ISBN-13: 978-1609182274.
Corroborates the integration of specific strategies developed in Cardiff
(see pages 105-116, 139-145). [Hard copy available from HEI upon
- Individual corroboration from Senior Commissioning Editor of Guildford
Press on the importance and success of the text book as the primary
source for teachers and practitioners wanting to learn about the
application of the research in different health care settings. Can also
confirm sales figures for the books.
- AETNA news release: `Aetna Members More Motivated to Make Healthy
Changes', 15 Feb 2012: http://www.aetna.com/news/newsReleases/2012/0215-Aetna-Members-More-
Motivated.html [saved as a pdf on 24.07.2013 and available on
request from HEI]. Confirms the integration of motivational interviewing
into AETNA's Care Management Disease Management programs, and numbers of
clinicians and support staff who have received training in MI.
- Individual corroboration from Professor of Health Behavior &
Health Education, School of Public Health, University of Michigan who
worked with AETNA Health Insurance Company in the delivery of staff
training in MI. Details of staff training were obtained directly from
Professor and the company. Confirms the influence of Cardiff research on
the policy and practice of the leading US government and professional
bodies, as well as in the private sector.
- The Brief Negotiated Interview, Boston School of Public Health: http://www.bu.edu/bniart/sbirt-
in-health-care/sbirt-brief-negotiated-interview-bni/ [saved as a
pdf on 13.08.2013 and available on request from HEI]. Confirms Cardiff
strategies at centre of intervention.
- Project ASSERT: SRIRT in Emergency Care, Boston School of Public
[saved as a pdf on 07.11.2013and available on request from HEI].
Confirms programme has been endorsed by the National Registry of
- Individual corroboration from Consultant in Emergency Medicine, Boston
Medical Centre, Boston. Confirms the successful application of the
research within emergency and public health medicine in the USA.
- Individual corroboration from MD, The Karolinska Insititute &
Swedish National Institute Of Public Health. Confirms the successful
application of research in Swedish Quitlines for tobacco and alcohol.
- Report: `Healthy Child Programme: The two year review', Department of
Health, 2009. Available to download at:
Corroborates the research as the evidence base for the Nurse
Partnership Programme (see pages 16, 44) [saved as a pdf on 24.07.2013
and available on request from HEI].
- Individual corroboration from Executive Director, Paediatric AIDS
Treatment for Africa. Can confirm the application of the research in
this African low resource setting.