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Safe Water System Manual




Motivational interviewing is described in section 7.0. In Zambia, volunteer community health promoters who were members of the local Neighborhood Health Committees were trained to use a communication approach based on the method known as motivational interviewing when interacting with community residents to promote the Safe Water System. Below is some further explanation of the method and training volunteers to implement it, based on experience in Zambia.

In sessions to train community volunteers to use motivational interviewing, the trainer describes the theoretical model of the stages of readiness to change and the methods of working with people at the different stages. Throughout the training, volunteers are encouraged to provide examples of their experiences as health promoters working in the community. The trainer then weaves these examples into the discussion, exercises, and practice to illustrate the theory and application of motivational interviewing.

The trainer describes the essential elements of effective brief interventions and discusses examples provided by the volunteers. The Miller and Rollnick books25, 33 on motivational interviewing use the acronym FRAMES to describe these elements (Feedback, Responsibility, Advice, Menu, Empathy, and Self Efficacy):

· Feedback involves non-judgemental sharing of local data on diarrhea rates, incidence of cholera, and water quality within the residents' own community. If needed, education on the causes of diarrhea and cholera can be delivered, within a motivational interviewing framework.
· Responsibility for change is emphasized to reside solely within the community resident.
· Advice is given but permission is requested beforehand. It is made clear that the views offered are solely the personal ones of the volunteer. The resident is free to weigh how the offered suggestions fit within his or her own values and ideas, and to accept or reject the advice.
· A menu of options for dealing with the problem is also beneficial.
· An empathic style is critical throughout the entire interchange.
· Self efficacy, or self confidence in achieving change, is supported whenever possible. If someone does not believe change is feasible, her or she is not likely to even begin to try. It is very important to support any thought, desire, or attempt at behavior change by expressing belief that change is achievable for that person.

The trainer describes the tools of motivational interviewing which the volunteers practice in training:

· use of open-ended questions
· affirmations
· reflective listening, and
· summarizing.

A good portion of the training focuses on developing the tools of summarizing and reflective listening. Reflective listening is the most difficult skill. Volunteers need a lot of practice to develop this skill and some volunteers develop the skill better than others. (A useful strategy in the field is to use a buddy system whereby volunteers with stronger skills are paired up with ones with weaker skills.)

The trainer also introduces principles of motivational interviewing:

· expressing empathy
· developing discrepancy
· avoiding argumentation
· rolling with resistance
· supporting self efficacy.

Since the principles are closely related to the elements and tools, they serve as a reminder as well as to unify the ideas.

Another important concept is eliciting change statements from residents. The trainer teaches this along with summarizing so the volunteers learn what to reinforce from what is said during an interaction. Most volunteers can understand this concept, though implementing it in the field is more difficult.

Throughout the training, the trainer emphasizes the style and spirit of motivational interviewing which involves an empathic, collaborative approach and avoids direct persuasion. If the timing and progress are right, the volunteer can offer an invitation for the individual to consider the benefits of using the Safe Water System. Volunteers learn that by working through a resident's ambivalence, using motivational interviewing tools and style, and supporting and developing a person's ideas about change, it is quite possible that a resident will make a commitment to adopt the Safe Water System. Subsequent interventions with the resident can then focus on maintaining the behavior change.

At the end of the training, the expectation is that the volunteers have understood the main ideas and have begun to master implementation of some of them, so that they can be more effective than they would be if delivering health education in the traditional didactic, authoritarian way. However, they still need further field supervision and guidance by the trainer.

In two Zambia studies, the rates of use of the Safe Water System were significantly higher in communities using a motivational interviewing approach when compared to communities using standard health education13 or to those using social marketing and health education.27 These higher rates have been sustained over time.

More work is needed to develop training specifically for motivational interviewing used in public health interventions in developing countries. Further adaptation of motivational interviewing, and other brief negotiation methods based on motivational interviewing, is expected. Training in motivational interviewing approaches must be provided by individuals previously trained and experienced in the method.

For further information, contact:
Dr. Angelica Thevos
Department of Psychiatry and Behavioral Sciences
Medical University of South Carolina
67 President Street
PO Box 250861
Charleston, SC 29425

Email: [email protected]


Centers for Disease Control and Prevention
National Center for Infectious Diseases
Division of Bacterial and Mycotic Diseases
Foodborne and Diarrheal Diseases Branch


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