Water System Manual
TRAINING IN MOTIVATIONAL INTERVIEWING
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.
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
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
· 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
· 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.
trainer describes the tools of motivational interviewing which the volunteers
practice in training:
use of open-ended questions
· reflective listening,
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.)
trainer also introduces principles of motivational interviewing:
· developing discrepancy
· avoiding argumentation
rolling with resistance
· supporting self efficacy.
the principles are closely related to the elements and tools, they serve as a
reminder as well as to unify the ideas.
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.
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.
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.
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.
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.
further information, contact:
Dr. Angelica Thevos
Department of Psychiatry
and Behavioral Sciences
Medical University of South Carolina
PO Box 250861
Charleston, SC 29425