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INTRODUCTION: Treatment interruption (TI), defined as >28 days late for antiretroviral therapy appointment, is one of the greatest challenges in controlling southern African HIV epidemics. Negative client-provider interactions remain a major reason for TI and a barrier to return to care, especially for men. Motivational interviewing (MI) facilitates client-driven counselling and improves client-provider interactions by facilitating equitable, interactive counselling that helps clients understand and develop solutions for their unique needs. Fidelity of MI counselling in resource-constrained health systems is challenging. METHODS: We developed a male-specific MI curriculum for Malawian male TI clients. Four psychosocial counsellors (PCs, a high-level Malawian counselling cadre) received a 2.5-day curriculum training and job aid to guide MI counselling approaches. PCs implemented the MI curriculum with men >15 years who were actively experiencing TI. Clients were found at home (through tracing) or at the facility (for those who returned to care on their own). MI counselling sessions were recorded, transcribed, translated into English and coded in Atlas.ti V.9. MI quality was assessed using a modified version of the validated MI Treatment Integrity tool. The tool has two measures: (1) counts of key MI behaviours throughout the session (questions, reflections, etc) and (2) overarching scores (using a 5-point scale) that characterise three MI dimensions for an entire counselling session (cultivating change talk, partnership and empathy). RESULTS: 44 MI sessions were recorded and analysed between 1 April 2022 and 1 August 2022. 64% of counselling sessions focused on work and travel as the main reason for TI. 86% of sessions yielded client-driven, tailored solutions for overcoming TI. PCs implemented multiple MI behaviours very well: asking questions, giving information, simple reflections and client affirmation. Few PCs used complex reflection, emphasised autonomy or sought collaboration with clients. Among overarching MI dimensions, PCs scored high in partnership (promoting client-driven discussions) and cultivating change talk (encouraging client-driven language and behaviour change confidence) but scored suboptimal in empathy. Only five sessions had confrontational/negative PC attitudes. CONCLUSIONS: PCs implemented MI with fidelity and quality, resulting in tailored, actionable plans for male re-engagement in HIV treatment in Malawi. TRIAL REGISTRATION NUMBERS: NCT05137210 and NCT04858243.

Those engaged in the research and practice of MI have shown interest in treatment adherence as an indicator of effective MI and have expressed curiosity in the threshold at which MI practice could be viewed as good enough'. The most widely used and often cited of MI integrity measures are the Motivational Interviewing Skills Code (MISC) and the Motivational Interviewing Treatment Integrity code (MITI). These adherence tools share similar descriptive coding systems for therapist in-session behavior. MI fidelity standards are often used as reference points for therapist performance, yet practitioners rarely meet full criteria. Further, substandard ratings have been associated with positive client change. These findings have elicited questions about the necessary levels of therapist treatment adherence to promote client change and suggested the need for empirically-derived fidelity standards. This study analyzed existing data from a sample of Motivational Enhancement Therapy (MET) sessions from Project MATCH (Matching Alcohol Treatments to Client Heterogeneity) that were audio recorded and previously coded with the MISC. MI adherence variables were analyzed along with client drinking outcomes to test the relationship between therapist fidelity and client change. Therapist adherence was determined using behavioral codes common to the MITI and MISC. Client change thresholds were determined using clinically significant change standards developed by Jacobson and Truax. The relationships between therapist adherence level and client change thresholds were examined using Receiver Operating Characteristic (ROC) analysis. Findings showed mixed support for the relationship between therapist adherence level and client drinking outcomes, but yielded levels of therapist MI adherence associated with client changes in drinking outcomes.

Motivational Interviewing (MI) is a widely-used talk therapy approach employed by clinicians to guide clients toward healthy behaviour change. Evaluating MI sessions and training MI counsellors relies on behavioural coding, the classification of counsellor and client utterances into predefined categories. Recent advances in Large Language Models (LLMs) now make it possible to automate not only behavioural coding, but the delivery of MI itself. This dissertation introduces AutoMISC, which performs utterance-level parsing and behavioural coding under the Motivational Interviewing Skill Code, the original annotation scheme for MI. AutoMISC achieves an overall accuracy of 70% and a macro F1 score of 0.42 for counsellor speech (19 categories) and 0.41 for client speech (17 categories) against expert-aligned annotations using GPT-4.1 (n= 821 utterances). Additional validation showed that the codes predict session-level counselling quality in a widely-used MI transcript dataset at 87% accuracy, and align with existing annotations in another dataset at 71% accuracy. We also demonstrate how the codes can visualize the trajectory of client motivation over a session alongside counsellor codes. We apply AutoMISC to the transcripts of a brief smoking cessation intervention experiment where tobacco smokers conversed with a fully generative MI counsellor chatbot evolved in collaboration with experienced MI clinician-scientists. Two versions were tested: (1) a single prompted LLM (106 participants), and (2) a two-stage approach which decouples technique selection from utterance generation (93 participants). Participant-reported confidence in quitting smoking was measured before the conversation and one week later. Both versions yielded an average increase in confidence of 1.7 on a 0-10 scale (p<0.001 for both). The first version scored well on participant-reported perceived empathy, higher than typical human counsellors, while the second scored lower. AutoMISC’s analysis of the transcripts provided deeper insights beyond participant-reported outcomes. Both versions showed adherence to MI standards in 99% of utterances. We found that the slope of the trajectory of the client’s motivation correlates with the change in confidence (Spearman’s r= 0.28, p<0.005 for Version 1; r= 0.20, p= 0.051 for Version 2). This work demonstrates the potential synergy between automated MI delivery and automated MI behavioural coding.

BACKGROUND: Heavy-drinking college students tend to have close social networks, and there is theoretical and empirical support for the idea that behavior change can spread through those networks via close ties. The objective of this research was to determine whether intervention-induced behavior change in a subset of heavy drinkers in a sociometric (whole) college class-year social network is transmitted to other heavy drinkers in the network, resulting in reduced behavioral risk and change in network ties. METHODS: We conducted a controlled trial in which most of a first-year college class (N = 1236; 56.9% female) was enrolled, with alcohol use and social network ties measured early in each of three semesters. Following a baseline assessment, the network was divided into two groups, brief motivational intervention (BMI) and natural history control (NHC) according to dormitory residence location. A subset of heavy drinkers in each group was selected, and those in the BMI group received an in-person intervention. RESULTS: Using stochastic actor-oriented modeling, we found a significant tendency for participants in the BMI group to shed ties with individuals with similar drinking behaviors between the first and second semesters, relative to the NHC group. Furthermore, heavy drinkers with reciprocal ties to intervention recipients in the BMI group showed a significant reduction in drinks per week. CONCLUSIONS: Individual alcohol interventions appear to have effects both on behavior and network connections among individuals who did not receive the intervention. Continued research is needed to identify the optimal conditions for the diffusion of behavior change.

BACKGROUND: Child maltreatment is a major public issue in the United States, yet most children affected by abuse or neglect never engage in evidence-based practices (EBP) for child mental health. Children's Advocacy Centers (CACs') are uniquely situated to serve as Family Navigators who connect children impacted by maltreatment to appropriate EBPs. In fact, the CAC position of Victim Advocate mirrors the Mental Health Family Navigator national initiative. METHODS: The feasibility study protocol is to develop, implement, and evaluate web-based and consultative training for Victim Advocates to enhance early engagement in services (E3 training). The interactive web-based training embeds key targets of knowledge and skills related to family engagement, trauma, and EBP services. Participating CACs were randomized to E3 webinar-based training, E3 webinar plus consultation, or delayed training. The project will test the E3 training's impact on key mechanisms of change (e.g., knowledge, skills) to improve rates of screening, referral, and access to EBP services. The feasibility of implementing the training program and differential impact and costs by level of training will be examined. DISCUSSION: The overarching goal of this project is to test the feasibility of training that is readily implemented through CACs and examine the mechanisms for improving early engagement and, ultimately, child, and adolescent mental health outcomes. Results and cost findings will be used to plan a large-scale comprehensive, mixed-methods hybrid type II effectiveness-implementation and cost-effectiveness trial of family navigator E3 training. If outcomes are positive, considerable infrastructure exists to support the scale-up and sustainability of E3 training nationwide, by embedding the training in national CAC training protocols. TRIAL REGISTRATION: NCT04221633 DATE AND VERSION IDENTIFIER: March 25, 2021; Vers. 1.0 (original); September 11, 2021; Vers 2.0 (revision); October 29, 2021; Vers. 3.0 (revision).

BACKGROUND: Encouraging consistent use of pre-exposure prophylaxis (PrEP) is essential for reducing HIV incidence, particularly among gay, bisexual, and other men who have sex with men (GBM), and especially those who engage in heavy drinking. Although practice guidelines recommend providing adherence counseling to PrEP patients, clinics and providers may not have the resources or expertise to provide it. Internet-facilitated interventions have been shown to improve HIV prevention outcomes, including medication and care adherence. Game Plan is a website we created to help users make a tangible plan for reducing their HIV risk. We designed additional components of Game Plan to address key individual level barriers to PrEP use. OBJECTIVE: The aim of this mixed methods research is to test the usability and user experience of these components with intended users: GBM who drink heavily and are on PrEP. METHODS: In study 1 (usability), we completed a detailed individual interview in which participants (n=10) walked through a prototype of the website, thinking aloud as they did, and completed a follow-up interview and web-based survey afterward. Study 2 (user experience) involved providing participants (n=40) with a link to the prototype website to explore on their own and asking them to complete the same follow-up survey afterward. Qualitative data were analyzed using thematic analysis, and descriptive statistics were used to analyze quantitative data. RESULTS: Users in both studies gave the website excellent ratings for usability, overall satisfaction, and quality, and most often described the site as informative, helpful, and supportive. Users also rated the site's content and feel as respectful of them and their autonomy, empathetic, and they stated that it conveyed confidence in their ability to change. The study 1 interviews highlighted the importance of the website's esthetics to the participants' engagement with it and its credibility in prompting genuine reflection. CONCLUSIONS: GBM who reported heavy drinking and used PrEP generally found a website focused on helping them to create a plan to use PrEP consistently to be helpful. Adopting user-centered design methods and attending to the esthetics of mobile health interventions are important steps toward encouraging engagement and reducing at-risk behaviors.

This study describes the development and evaluation of a competency based training program in behaviour change counselling for obesity management. This was a real world study attempting to obtain evidence on the learning experience; specifically, achievement of level of competency as well as personal experiences of the integration of skills learned into practice. This was a training effectiveness study involving a total of 28 evaluable licenced healthcare providers providing obesity care services. The design for this study is pre-experimental; specifically a one-group post-test only quasi-experimental design. Based on previous work developing a competency-based model of behaviour change counselling (developing change-based relationships, assessing and promoting readiness to change, implementing behaviour modification when ready, and addressing psychosocial determinants of behaviour) we report on training outcomes; specifically, the level of competency achieved in the various skill components of the intervention model. The model of training was based on corrective feedback, the development of peer-based learning and the creation of a mindmap to guide adaptation of interventions to the unique characteristics of individuals with obesity. Quantitative data on competency of components skills and qualitative information on the experience of training were used to evaluate the program. Objective assessment of skill competency post training demonstrated moderate to high skill in all aspects of behaviour change counselling. Learners reported frequent use of skills in clinical practice, particularly change-based relationships and readiness assessment/intervention. Qualitative interviews confirmed the value to learners in creating a safe place for corrective feedback, the development of the mindmap concept and the opportunity to teach back learned skills to peers. Provision of competency-based behaviour change counselling in obesity management is critical to support the reformulation of obesity as a chronic disease and to be an important adjunct to medical/surgical interventions. In this paper, we have demonstrated the value of an intensive training program for obesity providers. • The reformulation of obesity as a chronic disease allows treatments to be tailored to the complexity of the condition. • Such a development provides the opportunity to focus on behaviour change interventions to support medical therapies. • There is a lack of training programs providing core competencies from the perspective of behaviour change counselling. • In this paper we describe and evaluate a comprehensive training program. • Available evaluation data support the potential of this training program.

Summary of project/aims AUT was contracted by the Ministry of Health in January 2009 to deliver a study of the effectiveness of interventions for problem gambling. Five key aims were agreed for this project, which were to: - generate reliable findings on the effectiveness of intervention services in producing positive outcomes on a range of measures and impact on others - increase the body of evidence available on the clinical effectiveness of common problem gambling intervention practices in New Zealand and inform future clinical practice - compare the effectiveness (on a range of outcomes) of common problem gambling interventions in New Zealand with common problem gambling intervention practices that have been validated internationally, including pharmaceutical interventions - identify client characteristics that mitigate the effectiveness of validated interventions, with particular attention to client ethnicity and primary gambling mode - develop a potential two stage research proposal that builds upon this project to provide additional evidence on the long-term effectiveness and outcomes of the treatment under trial.

Objective: We present a mixed methods systematic review of the effectiveness of therapist empathic reflections, which have been adopted by a range of approaches to communicate an understanding of client communications and experiences. Methods: We begin with definitions and subtypes of empathic reflection, drawing on relevant research and theory, including conversation analysis. We distinguish between empathic reflections, reviewed here, and the relational quality of empathy (reviewed in previous meta-analyses). We look at how empathic reflections are assessed and present examples of successful and unsuccessful empathic reflections, also providing a framework of the different criteria used to assess their effectiveness (e.g., association with session or treatment outcome, or client next-turn good process). Results: In our meta-analysis of 43 samples, we found virtually no relation between presence/absence of empathic reflection and effectiveness, both overall and separately within-session, post-session and post-treatment. Although not statistically significant, we did find weak support for reflections of change talk and summary reflections. Conclusions: We argue for research looking more carefully at the quality of empathy sequences in which empathic reflections are ideally calibrated in response to empathic opportunities offered by clients and sensitively adjusted in response to client confirmation/disconfirmation. We conclude with training implications and recommended therapeutic practices.