Accepted Manuscript

Title: The effect of education through motivational

interviewing compared with conventional education on
self-care behaviors in heart failure patients with depression

Author: Ali Navidian Hajar Mobaraki Mansour Shakiba

PII: S0738-3991(17)30114-3
DOI: http://dx.doi.org/doi:10.1016/j.pec.2017.02.023
Reference: PEC 5600

To appear in: Patient Education and Counseling

Received date: 22-9-2016

Revised date: 22-2-2017
Accepted date: 24-2-2017

Please cite this article as: Navidian A, Mobaraki H, Shakiba M, The effect of education
through motivational interviewing compared with conventional education on self-care
behaviors in heart failure patients with depression, Patient Education and Counseling
(2017), http://dx.doi.org/10.1016/j.pec.2017.02.023

This is a PDF file of an unedited manuscript that has been accepted for publication.
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*Highlights (for review)

Highlights

The self-care improved in motivational interviewing and usual education groups.

Education by motivational interviewing was more effective than the usual education.

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Patient education in depressed HF should be done based on their psychological status.

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Page 1 of 18
*Manuscript

Title: The effect of education through motivational interviewing compared with

conventional education on self-care behaviors in heart failure patients with depression

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Abstract

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Objective: To determine the effect of education based on motivational interviewing on self-care

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behaviors in heart failure patients with depression.

Methods: In this study, 82 patients suffering from heart failure whose depression had been

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confirmed were selected and divided into two groups. The Self-care Heart Failure Index was
utilized to evaluate self-care behavior. The intervention group received four sessions of self-care

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behavior education based on the principles of motivational interviewing, and the control group
received four sessions of conventional education on self-care behavior. At 8 weeks after finishing
the interventions, the self-care behaviors of both groups were evaluated. Data were analyzed using
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paired and independent t-tests, chi-square, and analysis of covariance, as appropriate.

Results: The average increase in the overall scores and the scores on the three sub-scales of self-
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care behavior (maintenance, management, and confidence) of the heart failure patients with
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depression were significantly higher after education based on motivational interviewing than after
conventional self-care education (p < 0.05).
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Conclusions: Motivational interviewing had a significant positive effect on self-care behaviors in

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patients with heart failure and depression.

Practice Implications: Due to the effectiveness of the MI, using motivational interviewing for
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education in depressed HF patients is recommended.

Keywords: motivational interviewing, self-care behaviors, heart failure, depression, education

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 1. Introduction

The prevalence of heart failure (HF) is increasing worldwide [1]. In Iran, a developing
country, HF is increasing as a result of life-style changes and is currently estimated to afflict 3.3% of
the population [2]. HF is a complex syndrome that lowers the quality of life and leads to recurrent
hospitalizations, increased mortality, and high medical costs, which often are a significant burden

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for the patient and family [3, 4].

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It is not possible to restore full health in HF patients, but symptoms can be controlled by

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pharmaceutical as well as non-pharmaceutical interventions. Non-pharmaceutical approaches
include self-care behaviors that help to maintain health and prevent the progression of the illness

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[1]. Self-care consists of two elements: “self-care maintenance” (behaviors for physiologic stability)
and “self-care management” (altering behaviors in response to progression of signs and symptoms

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of disease) [5].

Although self-care seems to be an easy, linear task, it is in fact a complex process [6] that
includes both symptom evaluation and therapeutic response [3]. Despite the availability of good
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approaches to improve outcomes in HF, there is low adherence to self-care behaviors in some
patients, and overall adherence to these behaviors in the HF population is below the desired level
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[1, 3]. Self-care activities differ widely among HF patients, with 20–80% monitoring weight daily, 9–
53% exercising as recommended, 20–71% adhering to low-sodium intake, and 50–96% taking their
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medications as prescribed [7]. Moreover, a lack of active collaboration from HF patients leads to
exacerbation of symptoms and recurrent hospitalizations [4].
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Cognitive capability, level of perceived control, recognition, health literacy, intrinsic

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motivation, extrinsic factors, co-morbid diseases, physical and cognitive limitations, social support,
self-efficacy, anxiety, and depression are among factors that affect maintenance of self-care
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behaviors [8, 9]. Numerous barriers, including cognitive limitations and depression, are frequent in
HF patients [3]. Depression in heart attack patients is common, with a prevalence generally
estimated at 15–33%, but some studies report symptoms in up to 77.5% of these patients [10].
About 20% of HF patients meet the criteria for a formal diagnosis of major depressive disorder
[11]. Depression develops due to rejection of the disease, low motivation for treatment [12],
negative perception of physical health and quality of life, lower self-care potential [13], long-term
disease, delay in improvement, worsening symptoms, and recurrent hospitalization [14]. It seems
that the conventional education usually provided to HF patients for self-care (based on traditional
methods for patients with depression) is not as effective as expected. Navidian et al. (2015) showed

Page 3 of 18
that self-care education in the HF setting had less effect on the awareness, attitude, and
performance of depression patients compared to non-depression patients [15]. Therefore, a
modification of self-care education for HF patients with depression needs to improve efficacy.

Improvement of self-care behaviors in HF requires life-style changes. One way to engage the
patient is to use motivational interviewing, which has been shown to produce behavioral changes

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[16]. Motivational interviewing was developed for addiction treatment but has spread rapidly to

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other areas, including the management of chronic diseases (such as asthma, eating

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disorders/obesity, and diabetes) that entail behavioral and life-style changes [17]. Motivational
interviewing is an effective approach to enhance self-care behaviors, motivation, and coping

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approaches in patients with chronic diseases [18]. It is patient-centered and reinforces intrinsic
motivation through discovery, identification, and resolution of ambivalence [19]. In motivational
interviewing, patients are guided to identify personal values and objectives, and plan for changes in

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their life instead of depending on health care providers to resolve their problems [7]. The main
modalities of motivational interviewing include creating a therapeutic alliance, evaluating patients’
perspectives and life perspective and objectives recognizing their capabilities, identifying previous
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challenges, achievements, and feelings about health, and fostering a positive atmosphere for
therapy along with acceptance of their condition [20].
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There is always a gap between providing information about self-care behaviors for HF
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patients and maintaining those behaviors in a practical setting. It seems that this gap is wider for
HF patients with depression, because of their aggregate symptoms and psychological issues.
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Therefore, it is necessary to improve the treatment and education programs for such patients.
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Although studies have shown that motivational interviewing is effective for patients with
depression undergoing psychotherapy [21], there are no studies of motivational interviewing on
self-care in patients with HF complicated by depression. Therefore, the aim of this study was to
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determine whether the addition of motivational interviewing to conventional education increases

the effectiveness of therapeutic counseling in this patient population.

Page 4 of 18
 2. Methods

This study was conducted to compare the effects of two kinds of education on self-care
behaviors in HF patients with depression. The study population consisted of a convenience sample
taken from all HF patients admitted to cardiac units in the hospitals of Zahedan University of
Medical Sciences between March and June 2016. This research is registered in the Iranian Registry

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of Clinical Trials under the code IRCT2016092529954N2. The diagnosis of HF was made by

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cardiology staff, as recorded in the patients’ chart. A secondary diagnosis of depression was then

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given if the patient had a positive screening test (Beck’s Depression Inventory [BDI] score > 21),
and a confirmatory mental status examination (MSE) positive for depression by a clinical

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psychologist. Other inclusion criteria were a) a left ventricular ejection fraction < 40% measured by
echocardiography; b) being an urban resident accessible for further investigation and follow-up
evaluations; c) age between 20 and 80 years; d) full consciousness without communication

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problems or history of drug abuse/addiction; and e) no simultaneous participation in other
rehabilitation or education programs. The required study size was determined based on the mean
and standard deviation of self-care behavior scores in similar studies with a confidence interval of
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95% and power of 95% according to the sample size determination formula. This was equal to 41
participants in each group, i.e., 82 patients in total [15, 22]. The power analysis was performed
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using G Power. Group sample sizes of 41 (each) achieve 100% power to detect a difference of 17.0
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points between the null hypothesis that both group means are 23.6 and the alternative hypothesis
that the mean of the control group is 6.6 with estimated group standard deviations of 5.9 and 5.1
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and a significance level of 0.05 using a two-sided two-sample t-test.

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Data were collected using a two-part questionnaire. The first part addressed demographic
information, and the second part included the 22-question Self-Care Heart Failure Index
(SCHFIV6.2) developed by Riegel (2004) with three sub-scales [23]. The SCHFIV6.2 questionnaire
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assesses self-care (10 items), management of symptoms (6 items), and confidence (6 items) on 4-
point scales. After scoring, the results of each scale as well as the total score were converted to a 0
to 100 scale, and so the scores for each participant were expressed between 0 and 100. Reliability
and validity of this questionnaire in Iran were determined by Zamanzadeh et al. and Moaddab et al.
Construct validity of the SCHFIV6.2 was tested using confirmatory factor analysis and concurrent
validity was assessed by comparing the SCHFIV6.2 with the European Heart Failure Self-care
Behavior Scale (scale items are reversed; r = −0.71, p < 0.01). Using the test-retest method,
reliability was examined and the correlation coefficient between two time points was 0.89 and
Cronbach's alpha 0.91 [24, 25].

Page 5 of 18
 Patients fulfilling the inclusion criteria were selected among hospitalized HF patients, and
their informed consent was obtained in writing. The BDI was used to screen for depressive
symptoms and if the score was above 21, a MSE was done by a clinical psychologist to confirm
depression. If both depression and HF diagnoses were confirmed, the patient was entered into the

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study as a research participant. The participant population then was randomly split into two

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groups. The process of randomization involved randomly giving an envelope to each participant,

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containing the allocation to either group A (control) or group B (intervention).Patients were not
aware that they were receiving conventional education or education through motivational

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interviewing. Participants in each group completed the pre-test procedure (SCHFIV6.2). The
intervention group received 4 individualized sessions of self-care education based on motivational
interviewing during the final 4 days of hospitalization (Table 1). At 8 weeks after discharge, the

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SCHFIV6.2 was administered as a post-test procedure to the participants either at home or during a
visit to the heart clinic. Education using motivational interviewing was performed by the first
author, who had utilized the technique previously for issues of weight loss, hypertension, life-style
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changes, obsessive-compulsive disorder, addiction, and occupational safety. The control group
received conventional training on self-care behaviors individually, in short sessions over 4 days,
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using an educational booklet; they also received the post-test questionnaire after the same 8-week
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post-discharge interval. Conventional self-care education was provided by a nurse with experience
in cardiac patient education under the supervision of the head nurse. The content of self-care
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education was determined based on an assessment of needs, as previously reported [15, 22].
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2.1. Main hypothesis

The main hypothesis of this study was “The effect of education using motivational interviewing on
increasing self-care behaviors in HF patients with depression is different from that of conventional
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education.”

2.2. Statistical analysis

The data were analyzed using IBM SPSS (Statistical Package for the Social Sciences), Version
21.0 (IBM Corp., Armonk, NY, USA). Frequency, percentage, mean, standard deviation, minima, and
maxima were determined as descriptive statistics, and a paired t-test was used to compare pre- and
post-means in each group. Independent t-tests were used to compare the means of the two groups.
The chi-square test was employed to compare the frequency of qualitative variables between the
two groups, and the analysis of covariance (ANCOVA) to determine the effectiveness of

Page 6 of 18
motivational interviewing and control for the effect of some confounding variables. Differences
were considered significant if p < 0.05.

2.3. Ethical considerations

This study was registered with the ethics committee of Zahedan University of Medical
Sciences (No. 95/12). Providing information about the implementation of the research, duration of

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study, and type of intervention, obtaining written informed consent from participants, and assuring
participants of the confidentiality of the collected information and their freedom to participate and

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withdraw at any stage of the study were among the ethical considerations in this research.

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3. Results

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The results of the Shapiro–Wilk test on the SCHFIV6.2 scores showed that the data had a
normal distribution. Therefore, parametric tests were employed.

The age range of the subjects was 36 to 78 years (58.04 ± 11.99 in the intervention group
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and 58.58 ± 11.69 in the control group, Table 2). The majority of participants in the intervention
(53.7%) and control (61%) groups consisted of housewives and unemployed individuals. There
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were no significant differences in gender, marital status, educational attainment, or employment

status between the intervention and control groups. The average frequencies of hospitalization in
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the intervention and control groups were 5.56 ± 3.60 and 4.80 ± 3.21 times, respectively (p = 0.3).
The depression scores in the intervention and control groups were 26.9 ± 2.21 and 26.7 ± 1.83,
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respectively (p = 0.50). Thus, average depression scores and frequency of hospitalization did not
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differ between the two groups.

As shown in Table 3, the average increase in the scores on the three SCHFIV6.2 sub-scales
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(maintenance, management, and confidence) was significantly higher in the motivational

interviewing group than in the control group. The average increase in the total SCHFIV6.2 score of
the motivational interviewing group (23.61 ± 5.87) was significantly higher than that of the
conventional patient education group (6.59 ± 5.11). By controlling for the confounding effect of two
factors, namely the pre-test SCHFIV6.2 and depression scores , ANCOVA showed that in the post-
test phase, the average total SCHFIV6.2 score in the intervention group was higher than in the
conventional education group, which indicates a positive effect of education based on motivational
interviewing.

Page 7 of 18
 4. Discussion

The results of this study show that for HF patients with depression receiving education
based on motivational interviewing, the average total score for self-care behaviors post-
intervention was significantly increased compared to that in the pre-intervention phase, and to that
of the conventional education group in the post-intervention phase. Thus, using the principles of

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motivational interviewing in education for self-care behaviors in this population was shown to have

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a higher effectiveness than education and common treatments. If taking medications for chronic

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diseases such as hypertension is an example of self-care, the study of Ogedegbe et al. indicated that
motivational interviewing increased patients’ adherence and continuity of self-care in comparison

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to conventional education [26]. Creber et al. examined the effect of motivational interviewing on HF
patients, and showed that motivational interviewing improved adherence to a low-salt diet and
physical activity but did not change HF patients’ management of self-care behaviors or confidence

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levels [27]. These results are somewhat different from those in the current study, which may be
attributable to the shorter follow-up interval (56 vs. 90 days) in our study. Earlier, Paradis et al.
found that training based on motivational interviewing significantly increased the self-efficacy of
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HF patients with depression at 1 month after the intervention, which is consistent with our findings
at 8 weeks post-intervention [28].
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The effectiveness of motivational interviewing in our study may be explained by the type of
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intervention applied, i.e., four face-to-face sessions (90 minutes each), instead of a single
motivational interviewing session and two or three follow-up telephone calls as utilized previously
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[26-28]. During our study, telephone contact was available for patients if necessary. Overall, our
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results suggest that education based on motivational interviewing in our Iranian sample is more
effective than telephone training.
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Interestingly, Solomon et al. reported that motivational interviewing by telephone did not
increase adherence to taking medications in patients suffering from osteoporosis [29]. Hardcastle
et al. examined the effectiveness of motivational interviewing using 5 face-to-face sessions in a 6-
month period, and reached the conclusion that counseling based on non-intensive motivational
interviewing could decrease high cholesterol, excess weight, and risk of heart disease [30]. Chair et
al. examined the effect of 10 sessions of motivational interviewing (30 to 45 minutes each)
compared to conventional education programs on participants in a heart rehabilitation program in
Hong Kong. After 1 year, the results showed that motivational interviewing did not affect the

Page 8 of 18
clinical and psychological consequences of HF beyond enhancing certain aspects of quality of life
[31].

Thus, the literature indicates that motivational interviewing in non-intensive face-to-face

sessions can lead to changes in unhealthy behavior and improve clinical outcomes in the short
term. Motivational interviewing depends on collaboration, and elicits active thinking about health

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behaviors in patients, rather than patients simply being given information by a counselor. In

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essence, by working with patients’ active involvement and autonomy instead of just presenting

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likely consequences and outcomes based on expert opinion, there is a greater chance of behavioral
change [17, 20].

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In this study, the control group showed a slight increase (about 6 to 7 points out of 100) in
the average scores on all three SCHFIV6.2 sub-scales. These increases were quite modest in

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comparison to those of 20 to 26 points in the intervention group. Patients with HF and depression
are not likely to respond to traditional educational approaches, as previously noted by Navidian et
al. Psychological elements, including emotional, physical, and cognitive symptoms of depression,
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coupled with HF can hinder a patient’s capability for self-care, as ongoing disappointment,
frustration, and low motivation reduce adherence to self-care behaviors in this setting [15].
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Motivational interviewing is a client-centered approach that relies on reflective listening

instead of confrontation. It helps to propel the balance of decision-making by the patient toward
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behavior change through maintaining a non-judgmental perspective, expressing empathy, and

putting emphasis on patient values and objectives by developing insight and discretion, rolling with
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resistance, and supporting self-efficacy [32]. Such therapeutic elements in motivational

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interviewing increase intrinsic motivation and facilitate the ability of cardiac patients with
depression to face the barriers of change and the possibility of changes in life-style. Motivational
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interviewing has also been proved useful for difficult situations, increasing motivation, maintaining
morale during arduous treatment programs, and enhancing the effectiveness of psychological
treatments such as exposure with response prevention in psychotherapy [20, 33]. As Swartz et al.
reported, motivational interviewing provides an opportunity for patients with depression to
discover and resolve ambivalence, thus facilitating participation in and adherence to medical
treatment programs [21].

The recent literature on motivational interviewing indicates that it is a useful approach to

the behavioral modification of unhealthy habits that can impact on the morbidity of a range of
disease processes. Clinical trials on the efficiency of motivational interviewing have shown that

Page 9 of 18
people can benefit from this approach, including individuals undergoing hemodialysis [34], as well
as those needing to increase their consumption of fruits and vegetables [35], comply with HIV
treatment regimens [36], improve occupational safety behaviors [37], maintain quality of life in HF
[18], improve physical activities [38], adhere to methadone treatment [39], and enhance action-
oriented behaviors [40]. The results of the present study, together with those of previous studies,

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strongly suggest that motivational interviewing in HF patients with depression who are

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predisposed to poor self-care can lead to significantly improved health habits and outcomes.

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In this study, education using motivational interviewing was performed by the first author,
who had extensive work experience in the field of motivational interviewing. It is important to

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ensure that the person performing motivational interviewing has the necessary experience;
otherwise, the fidelity to the principles of motivational interviewing could be reduced during the
intervention. In this study, in addition to the effect of motivational interviewing techniques, part of

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the impact of the motivational interviewing approach in promoting self-care behaviors could be due
to the counselor’s competency, performance, and experience, especially since education using
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motivational interviewing was provided face-to-face in this study, unlike in previous studies.
Therefore, the positive outcome in the motivational interviewing group may be an optimistic sign,
and this point needs to be considered as a limitation in the practical implications of the results of
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this study. Further research is needed to explore this possibility.

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4.1. Study Limitations

Limitations to the present study include the possible effect of motivational interviewing
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being performed by the first author, who had extensive experience in this area; the lack of a control
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group without any educational intervention (due to ethical considerations); and the lack of long-term follow-up
to examine the effects of the interventions.
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4.2. Conclusion

Despite the positive effect of motivational interviewing on self-care behaviors in

comparison to the conventional and customary forms of patient education, further research is
needed to accurately identify the optimal patient-centered approaches in order to enhance self-care
behavior in HF patients with depression. However, based on the findings of this study, it seems that
motivational interviewing is a promising approach. Health care providers, by screening patients
with HF for depression, may be better able to intervene and utilize motivational interviewing for
active education programs for this subgroup of HF patients and enhance the effectiveness of patient

Page 10 of 18
education to improve compliance with treatment plans. Self-care education for HF patients based
on new theories of behavioral change such as motivational interviewing coupled with monitoring of
psychological symptoms is recommended. It is probable that the ongoing development of
motivational interviewing techniques will prove beneficial throughout the world for a variety of
medical syndromes and psychological stressors.

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4.3. Practice Implication

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The motivational interviewing can lead to improvements in self-care in HF patients with
depression, and there may be benefits in incorporating it into clinical practice. In order to increase

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patient adherence to self-care behaviors, clinicians can integrate the principles of motivational
interviewing in conventional education programs for HF patients with depression. Therefore, using

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motivational interviewing in the education of this patient population is recommended.
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Competing interests
The authors declare that they have no competing interests.
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Financial Support
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The researchers received no financial support or grant from any funding agency in the public or
commercial sectors.
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Authors’ contributions
All authors conceived the study and contributed to the study design. AN performed motivational
interviewing sessions, interpreted the data, and supervised the study. HM and MSH gathered the
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data, performed statistical analysis, and helped with drafting the manuscript. All authors reviewed
and edited the manuscript, and saw and approved the final draft.

Acknowledgments
The authors would like to thank the hospital managers, cardiologists, nurses and head nurses in the
heart units, and all the patients who voluntarily participated in the study, for making this research
possible.

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Page 11 of 18
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Table 1: Structure and concept of educational sessions based on motivational interviewing
Session Educational concept
1st Introduction, illness review, definitions, causes, symptoms, course of illness (practice

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recognizing the effect of not respecting self-care behaviors on various aspects of life,
practice of identification and appellation of feelings)

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2nd Importance of self-care, diet, weight control, rest and activities, measuring the volume
of urine (describing a typical day of life, evaluation of advantages and disadvantages

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of lack of respecting self-care behaviors in the short and long term; and practice of
decisional balance)
3rd Monitoring the symptoms of deterioration in heart failure illness and required actions,

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restriction of alcohol and smoking, taking medicines (practice of identifying and
prioritizing top values and developing the clear and evident discrepancy in order to
provide intrinsic motivation)
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4th Showing a short film about heart failure and debate about topics involved as well as
summarizing (rewards for achievement, support self-efficacy, recognition of tempting
situation, individuals’ degree of self-confidence in control or lack of control of the
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behavior in tempting situations)

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Page 16 of 18
Table 2. Demographic characteristics of patients in the motivational interviewing (MI) education group and conventional education group

Variable MI education Conventional education Test results

N (%) N (%)

Sex

Women ‫‏‬22 (53.7) ‫‏‬21 (51.2) ‫‏‬p = 0.8

Men ‫‏‬19 (46.3) ‫‏‬20 (48.8)

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‫‏‬41 (100) ‫‏‬41 (100)

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Total

Education

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Lower than diploma ‫‏‬31 (75.6) ‫‏‬31 (75.6) p=1

Higher than diploma ‫‏‬10 (24.4) ‫‏‬10 (24.4)

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Total ‫‏‬41 (100) ‫‏‬41 (100)

Marital

Single ‫‏‬16 (39) ‫‏‬15 (36.6) p = 0.9

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Married ‫‏‬25 (61) ‫‏‬26 (63.4)

Total ‫‏‬41 (100) ‫‏‬41 (100)

Occupation
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Employee ‫‏‬19 (46.3) ‫‏‬16 (39) p = 0.3

Housewife ‫‏‬14 (34.1) ‫‏‬16 (39)

Unemployed 8 (19.6) 9 (22)

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Total ‫‏‬41 (100) ‫‏‬41 (100)

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Main complaint

Shortness of breath ‫‏‬22 (53.7) ‫‏‬13 (31.7) p = 0.2

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Limbs swelling ‫‏‬7 (17.1) ‫‏‬11 (26.8)

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Cough ‫‏‬10 (24.4) ‫‏‬13 (31.7)

Tiredness ‫‏‬2 (4.8) ‫‏‬4 (9.8)

Total ‫‏‬41 (100) ‫‏‬41 (100)

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‫‏‬ Mean ± SD Mean ± SD

Age (years) 58.04 ± 11.99 58.58 ± 11.69 p = 0.8

Hospitalization 5.56 ± 3.60 4.80 ± 3.21 p = 0.3

Depression score 26.92 ± 2.21 26.68 ± 1.83 p = 0.5

Page 17 of 18
Table 3. Self-care Heart Failure Index mean scores of the intervention and control groups before and after the educational intervention

Variable ‫‏‬Before ‫‏‬After ‫‏‬Changes Paired t-test (Before-

After)
Mean ± SD Mean ± SD Mean ± SD

t
Self-care Maintenance

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MI education 52.86 ± 10.57 78.84 ± 6.42 25.97 ± 8.34 0.0001

Conventional education 53.10 ± 6.97 60.00 ± 7.15 6.89 ± 5.63 0.0001

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Independent t-test 0.9 0.0001 0.0001

Self-care Management

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MI education 52.13 ± 10.73 74.49 ± 6.85 22.35 ± 9.06 0.0001

Conventional education 53.65 ± 8.13 60.36 ± 7.63 6.70 ± 6.24 0.0001

Independent t-test ‫‏‬0.4 0.0001 0.0001 ‫‏‬

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Self-care Confidence

MI education 51.22 ± 10.64 72.15 ± 7.87 20.93 ± 8.04 0.0001

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Conventional education 47.35 ± 10.97 53.35 ± 9.86 5.99 ± 7.21 0.0001

Independent t-test ‫‏‬0.1 0.0001 0.0001

Total Self-care
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MI education 52.21 ± 8.87 75.83 ± 5.59 23.61 ± 5.87 0.0001

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Conventional education 51.69 ± 6.71 58.28 ± 6.86 6.59 ± 5.11 0.0001

Independent t-test 0.7 0.0001 0.0001

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Page 18 of 18