Abstract
Background Rheumatoid arthritis (RA) affects 400, 000 people in the United Kingdom. The main physical symptoms are pain, stiffness and swelling of the joints. RA also has substantial social and psychological impact. Intensive management incorporating drug therapy and care pathways has been found to be effective in leading to remission in severe RA disease. However, most people with RA are in the moderate disease category in neither relapse nor remission states. Moderate RA treatment intensification care pathways have not been established. The TITRATE trial is a randomised controlled trial comparing an intensive management intervention with standard care in people with moderate RA. A major component of TITRATE was the provision of monthly one-hour treatment support sessions for 12 months, based on motivational interviewing techniques delivered by trained rheumatology practitioners.Aims The study aims to: 1) identify rheumatology practitioners’ perspectives on barriers and enablers to motivational interviewing technique delivery, and 2) determine whether participants’ psychological need satisfaction was the mechanism of any change underpinning the motivational interviewing component of the intensive management intervention.
Methods A mixed methods process evaluation nested within the TITRATE trial. A cohort of trial participants in the intensive management arm of the TITRATE trial were recruited to the process evaluation (n=26). Data collected for the prospective cohort study were 1) audio recordings of TITRATE intervention sessions four to six which were assessed for motivational interviewing fidelity, 2) perceived autonomy support and need satisfaction collected by structured telephone interview following sessions six and nine. These were analysed alongside trial outcome data for medication adherence and disease activity, collected at 12 months. Semi-structured interviews were conducted with a sample of participants from the cohort study (n=15) and rheumatology practitioners (n=16). Qualitative data were analysed using a framework analysis approach, where the thematic framework was informed by self-determination theory. Rheumatology practitioner data was analysed using the theoretical domains framework. Cohort study data were analysed using mediation analyses.
Results Rheumatology practitioners demonstrated an understanding of both the principles of motivational interviewing and its techniques. Their positive regard of the holistic approach served as an enabler to motivational interviewing technique delivery. Certain sub-groups of people with RA were more difficult for the practitioners to engage with the MI techniques and goal setting. Interview and cohort study findings relating to psychological need satisfaction as the mechanism of change were inconsistent. Qualitative findings indicated that competence, participant acceptance, and self-awareness constructs mediated practitioners use of the motivational interviewing techniques and participant self-management. None of the variables in the mediation analyses were significantly related to one another. There was a moderate significant positive correlation between change in autonomy and change in relatedness.
Conclusion This study provides a novel exploration of the mechanisms through which motivational interviewing techniques work, within the context of rheumatology care. There is evidence that motivational interviewing techniques support RA self-management. Further research is needed to learn best how to optimise rheumatology practitioner MI technique training, and tailor support to individual patients.
| Date of Award | 1 May 2020 |
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| Original language | English |
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| Supervisor | James Galloway (Supervisor), Jackie Sturt (Supervisor) & Kathryn Hamilton (Supervisor) |