Culturally Relevant Adaptations of Evidence Based Practices
Training and Technical Assistance
-- Gaborone, Botswana --
November 7-11, 2006
Prior to the training event, needs assessments, conference calls, and planning sessions were conducted by a team of collaborators. The team featured Marion Carter and Prisca Tembo of the BOTUSA Project; Maxime Germain, Christopher Hisayi, and Morekwe Selemogwe of the Blossom Counseling Centre; and the ATTC trainers Jacki Hecht, Stephanie Howard, Maureen Orwa, and Dick Spence. Expert consultation to assist in preparing the BMI curriculum was generously provided by Mary Velasquez, Kirk von Sternberg, Paul Seale, and John Higgins-Biddle.
Seventeen trainees were in attendance representing 14 different health, education, and service agencies. Participants consisted of Counselors, Nurses, Trainers, Social Workers, and Health Educators. In their practice they tend to use both English as well as Setswana in working with patients.
In a survey completed at the conclusion of the workshop, all the participants reported they were satisfied or very satisfied with the quality of the training they received. The items with strongest agreement indicated that the instructors were well prepared and receptive to participants’ comments, and that the participants expect to use knowledge and skills gained from the training, with over 80% of participants reporting they very strongly agreed with these statements.
Some questions were repeated in the pre and in the post surveys. The following table shows the differences in reported confidence for using BMI skills:
Percentage of participants who reported confidence in:
|Talking with patients about their alcohol usage||65%||100%|
|Assessing how heavily they use alcohol||47%||100%|
|Telling patients what the risky limits are for drinking||53%||95%|
|Giving advice to patients to reduce drinking||65%||95%|
|Finding out patients’ readiness to reduce their drinking||65%||100%|
|Helping a patient develop goals for reduced drinking||59%||100%|
Before the workshop only 12% of participants agreed they had enough knowledge about Motivational Interviewing to counsel patients, compared with 100% at the end of the workshop.
Before the workshop 12% of participants agreed that talking with patients about their drinking would take too much time while 34% of participants agreed with the statement at the end of the workshop.
Before the workshop only 35% of participants thought it was reasonable to expect that a brief conversation can help patients reduce their risky alcohol usage. This is compared with an 86% positive response rate in support of brief conversations at the end of the workshop.
Following the training 73% of participants reported that they intended to begin using BMI in their work the very next week or sooner.
Role-play sessions were referenced as the most effective aspect of the training experience as they gave participants the opportunity to practice BMI.
A majority of respondents expressed concern over future levels of supervisory support of BMI, stating that the support of their supervisors will be essential to implementing BMI with their clients. The potential lack of managerial support was sited as the greatest perceived challenge to using BMI.
Several participants requested that a Setswana version of the BMI training and tool be made available in addition to posters, brochures and handouts to help introduce the intervention into their health care settings.
Observers, participants, and trainers also completed a debriefing form to provide additional feedback about their experience.
It was reported that the role plays worked especially well as teaching tools as did the discussion sessions and presentations.
When asked what didn’t work well in the training, limited feedback was given that the training was both too short and too long, suggesting a variety of experiences for attendees. Changes such as adapting the materials into Setswana, building on the trainers’ understanding of cultural patterns, and providing workshop certificates were recommended for future improvements to the workshop. It was also mentioned that referring to the BMI more in initial background slides, incorporating Botswana specific alcohol abuse data into the content, and describing the difference among other screening tools would be useful. Additional suggestions were made to extend the TOT into two days, to clarify TOT expectations further, and to divide the tool into three steps for both teaching and practice purposes.
Attendees reported high satisfaction that the workshop objectives were met and found the training to be culturally appropriate for Botswana. The interactive nature of the workshop was pointed to as an example of how the needs and hopes of the participants were explored.
Respondents reported that the trainers were knowledgeable, prepared and clear. Additionally, many attendees expressed satisfaction with the amount of opportunity trainers provided to practice skills during the workshop and increased time for practice was also suggested.
Rationale for Brief Motivational Intervention (BMI)
by Healthcare Workers in Botswana
Need for an Alcohol Intervention
Many healthcare patients have elevated HIV related risk due to heavy use of alcohol. Under the influence of heavy drinking, these patients often do not make good decisions about sexual practices, or other health behaviors. They are more likely to engage in risky sexual behaviors and thus be more likely become infected or transmit infection to others, or to fail to adhere to their medication schedule if taking Anti-Retroviral Medications. Alcohol abuse is regarded by many healthcare workers as the primary reason for medication non-adherence. However, specialized treatment for alcohol dependence is generally not available in Botswana, and an intervention is needed which could be implemented by healthcare workers to identify heavy drinkers and engage them a brief therapeutic interaction targeting risky drinking behavior.
Screening and Brief Intervention methods, and Motivational Interviewing are techniques that have strong evidence of effectiveness. They are two closely related methods which are often used together. BMI uses both of them in a brief script for a single interaction. Research indicates that a single session may have a lasting impact on behavior. This BMI script has three screening questions to identify risky levels of drinking. Patients who are heavy drinkers are provided with direct advice to cut back or quit. Then the patients are asked about their readiness to reducing their drinking, and their confidence level of being able to cut back if they try. If they are ready, patients are given an opportunity to develop specific goals and strategies for reduced drinking.
BMI is recommended for use with all healthcare patients as part of a normal health assessment when providing routine healthcare services. Research evidence indicates that this kind of intervention will be effective immediately for one in eight heavy drinkers in helping them reduce their drinking to within safe levels.
The BMI does not assume the availability of treatment resources for referral of alcohol dependent patients. It may provide some moderate benefit for them, but the primary benefit will be realized in reduction of drinking among moderate or heavy, but not dependent, alcohol users. When dependent patients are identified, they are encouraged to seek treatment if available, quit drinking completely, to connect with AA groups, and to enlist family members or other supportive persons in helping them work on their long term recovery.
Feasibility of Incorporating BMI within the Practice of Healthcare Workers.
This method is quick (5-10 minutes). It is simple; the script has been placed in a Pocket Guide which the healthcare worker can use as a reference when talking with patients. One side guides the brief intervention and the other side guides a motivational interviewing discussion. It can be used as a self-guide for patients; a paper copy may be given to the patient as a record of their discussion and a reminder of their readiness ratings and identified goals and methods. During trainings for this method, healthcare workers are able to observe others using the BMI script and also to practice using the script until they are comfortable with using it.
As with any change in professional practice, administrative and clinical support is necessary to ensure the change is successfully implemented and sustained. Follow-up training or technical consultation is very helpful when possible. Peer networking is also a good way to provide for implementation support.
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