Barriers and facilitators to the implementation of motivational interviewing (MI) with fidelity across three Caribbean nations

Abstract

Background: Motivational Interviewing (MI) is one of the most effective behavior-change interventions to enhance communication between HIV providers and patients. When implemented with fidelity, MI improves rates of antiretroviral adherence, compliance with medical guidance, and reduces missed visits. However, attaining fidelity is particularly difficult in resource-constrained settings. Considering knowledge gaps related to how behavior-change interventions should be delivered to attain fidelity in resource-constrained settings, we tested four implementation models across three countries. Methods: Collaborating with governmental and civil society organizations, we tested models in Jamaica, Dominican Republic, and Saint Lucia (2014-2018). The first included a two-day face-to-face workshop followed by six individual coaching sessions. The second reduced the number of coaching sessions and added a face-to-face booster (Jamaica only). The third retained the two-day workshop and dropped all coaching. The fourth was a high-contact model implemented solely by local trainers (Jamaica only). Findings: Workshop satisfaction was high across all models. Only 50% of the first model’s trainees (N=20) completed 3+ coaching sessions. Four trainees (20%) attained high fidelity (3.5+/4.0). In the second model (N=21) coaching attrition stayed constant with about 50% of trainees completing 3-4 sessions. Attendance in the face-to-face booster was strong with about two-thirds of trainees participating. In the third model, satisfaction levels were very high (over 90%), but only 2/11 (18%) trainees attained solid fidelity. In the fourth model 9/12 trainees completed the program; 8 attained solid fidelity (67%) reflecting a significant improvement compared to prior models. Implications for D&I Research: Implementing evidence-based interventions with fidelity in resource-constrained settings is critical to addressing gaps in HIV care. This requires that cultural preferences and inner and outer contexts are considered. Our iterative process highlighted four findings to be further examined. Trainees who participated in workshops were able to attain beginner-level fidelity when trained by senior-level facilitators. Although the second model was adapted to trainees’ preferences, no trainees attained high fidelity. In the Dominican Republic, facilitators’ lack of Spanish proficiency was a barrier, and the highest face-to-face contact model yielded the highest trainee fidelity. Since evidence-based interventions often cannot be successfully implemented leveraging protocols designed for the high-resource settings, more global intervention implementation studies are warranted.