Master of Nursing

MDN 5105: Research Project HT043999E

Effectiveness of Brief Motivation Interviewing versus Health Education in
Lowering Low-Density Lipoprotein levels in Newly Diagnosed
Hyperlipidemia patients in the Community Setting

1. Introduction
High Low Density Lipoprotein (LDL) levels are highly associated with acute coronary
disease and ischaemic heart disease which are among the top 10 principle causes of death
(Ministry of Health [MOH], 2005). According to MOH (2001) clinical practice
guidelines, patients with LDL levels not within the normal range have to make lifestyle
changes. The importance of changing health behavior thus reaching desired medical
outcome cannot be undermine in this aspect.

1.1 Literature Reivew and Identification of Gaps

Motiational Interviewing (MI) is a framework defined as “a directive, client-centered
counseling style for eliciting behavior change by helping clients to resolve and explore
ambivalence” (Rollnick and Miller, 1995 cited in Miller, 1996, p.839). The 5 basic
principles include expressing empathy, developing discrepancy, avoiding argumentation,
rolling with resistance and supporting self-efficacy.

The human behavior theory that underlies MI is the Transtheorectical Change model
(TTM). TTM believes that an individual undergo pre-contemplation and contemplation
stages. These 2 stages are necessary before the individual reaches a stage to start
preparing and taking action which resulted in a changed behavior. After a changed
behavior, there are the maintenance phase and relapse phase. MI can be used in any of
these stages (DiClemente and Velasquez, 2002). The main assumption of MI is that these
stages of change are “fluid”, not as “fixed” in time as the TTM suggested. Thus it is
possible to change a person’s stage of change by creating awarenesss of the ambivalence.
Afterwhich, to explore this ambivalence and to resolve it.

With a deeper understanding in human behavior, the usual health education, which
consists didatic teaching, might not be effective in bringing about a change in human
health behavior. Thus, employing brief MI counseling strategy can afterall change health

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Master of Nursing
MDN 5105: Research Project HT043999E
behaviors more effectively by exploring and resolving the ambivalence in one outpatient
nurse consultation.

Few studies had been done on Motivational Interviewing counseling technique on

modifying dietary and exercise behaviors. Resnicow et al (2002) had identified only 6
studies done to measure the efficacy of MI in regards to modifying exercise and diet
behaviors. 4 of these studies were secondary prevention trials and 2 of these studies were
primary prevention trials. Out of these studies, only 1 study done by Mhurchu, Margetts
and Speller (1998), studied on hyperlipidemia patients using MI based counseling in
comparison to a standard dietary intervention.

A meta-analysis on efficacy of MI (Burke, Arkowitz & Menchola 2003) revealed that the
findings from 4 studies done using MI to modify diet and exercise behaviors remain
preliminary. Furthermore, in most of these studies, the MI interventions were delivered
by psychologists, dieticians and medical practitioners. Only the study by Woollard (1995)
done on hypertensive patients had nurse counselors to deliver to the MI intervention.

This paper proposes that MI can be modified into a brief sructured format which consists
the 5 principles and with the same aim effectively change health behaviors in
hyperlipidemia patients. The changing of health behaviors will result in better health
medical outcomes. Also this brief structured format can used by registered staff nurses.
This is further supported by the fact that MI was initially employed to change addictive
behaviors. For nonaddictive behaviors, less time might be require to resolve ambivalence
(Resnicow et al, 2002), thus the possibility of applying brief MI counseling strategy in
outpatient setting to change health behaviors.

Conclusions cannot be generalised to the general population as only 1 study had been
done on hyperlipidemia patients. Futhermore, most of the studies were not done locally.
MI a counseling strategy can be assumed as a method of communication. Different
cultures have influences on the effectiveness or acceptability of a particular method of
communication. Through doing this study in Singapore, acceptability and practicability

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Master of Nursing
MDN 5105: Research Project HT043999E
of this counseling strategy can be established by the subjects’ responses reported by the
interventionist. Burke, Arkowitz and Dunn (2002) mentioned that the lack of integrity
checks in the studies done resulted in low content validity of the independent variable of
interest which is the MI intervention. Thus, weaknesses of present studies include the
imbalances between internal validity and external validity of the studies.

This study will be conducted in Singapore, at one of the branches of XXX Polyclinics,
XXX polyclinic, as a pilot project. The full implementation of the study will be
conducted across 9 polyclinics to cover the hyperlipidemia secondary prevention general
population. This will help to establish external validity and conclusions of study can be
generalised to the local population. The Brief MI intervention will have intergrity check
to ascertain that the intervention given is MI and not other kinds of counseling strategy
models like transtheoretic model (TTM) or cognitive behavior therapy (CBT), (Resnicow
et al, 2002).

1.2 Significance of Study

Changing health behaviors like changing eating habits and exercising regularly had been
established as effective in lowering lipid levels. The lowering of lipid levels will in turn
lead to a lower probability of having heart diseases and stroke. Although cost-anlaysis is
not included in this study. It is logical to assume that costs of treating, rehabilitating and
providing care to both heart diseases and stroke will be reduced with better medical
outcomes. Lowering lipid levels not only have cost benefits but also other intangible
benefits, e.g. better quality of life.

Though in Singapore, nurses are already playing a crucial role in providing health
education for hyperlipidemia patient in the current outpatient medical setting. It is
important that health education or counseling continues to innovate and evolve. Using
evidence based to establish the effectiveness of the current and “new” nursing
interventions that can being given to change health behaviors.

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Master of Nursing
MDN 5105: Research Project HT043999E
1.3 Research Puporse/ Aim
The aim of this study is to determine the effectiveness of Nurse-Led counseling strategy
Brief Motivational Interviewing (MI) in lowering low-density lipoprotein (LDL) levels
for newly diagnosed hyperlipidemia patients in outpatient medical setting. The
conduction of the pilot study will at Yishun Polyclinic, one of the branches of National
Healthcare Group Polyclinics (NHGP). The full conduction of this study will be done
across the nine polyliclinics of NHGP. This research hypothesizes that Brief MI is more
effective than the usual practice of health education in lowering LDL levels for newly
diagnosed hyperlipidemia patients.

1.4 Ethical Considerations

Ethical approval had been obtained from the DSRB committee on the 2nd September 2005
with reference no. DSRB-A/05/303 (Appendix A1). A sample of the consent form can be
found on Appendix A2.

2. Methodology
2.1 Research Design
A randomized prospective interventional study comparing effectiveness of lowering LDL
levels using Brief MI counseling strategy versus Health Education in newly diagnosed
hyperlipidemia patients in the primary healthcare setting. Objectives were to compare the
effectiveness of the 2 methods using (1)primary outcome measures: Total cholestrol (TC),
low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides (TG) and
(2) secondary outcomes measures: dietary, exercise changes and body mass index (BMI).

Differentiation of Interventions Given

The usual health education involves didatic teaching and giving the patient information of
good health behaviors. Brief MI counseling strategy is to used the 5 MI principles
described above to move subject along the stage of change to want to change health
behavior.

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Master of Nursing
MDN 5105: Research Project HT043999E
Integrity of the Brief MI counseling stratgy in this research will be addressed by
structuring the counseling strategy in a “fixed” format as a conversational transcript
(Appendix B1). Each question and statement structured had indication of the principle of
MI that is being applied. Expert opinion will be sought to finalise the conversational
transcript of the Brief MI intervention. The expert opinion committee consists of 3 senior
nurse counselors with altogether over 80 years of experience in counseling patients and a
National Healthcare Group health promotion doctor who specialise in teaching health
education and counseling.

A conversational transcript for health education is also formatted for the nurse-
interventionist usage (Appendix B2). To reduce inter-rated reliability of the study, only 1
nurse will be the interventionist for this project. The nurse-interventionist is trained to
follow the conversational transcript strictly in an afternoon session with a role-play
session with the collaborator of this study. Questions were encouraged during the training
session.

This study had an initial plan to record the counseling session of each subject. After
which, each member (blinded to the intervention carried out) of the expert opinion
committee would assess individually the style of the counseling method used. The results
will compare with the actual intervention given to further validate the difference and
enhance the integrity of usual health education and Brief MI counseling strategy.
However, this plan was unable to be carried out as most of the patients refused for their
sessions to be recorded.

2.2 Sampling Plan

Patients who fulfilled the following inclusion criteria will be recruited in this study.
Inclusion Criteria include:
•Newly diagnosed patients with hyperlipidemia not within normal range according to
MOH clinical guidelines.
•The initial diagnosis is made by polyclinic doctors
•Subjects not prescribed with any anti-lipid lowering agents

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Master of Nursing
MDN 5105: Research Project HT043999E
•Subjects with only primary hyperlipidemia will be included.
•Subjects who are able to understand and converse in English or Mandarin will be
recruited. This is because the MI counseling format will be written in English and
Chinese format.
•Subjects who are non-smokers. Smoking is an established risk factor for increased
lipid levels and can decrease the potential effects of the intervention.

Patients who are (a) newly diagnosed secondary hyperlipidemia cases (include patients
with already a primary diagnosis of hypertension, diabetes mellitus etc.) (b) diagnosed by
private clinics practitioners initially (c) unable to understand and converse in English and
Mandarin (d) mentally confused and disorientated and (e) smokers will be excluded from
this study.

Potential subjects were referred by the doctor to the nurse interventionist. Sample of
invitation letter can be found in Appendix C1. The nurse interventionist will recruit
subjects according to the inclusion and exclusion criteria. The subjects will be
randomized into 2 groups. Randomization is done using sealed envolopes method in
batches of 10. After obtaining written consent, the nurse interventionist will draw a sealed
envelop with instructions to employ the type of “intervention” to be given: usual health
education or Brief MI counseling strategy. A flow chart on the recruitment process can be
found in Appendix C2. As this project is a pilot study, limited manpower is allocated.
Only 1 nurse interventionist is employed for this study.

From Mhurchu, Margetts & Speller (1998) it is postulated that the MI group will have a
further 10% reduction in all laboratory data (TC, LDL, HDL and TG levels) compared to
the control group. Setting the standard deviation of the difference in all laboratory data
between the two groups to be 10%, 20 subjects in each group will be required for a power
of 80% and a 2-sided test of 5%.

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Master of Nursing
MDN 5105: Research Project HT043999E
2.3 Data Collection Methods
Baseline data which include demographic data will be collected by the nurse prior to
giving intervention to both groups. Primary outcome measures such as TC, LDL, HDL,
and TG levels are analysed by National University Hospital laboratories from subjects’
blood taken by the NHG diagnostic laboratories. These readings are considered clinically
reliable and valid for Singapore clinical context.

Secondary data include dietary and exercise habits will be collected through
questionnaires. Dietary habits consist of assessing (1) fat intake and (2) fruits and
vegetables intake. After 3 months, subjects will return to the clinic for follow up, final
post-intervention outcomes will be collected by the data collection nurse (another nurse
different from the nurse interventionist).

Dietary Fat Intake Questionnaire (Appendix D1)

The Northwest Lipid Research Clinic a fat intake score is selected for this study due to its
ease of self-administration, able to score under 3 minutes without a trained interviewer.
The fat intake score is a brief dietary questionaire to screen and monitor diet intake
related to plasma cholestrol (Retzlaff, Dowdy, Walden, Bovbjerg and Knopp, 1997).
Reliability of this scale has a test-retest correlation coeeficients of 0.88 for men and 0.90
for women. Correlation with 4-day food records in total fat, saturated fat and cholesterol
ranged from 0.42 to 0.60. These validity coefficients though lower than intensive
instruments, however, they may be acceptable withing the outpatient clinical setting for
general setting (Calfas, Zabinski and Rupp, 2000). As this questionaire is used in United
Kingdom context, certain examples of food and units of measurement (e.g. ounces) are
not acceptable in local context. NHGP dietician was consulted to replace the terms to
local setting.

Fruit and Vegetable Intake Questionnaire (Appendix D2)

Intake of 2 servings of fruits and 2 servings of vegetables daily is recommended
according to Ministry of Health (Health Promotion Board, 2005). The questionaire for
fruit and vegetable intake is designed to ask subjects to specify the frequency and amount

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Master of Nursing
MDN 5105: Research Project HT043999E
of fruit and vegetable intake. NHGP dietician was consulted to verify the content validity
of this questionnaire.

Exercise Habits Questionnaire (Appendix D3)

Internatonal Physical Activity Questionnaire (IPAQ), short version, was selected for this
study to assess subjects’ exercise habits. The test re-test reliability coefficient for this
instrument acorss European countries ranged from 0.67 to 0.95 (Oja, 2003). Total weekly
activity in MET minutes for vigorous and moderate intensity activity and walking will be
estimated using this instrument. Daily sitting time can be used as a measure of inactivity.

2.4 Data Analysis Plan

All analyses will be performed using SPSS 13.0. 2 Sample T-test will be applied to
compare the differences in the change between baseline and 3 month of LDL, HDL, TG
and Total cholesterol when normality (checked using Komolgorov Smirnov 1 Sample
test) and homogeneity assumptions are satisfied, otherwise Mann Whitney U test will be
applied. A multiple regression analysis will be performed to adjust for relevant
covariates*.

McNemar test will be applied to assess the change in dietary and exercise habits with
each group. Statistical significance will be set at p < 0.05.

* As multiple regression analysis method had not been taught. This statistical analysis will not be
performed for this study. This is approved by the Research Supervisor.

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Master of Nursing
MDN 5105: Research Project HT043999E
3. Results
3.1 Baseline analyses
The usual care and intervention groups were compared on demographics, levels of lipid
levels, body mass index (BMI) and fat score at baseline (Table 1 and 2). Within the Brief
MI intervention group, 3 (75%) were male and 1 (25%) was female. The intervention
group has a higher proportion of men compared to the usual care group which has 100%
female subjects. All the subjects in this study are mainly Chinese; only 1 subject in the
intervention group is an Indian. The usual care group appears to be less educated than the
intervention group. All of them are primary level educated, whereas 50% of the Brief MI
intervention group is educated at secondary level or higher. The mean age of subjects in
the usual care group is 55, which is older than the Brief MI intervention group with a
mean age of 49.5. Both groups have about the same mean BMI, 23.62 (control) and 23.94
(intervention), which falls above the health BMI range of 19.5 to 22.9. There are no
statistically significant differences in the demographic characteristics, age and BMI
between 2 groups.

Baseline comparisons on the lipid levels and fat scores are done between 2 groups to
establish similarities and potential confounding factors (Table 2). Generally the Brief MI
intervention group has a poorer lipid profile compared to the usual care group. Higher
mean TC levels (6.91mmol/L), LDL levels (4.30mmol/L), HDL levels (1.54mmol/L), and
TG levels (1.44mmol/L) are reported in the intervention group. This is in comparison
with the usual care group, with mean TC levels of 6.07mmol/L, LDL levels of
4.00mmol/L, HDL levels of 1.46mmol/L and TG levels of 1.34mmol/L. Again,
statistically significant differences in these lipid levels cannot be established. Though the
subjects in the intervention group have a poorer lipid profile, they reported better fat
scores with a mean fat score of 26.75 compared to the usual care group with a mean fat
score of 29.0.

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Master of Nursing
MDN 5105: Research Project HT043999E

Table 1: Demographic Characteristics of Subjects

Health Education Motivational Interviewing Sig.
(n=2) (n= 4)
Gender 0.40*
Male - 3 (75%)
Female 2 (100%) 1 (25%)
Race 1.0*
Chinese 2 (100%) 3 (75%)
Indian - 1 (25%)
Educational Level 0.47**
Primary 2 (100%) 2 (50%)
Secondary - 1 (25%)
Tertiary - 1 (25%)
Mean Age ± SD 55 ± 4.24 49.5 ± 7.14 0.39**
(52 to 58) (39 to 55) *
Mean BMI ± SD 23.62 ± 1.24 23.94 ± 2.21 0.86**
(22.74 to 24.49) (20.88 to 25.65) *
(a to b)= (min value to max value)
* Using Chi-Square Fisher’s Exact Test of significance, p>0.05
** Using Pearson Chi-Square Test of significance, p>0.0.5
*** Using Independent sample T-test of significance, p>0.05.Equal variances assumed, as Levene’s Test
for equality of variances >0.05.

Table 2: Baseline Lipid Levels and Fat Scores between 2 Groups

Motivational Sig.
Health Education
Interviewing
(n=2)
(n= 4)
Lipid Levels
Mean TC (mmol/L) ± SD 6.07 ± 0.35 6.91 ± 0.85 0.27+
(5.82 to 6.32) (5.88 to 7.94)
Mean LDL (mmol/L) ± SD 4.00 ± 0.32 4.30 ± 0.56 0.54+
(3.78 to 4.23) (3.65 to 5.01)
Mean HDL (mmol/L) ± SD 1.46 ± 0.07 1.54 ± 0.51 0.85+
(1.41 to 1.51) (0.96 to 2.10)
Mean TG (mmol/L) ± SD 1.34 ± 0.23 1.44 ± 0.42 0.78+
(1.18 to 1.50) (0.88 to 1.84)
Fat Score ± SD 29.0 ± 1.41 26.75 ± 1.71 0.19+
(28 to 30) (25 to 29)
(a to b)= (min value to max value)
+:Using Independent sample T-test of significance, p>0.05. Equal variances assumed, Levene’s Test for
equality of variances for all variables >0.05.

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Master of Nursing
MDN 5105: Research Project HT043999E
3.2 Follow-up data
3.2.1 Lipid Levels and Weight
Table 3 contains the descriptive statistics as well as the difference scores from baseline to
3-month follow up for total cholesterol (TC), low-density lipoprotein (LDL), high-density
lipoprotein (HDL), triglyceride (TG) and weight values in both groups. The subjects in
the usual care group appear to perform better than the subjects in the intervention group.
There was no statistically significant in the differences of improvements in the TC, HDL
and TG levels between both groups.

For LDL levels, the intervention group has increased LDL levels instead of a reduction.
One of the subjects in the intervention group skewed the levels by having a post-LDL
value of 5.13mmol/L with a pre-LDL value of 3.65mmol/L. When statistical tests were
run without this subject, there was an improvement in LDL levels in the intervention
group by 0.26mmol/L. However, this difference is not statistically significant with z score
of -0.124, p-value 0.91.

The intervention group has a reduction of weight in the subjects by 0.68kg (1.11%
reduction) compared to the usual care group with an increased of 0.17kg. This difference
is also statistically insignificant.

When non-parametric is assumed for this analysis, Mann-Whitney U test of significance

also showed no statically significant between the differences of mean rank score of TC,
LDL, HDL, TG and weight between 2 groups (Table 4). The mean rank score for both TC
and weight variables, 3.5, were similar for both groups. Although Table 4 showed that the
usual care group did better than the intervention group in LDL, HDL and TG values, the
mean rank score differences range from only 0.75 to 1.5.

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Master of Nursing
MDN 5105: Research Project HT043999E
Table 3: Mean values of Lipid Levels and Weight changes between
Baseline and 3-month follow-up
Health Motivational
Test statistic P-value+
Education Interviewing
TC Levels
Baseline M ± SD 6.07 ± 0.35 6.91 ± 0.85 t = -1.28 0.27
Post M ± SD 5.84 ± 0.34 6.74 ± 0.78 t = -1.48 0.21
Δ score ± SD -0.23 ± 0.69 -0.17 ± 0.46 z = -0.13 0.91
% Reduction 3.79% 2.46%
LDL Levels
Baseline M ± SD 4.00 ± 0.32 4.30 ± 0.56 t = -0.67 0.54
Post M ± SD 3.68 ±0.36 4.47 ± 0.52 t = -1.90 0.13
Δ score ± SD -0.33 ± 0.68 0.17 ± 0.98 z = -0.64 0.56
% Reduction 8.25% -3.95%
HDL Levels
Baseline M ± SD 1.46 ± 0.07 1.54 ± 0.51 t = -0.20 0.85
Post M ± SD 1.60 ± 0.06 1. 61 ± 0.53 t = -0.04 0.97
Δ score ± SD 0.14 ± 0.18 0.07 ± 0.14 z = 0.52 0.63
% Reduction 9.59% 4.54%
TG Levels
Baseline M ± SD 1.34 ± 0.23 1.44 ± 0.42 t = -0.30 0.78
Post M ± SD 1.23 ± 0.08 1.42 ± 0.14 t = -1.78 0.15
Δ score ± SD -0.12 ± 0.30 -0.02 ± 0.29 z = -0.38 0.72
% Reduction 8.96% <0.01%
Weight
Baseline M ± SD 54.50 ± 4.24 61.15 ± 11.75 t = -0.74 0.50
Post M ± SD 55.4 ± 2.69 60.47 ± 11.22 t = -0.60 0.58
Δ score ± SD 0.9 ± 1.56 -0.68 ± 0.64 z = 1.91 0.13
% Reduction -0.17% 1.11%
+ Equal variances assumed, Levene’s Test for equality of variances for all variables >0.05.

Table 4: Differences in Rank Scores1 of Changes between Baseline

and 3-month follow-up
HE+ MI+ P-value.+
Mean Sum of Mean Sum of
Rank Score Ranks Rank Score Ranks
TC 3.5 7 3.5 14 1.0
LDL 4.5 9 3.0 12 0.53
HDL 4.25 8.5 3.13 12.5 0.53
TG 4.00 8 3.25 13 0.8
Weight 3.5 7 3.5 14 1.0
1. Scores are ranked in order of 1 – lowest degree of change to 6 – highest degree of change
+ Using Mann-Whitney U Test of Significance.

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Master of Nursing
MDN 5105: Research Project HT043999E
3.2.2 Fat Dietary Intake
A score of 24 or less in the Northwest Lipid Research Clinic fat intake score indicates a
diet intake of moderate to low fat and cholestrol. Table 5 shows the fat intake scores for
both at baseline and follow up were above 24 for the usual care group (29, 26.5),
although there was a 2.5 reduction in the score. The intervention group has an
improvement of 3.5 score rating from 26.75 to 23.25. Statistically significane in the
changes of fat score between these 2 groups cannot be established.

Table 5: Mean values of Fat Score changes between Baseline and 3-

month follow-up
Health Motivational Test statistic P-value+
Education Interviewing
Baseline M ± SD 29.00 ± 1.41 26.75 ± 1.71 t = 1.59 0.19
Post M ± SD 26.50 ± 3.54 23.25 ± 2.22 t = 1.44 0.22
Δ score ± SD -2.5 ± 4.95 -3.5 ± 2.38 z = 0.36 0.74
Fat score less than 26 considered adherence to low fat diet.
+ Equal variances assumed, Levene’s Test for equality of variances for all variables >0.05.

3.2.3 Fruit and Vegetable Intake

Table 6 and 7 show the changes in fruit intake frequencies and amount in the 2 groups at
baseline and 3-month follow up. Subjects in both groups showed improvements at 3-
month follow up, reaching the ideal fruit intake frequency. For fruit amount intake, 1
subject (50%) in the usual care group did not reach the adequate fruit amount intake of 2
servings after usual care intervention. Whereas the subjects in the brief MI counseling
group all the subjects maintain/ reach adequate fruit amount intake. The differences in
this change of fruit amount intake are insignificant using McNemar test of significance.

Table 6: Changes in Fruit Intake Frequencies in 2 Groups between

baseline and 3-month follow-up
Health Education
Post-Intervention Fruit Intake Frequency
Pre-Intervention Fruit Intake Frequency Ideal Non-ideal
Ideal1 1a 0
Non-ideal2 1a 0
Motivational Interviewing
Post-Intervention Fruit Intake Frequency
Pre-Intervention Fruit Intake Frequency Ideal Non-ideal
a
Ideal 2 0
Non-ideal 2a 0

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Master of Nursing
MDN 5105: Research Project HT043999E
1. Ideal: Consume fruits daily. 2. Non-ideal: Consume fruits less than daily.
a: p>0.05 using McNemar Test of Significance for both groups
Table 7: Changes in Fruit Amount Intake in 2 Groups between
baseline and 3-month follow-up
Health Education
Post-Intervention Fruit Amount
Pre-Intervention Fruit Amount Adequate Not Adequate
Adequate 1 1a 0
2
Not Adequate 0 1a
Motivational Interviewing
Post-Intervention Fruit Amount
Pre-Intervention Fruit Amount Adequate Not Adequate
Adequate 2a 0
Not Adequate 2a 0
1. Adequate: Consume 2 or more servings of fruits
2. Not Adequate: Consume less than 2 servings of fruits
1 serving of fruit =
a: p>0.05 using McNemar Test of Significance for both groups

All the subjects reported daily intake of vegetables at baseline for both groups. This
fulfills the recommendations by the Ministry of Health. However, 1 subject (50%) in the
usual care group and 2 subjects (50%) from the intervention group do not fulfill the
adequate vegetable amount intake. There was no change of vegetable amount intake after
usual care intervention in this subject, whereas the 2 subjects from the brief MI
counseling group reach the adequate vegetable amount intake at 3-month follow up.
These differences were also not statistically significant.

Table 8: Changes Vegetable Amount Intake in 2 Groups between

baseline and 3-month follow-up
Health Education
Post-Intervention Veg Amount
Pre-Intervention Veg Amount Adequate Not Adequate
1 a
Adequate 1 0
Not Adequate 2 0 1a
Motivational Interviewing
Post-Intervention Veg Amount
Pre-Intervention Veg Amount Adequate Not Adequate
Adequate 2a 0
a
Not Adequate 2 0
1. Adequate: Consume 2 or more servings of vegetables.
2. Not Adequate: Consume less than 2 servings of vegetables.
1 serving of vegetables =
a: p>0.05 using McNemar Test of Significance for both groups

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Master of Nursing
MDN 5105: Research Project HT043999E

3.2.4 Exercise Habits

Estimation for total weekly activity in MET minutes for vigorous and moderate intensity
activity and walking was supposed to be done. However, the subjects for this study had
difficulty recalling the amount of time they spent on physical activity. Thus, only
frequencies for intensive and moderate activities were captured.

All the subjects in the 2 groups did not engage in some form of intensive activities at
baseline or 3-month follow up. Changes in engagement of moderate activities were
present and shown in Table 9. 1 subject in the usual care group did not engage in
moderate activities at baseline. This health behavior did not change at 3-month follow up.
For the intervention group, 3 subjects whom did not engage in moderate activities,
engage in some form of activities at 3-month follow up. The remaining only subject in
the intervention group whom did engage in moderate activities at baseline, reported not
engaging in moderate activities at 3-month follow up.

Tables 9: Changes in engagement of Moderate Activities in 2 Groups

between baseline and 3-month follow-up
Health Education
Post-Intervention Moderate Activities
engagement
Pre-Intervention Moderate Activities engagement1 Yes No
Yes 1a 0
No 0 1a
Motivational Interviewing
Post-Intervention Moderate Activities
engagement
Pre-Intervention Moderate Activities engagement Yes No
Yes 0 1a
No 3a 0
1. Moderate exercise - activities that take moderate physical effort and make you breathe somewhat harder
than normal. E.g. cycling at regular pace, swimming, etc. Do not include walking
a: p>0.05 using McNemar Test of Significance for both groups.

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Master of Nursing
MDN 5105: Research Project HT043999E

4. Discussion
Lifestyle changes counseling or education for people with hyperlipidemia is based on 3
assumptions: education increases knowledge, increased knowledge leads to an
improvement in dietary and exercise habits and finally the changed health habits lead to a
reduction in the lipid levels. Even though the results suggested that the brief MI
counseling strategy group did better in the fat score, fruit and vegetable amount intake
and engaging in moderate exercise compared to the usual care group. These also suggest
that brief MI counseling intervention can change health behaviors. The fact that statically
significance cannot be established, brief MI counseling strategy cannot be viewed as
more effective or superior to the usual health education. Although it can be ascertain that
brief MI counseling strategy is not less effective or inferior to the usual health education.

Furthermore, evidence for MI counseling strategy in the area of diet, exercise and other
lifestyle behaviors is mixed (Burke, Arkowitz and Dunn, 2002). The findings in this study
are similar to the Mhurchu, Margetts and Speller’s (1998) study on hyperlipidemia
patients with MI as the intervention studied. There was also no significant difference in
the reductions of lipid levels between the 2 groups.

The timing between the effects of changed health behaviors on the lipid levels is an
important consideration for this study. This study assumed that the effects of changed
health behaviors will happen at 3 month. However there is this possibility that the
intervention group after changes in health behaviors might lead to decrease in the lipid
levels at a later time or more sustained reduction of lipid levels which cannot be
established in this study than the usual care group.

Effectiveness of Motivational Interviewing Study Page 16 of 19

Master of Nursing
MDN 5105: Research Project HT043999E

5. Limitations
The original calculated sample size of 40 (to obtain 80% power) was not achieved and
this reduced the power of the study. The reduction in study power suggests that results
should be interpreted with some caution since it is possible that the smaller sample size
may have reduced the power to detect as statistically significant difference. Few factors
contribute to the small sample size: (1) too stringent inclusion and exclusion criteria (2)
small incidence of pure hyperlipidemia patients in Yishun polyclinic.

Health behaviors can be influenced by a lot of factors that are uncontrolled in the clinical
setting. One subject in the intervention group which had extremely post high LDL value
reported taking daily evening primrose pills to bring down her cholesterol. The subject in
the intervention group which pre-intervention engage in moderate activities stopped
engaging in moderate activities due to a change of his work nature. Lastly, one of the
subjects in the usual care group is the wife of another subject in the intervention group.
Although both of them have reductions in the LDL values and improvement in health
habits, the changes due to the interventions cannot be ascertain as family support might
be factor in resulting in these changes.

6. Conclusion
In conclusion, there are evidences to suggest brief MI counseling strategy can change
health behaviors. The small sample size is the main concern for this study results. The
study should be done in a larger scale. Time period for assessment in a change of health
behaviors for the next project can be done at a more regular period of 1 week post
intervention, 3 months and 6 months. The lipid levels can also be considered to measure
also at a 6-month period to determine the effects of the change health behaviors. Lastly,
subjects who lived in the same household should be captured and analysis can be adjusted
accordingly.

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Master of Nursing
MDN 5105: Research Project HT043999E
Brief MI counseling strategy, at preliminary stage, showed that there might be used in
changing health behaviors. However, the effectiveness of this strategy cannot be
established as more superior than the usual health education. But it can be ascertain that it
is not less inferior to usual health education.

Effectiveness of Motivational Interviewing Study Page 18 of 19

Master of Nursing
MDN 5105: Research Project HT043999E

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