Review of the Implementation of Motivational Interviewing as a Personalised Behaviour Change Counselling Approach for Disease Control in South African Primary Health Care

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While counselling is mandated in key disease initiatives, primary health care services often employ directive, information-based methods that do not sufficiently encourage lasting behaviour change. Motivational Interviewing is a person-centred, evidence-based approach that enhances motivation, fosters adherence, and supports active engagement in care. However, the extent of its application in South African PHC remains underexplored. This review synthesises current evidence on MI’s usage in South African primary health care, emphasising its effectiveness, identifying implementation gaps, and its potential to enhance person-centred disease management. Methods This scoping review followed the Arksey and O’Malley framework and PRISMA-ScR guidelines. The research question was formulated with an expansive scope to comprehensively map MI’s application, ensuring alignment with policy-oriented aims to integrate MI systematically into PHC. Electronic databases and grey literature were searched for studies published from 2000 to 2025 on MI or similar counselling in South African PHC and community public sector settings. Data were collected and summarised against established objectives to generate critical insights to inform policy and practice improvements. Results Of the 38 identified records, 21 studies met the inclusion criteria. Among these, 81% used MI as brief, MI-informed counselling in routine PHC services rather than full-protocol MI. Reported benefits included improved medication adherence, increased engagement and retention in care, and stronger patient-provider relationships. Challenges included limited staff training, inadequate supervision or monitoring, and reliance on project-based delivery. Conclusion Motivational Interviewing is practical and can be scaled up to support behaviour change in South African PHCs, particularly to improve adherence and long-term care engagement. However, its effectiveness is constrained by uneven implementation and insufficient system support. Integrating MI into national policies, PHC routines, and workforce training could strengthen person-centred care and improve disease control. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/15-453", "name": "Review of the Implementation of Motivational Interviewing as a Personalised..." } } ] } Home Browse Review of the Implementation of Motivational Interviewing as a Personalised... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Tshitangano TG. Review of the Implementation of Motivational Interviewing as a Personalised Behaviour Change Counselling Approach for Disease Control in South African Primary Health Care [version 1; peer review: 1 not approved] . F1000Research 2026, 15 :453 ( https://doi.org/10.12688/f1000research.178323.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Review Review of the Implementation of Motivational Interviewing as a Personalised Behaviour Change Counselling Approach for Disease Control in South African Primary Health Care [version 1; peer review: 1 not approved] Takalani Grace Tshitangano https://orcid.org/0000-0002-6517-4242 Takalani Grace Tshitangano https://orcid.org/0000-0002-6517-4242 PUBLISHED 30 Mar 2026 Author details Author details Department of Public Health and health systems, University of Limpopo Faculty of Health Sciences, Polokwane, Limpopo, 0727, South Africa Takalani Grace Tshitangano Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Health Services gateway. Abstract Addressing the pervasive issue of low medication adherence is a critical step in reducing South Africa’s disease burden. While counselling is mandated in key disease initiatives, primary health care services often employ directive, information-based methods that do not sufficiently encourage lasting behaviour change. Motivational Interviewing is a person-centred, evidence-based approach that enhances motivation, fosters adherence, and supports active engagement in care. However, the extent of its application in South African PHC remains underexplored. This review synthesises current evidence on MI’s usage in South African primary health care, emphasising its effectiveness, identifying implementation gaps, and its potential to enhance person-centred disease management. Methods This scoping review followed the Arksey and O’Malley framework and PRISMA-ScR guidelines. The research question was formulated with an expansive scope to comprehensively map MI’s application, ensuring alignment with policy-oriented aims to integrate MI systematically into PHC. Electronic databases and grey literature were searched for studies published from 2000 to 2025 on MI or similar counselling in South African PHC and community public sector settings. Data were collected and summarised against established objectives to generate critical insights to inform policy and practice improvements. Results Of the 38 identified records, 21 studies met the inclusion criteria. Among these, 81% used MI as brief, MI-informed counselling in routine PHC services rather than full-protocol MI. Reported benefits included improved medication adherence, increased engagement and retention in care, and stronger patient-provider relationships. Challenges included limited staff training, inadequate supervision or monitoring, and reliance on project-based delivery. Conclusion Motivational Interviewing is practical and can be scaled up to support behaviour change in South African PHCs, particularly to improve adherence and long-term care engagement. However, its effectiveness is constrained by uneven implementation and insufficient system support. Integrating MI into national policies, PHC routines, and workforce training could strengthen person-centred care and improve disease control. READ ALL READ LESS Keywords Motivational interviewing; primary health care; behavior change counselling; therapy adherence; disease control; South Africa Corresponding Author(s) Takalani Grace Tshitangano ( [email protected] ) Close Corresponding author: Takalani Grace Tshitangano Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2026 Tshitangano TG. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Tshitangano TG. Review of the Implementation of Motivational Interviewing as a Personalised Behaviour Change Counselling Approach for Disease Control in South African Primary Health Care [version 1; peer review: 1 not approved] . F1000Research 2026, 15 :453 ( https://doi.org/10.12688/f1000research.178323.1 ) First published: 30 Mar 2026, 15 :453 ( https://doi.org/10.12688/f1000research.178323.1 ) Latest published: 30 Mar 2026, 15 :453 ( https://doi.org/10.12688/f1000research.178323.1 ) 1. Introduction 1.1 Background South Africa has a complex health profile, with a lasting quadruple burden of disease: communicable diseases (especially HIV and tuberculosis), non-communicable diseases, mental health conditions, and injuries ( Mayosi et al., 2012 ; Bradshaw et al., 2022 ). Even with improved access to biomedical care, disease control outcomes remain below expectations in many programs, especially in the public-sector PHC ( Hanmer & Whittaker, 2020 ). Additional evidence indicates that factors such as nonadherence to treatment, delays in seeking care, unhealthy behaviors, and poor retention significantly affect disease outcomes ( Vos et al., 2020 ; Bradshaw et al., 2022 ). In South Africa, these problems are exacerbated by inequality, poverty, stigma, multiple illnesses, and health system challenges, placing additional pressure on PHC services to support sustained behavior change ( Ngene et al., 2023 , pp. 1–10). National health policies stress the importance of counselling and psychosocial support in disease control for HIV, TB, NCDs, and mental health programs ( Department of Health [DoH], 2016 ; DoH, 2023 ). Still, the effectiveness of counselling in routine PHC services varies, raising concerns about whether current approaches are suitable and consistent ( Sorsdahl et al., 2015 ). 1.2 Problem statement Although counselling is required in major disease programs, South African PHC primarily uses information-giving and prescriptive methods, known as information–education communication (IEC) strategies ( WHO, 2010 ; Ticha et al., 2022 ). These methods assume that more knowledge leads to behavior change. Still, evidence indicates that knowledge alone is insufficient for sustained adherence, lifestyle change, or long-term care, particularly when ambivalence, stigma, or economic hardship are present ( Miller & Rollnick, 2013 ). By contrast, Motivational Interviewing has been shown to significantly reduce relapse rates across various health settings by actively engaging patients in their care processes ( Sorsdahl, Stein, Corrighall, Cuijpers, Smits, Naledi, & Myers, 2015 ). This highlights the potential inadequacies of IEC approaches and underscores the need to integrate MI into South African PHC to drive meaningful and sustainable behavior change ( Da Silva, Schneider & Okello, 2015 ). Because of this, South Africa still faces high rates of loss to follow-up in TB and HIV programs, low rates of viral suppression and treatment completion, and poor control of chronic NCDs like diabetes and hypertension ( Mwansa-Kambafwile et al., 2020 ; Bradshaw et al., 2022 ; Malan et al., 2024 ). Health workers often report a lack of confidence and skills to manage patient resistance, ambivalence, and withdrawal, which makes counselling less effective ( Tichá et al., 2022 ). Although there is international evidence for other counselling methods, there is little summary of how these, particularly Motivational Interviewing, are used in South African PHC. 1.3 Rationale Motivational Interviewing (MI) is a collaborative, person-centered counselling method that helps people find their own motivation for change by working through ambivalence ( Miller & Rollnick, 2013 ). MI has been shown to be effective for many health behaviours, including medication adherence, reducing substance use, changing lifestyle behaviours, and engaging in chronic disease care ( Lundahl et al., 2013 ). MI is especially well-suited to PHC contexts because it: • Can be delivered as brief interventions within routine consultations. It is consistent with task-shifting and multidisciplinary team models. • Emphasises empathy, partnership, and autonomy, which are central to people-centred care. This alignment directly supports the PHC re-engineering goals by enhancing patient satisfaction, improving health outcomes, and fostering provider collaboration, which are key PHC performance indicators. In South Africa, MI aligns well with PHC re-engineering, ward-based outreach teams, new service delivery models, and National Health Insurance (NHI) goals focused on quality, efficiency, and patient experience ( DoH, 2011 ; DoH, 2023 ). Although MI is mentioned more often in policy and training, its actual use, range, and impact in South African PHC remain scattered and poorly summarised ( Da Silva, Schneider, & Okello, 2015 ). 1.4 Contribution to the body of knowledge This review is the first to fully summarise the use of MI in South African PHC and community public health services. It addresses the decisive policy gap of how Motivational Interviewing can be systematically integrated into national health frameworks to enhance behaviour change strategies in PHCs. By demonstrating the practicality and scalability of MI within the current health care models, this review answers the critical policy question: How can MI be implemented comprehensively to bolster existing national health strategies? It shows that MI is mostly used as brief, MI-informed counselling in regular care, especially in HIV and non-communicable disease programs, with some new use in TB services. The review identifies systemic gaps, including limited training, insufficient supervision and monitoring, and project-based delivery. The data show MI to be a practical and scalable counselling method that aligns with PHC re-engineering, people-centred care, and National Health Insurance goals ( Rollnick et al., 2008 ). The review outlines steps to integrate MI into policy, workforce training, and research to improve disease control in South Africa. 1.5 Aim of the review This scoping review aimed to systematically map and synthesise the existing evidence on the use of Motivational Interviewing as a behaviour-change counselling approach for disease control within South African primary health care and community-based public health services. 1.6 Objectives The objectives of the review were to: a. Identify how Motivational Interviewing has been applied within South African PHC and community health settings. b. Describe the disease programs and populations in which MI has been used. c. Summarise reported outcomes associated with MI-based interventions for disease control, including adherence, retention in care, and patient engagement. For each reported outcome, align it with a measurable indicator, such as the percentage of patients retained in care, adherence improvement rates, and patient engagement levels assessed using standardised tools or surveys. These metrics will provide a clearer framework for evaluating the effectiveness of MI-based interventions. Identify implementation facilitators, barriers, and gaps to direct future policy, practice, and research. 2. Materials and methods 2.1 Study design A scoping review was conducted to map the extent, nature, and characteristics of the evidence on the use of Motivational Interviewing (MI) as a behaviour change counselling approach within South African primary health care (PHC) services. The review followed the five-stage framework proposed by Arksey and O’Malley (2005): (1) identifying the research question; (2) determining relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarising, and reporting results. Reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). 2.2 Identifying the research question In accordance with the first stage of the Arksey and O’Malley (2005) scoping review framework, the research question was formulated to be broad, exploratory, and encompassing, representing the purpose of a scoping review to map the extent, range, and nature of evidence rather than to assess intervention effectiveness. The research question was informed by: a. South Africa’s burden of disease and policy emphasis on counselling within primary health care (PHC); b. Emerging use of Motivational Interviewing (MI) in local programs; and c. The absence of a consolidated synthesis of MI use within South African PHC services. The primary research question guiding this review was: How has Motivational Interviewing been used as a behaviour change counselling approach for disease control within South African primary health care and community-based public health services ? To operationalise this broad question and guide systematic study identification and data charting, the following sub-questions were specified: a. In what ways has Motivational Interviewing been applied within South African PHC and community health settings? b. Which disease programs and populations have been targeted by MI-based interventions? c. What outcomes related to disease control (e.g., adherence, retention in care, engagement) have been reported in association with MI-based counselling? d. What implementation facilitators, barriers, and gaps are reported in the South African context? The author intentionally framed these questions to capture both intervention characteristics and health system considerations, guaranteeing alignment with the review’s objective of informing policy, practice, and future research. The research questions also guided the development of the search strategy, eligibility criteria, data extraction framework, and thematic synthesis. The author selected a scoping review approach because the aim was to map how Motivational Interviewing has been applied within South African PHC, identify gaps, and inform implementation, rather than to evaluate the effectiveness of the intervention. 2.3 Determining relevant studies The author conducted electronic database searches in PubMed/MEDLINE, Scopus, Web of Science, PsycINFO, CINAHL, Sabinet, and African Journals Online. In addition, the author identified grey literature through searches of South African Department of Health repositories, provincial health department reports, the Human Sciences Research Council, the World Health Organisation, UNAIDS, and university institutional repositories. Searches covered the period from January 2000 to December 2025 and were limited to English-language publications from South Africa. The starting point of 2000 coincides with the introduction of significant health policy reforms in South Africa, including key strategies for controlling communicable and non-communicable diseases. The full search strategy for all databases is provided in Appendix A. Eligibility criteria Studies were eligible for inclusion if they: a. were conducted in South Africa; b. examined Motivational Interviewing or MI-consistent counselling approaches; c. were implemented within PHC or community-based public health settings; and d. addressed disease prevention, compliance with treatment, retention in care, or long-term condition management. Studies conducted exclusively in specialist or tertiary psychotherapy settings, or those without a clear MI component, were excluded. 2.4 Study selection Following duplicate removal, titles and abstracts were screened against the inclusion criteria. Full-text articles were then assessed for eligibility. Reasons for exclusion at the full-text stage included lack of MI content and non-PHC settings. Thus, records identified through database searching (n = 32); additional records identified through grey literature (n = 6); total records identified (n = 38); duplicates removed (n = 5); records screened (title/abstract) (n = 33); records excluded (n = 7); full-text articles assessed for eligibility (n = 26); full-text articles excluded (n = 5; reasons: not MI-focused or not PHC); studies included in the scoping review (n = 21). This study selection process is summarised in a PRISMA-ScR flow diagram in Appendix B ( Figure 1 ). Figure 1. Prisma flow diagram. 2.5 Data charting and synthesis The author used a structured data charting form to extract information on study design, setting, population, disease focus, description of the MI intervention, outcomes, and reported implementation facilitators and barriers. Inter-rater reliability checks and pilot testing of the data extraction form were conducted as safeguards to ensure accuracy and consistency in data charting ( Büchter et al., 2020 ). Extracted data were synthesised narratively, with results grouped thematically by disease focus and implementation characteristics. Risk of bias and methodological considerations Consistent with PRISMA-ScR guidance, a formal risk-of-bias assessment was not conducted, as the primary purpose of this scoping review was to map available evidence rather than to evaluate intervention effectiveness. However, to strengthen transparency and tackle potential methodological weaknesses, the contracted independent reviewer identified sources of bias across the included studies, which were assessed narratively and reported in the limitations section. 3. Results A total of 21 studies met the inclusion criteria and were included in the scoping review. The results are presented in accordance with the review objectives (Appendix C: Table 1 – Charting of Data). 3.1 Application of motivational interviewing within South African PHC and community health settings The included studies demonstrated that Motivational Interviewing (MI) has been applied in South Africa predominantly as brief, MI-informed counselling, rather than as full-protocol MI. On average, these interventions lasted 10–15 minutes, aligning with the time constraints typically observed in South African PHC settings. PHC clinic nurses and community health workers delivered interventions mainly within public-sector primary health care (PHC) facilities and community-based services, including clinics, ward-based outreach teams, and follow-up support programs ( Da Silva et al., 2018 ; Ticha et al., 2022 ). Professional nurses primarily delivered MI-based counselling, while lay counsellors, community health workers, and health promoters undertook this task , reflecting task-shifting practices within the South African PHC system ( Da Silva et al., 2018 ; Ticha et al., 2022 ). MI principles, such as open-ended questioning, reflective listening, affirmations, and elicitation of change talk, were commonly integrated into routine counselling encounters, including treatment initiation, follow-up visits, and defaulter tracing ( Miller & Rollnick, 2013 ; Malan et al., 2024 ). However, few studies reported the use of validated fidelity assessment tools, and MI delivery was often described as “MI-based” or “MI-informed” rather than standardised. 3.2 Disease programs and populations targeted by MI interventions in South Africa MI interventions were most frequently applied within HIV care, particularly for antiretroviral therapy (ART) adherence, retention in care, and re-engagement following loss to follow-up ( DoH, 2016 ; HIV Retention Study, 2025; UNAIDS, 2024 ). A second major focus area was non-communicable diseases (NCDs), including diabetes and hypertension, where MI-informed counselling supported lifestyle modification and long-term medication adherence ( Malan et al., 2024 ; Bradshaw et al., 2022 ). The review identified emerging evidence in: • Tuberculosis (TB) treatment support, including adherence counselling and stigma-sensitive interventions ( Mwansa-Kambafwile et al., 2020 ; Foster et al., 2024 ) • General PHC populations , where MI principles were used to support health-seeking behaviour and continuity of care ( Da Silva et al., 2018 ) Most interventions targeted adult patients, with limited focus on adolescents, youth, maternal health, or individuals with multimorbidity, despite the growing burden of co-existing conditions in South Africa ( Mayosi et al., 2012 ; Vos et al., 2020 ). 3.3 Reported outcomes associated with MI-based interventions Across included studies, MI-based counselling was associated with several positive outcomes relevant to disease control. These included: • Improved therapy adherence, particularly in HIV and NCD programs ( Lundahl et al., 2013 ; Malan et al., 2024 ) • Enhanced retention in care and reduced disengagement, including improved follow-up attendance and re-engagement after treatment interruption ( Mwansa-Kambafwile et al., 2020 ; HIV Retention Study, 2025) • Increased patient involvement and motivation, characterised by greater participation in decision-making and openness in discussing barriers to care ( Miller & Rollnick, 2013 ; Ticha et al., 2022 ) • Strengthened patient–provider relationships, including increased trust and perceived empathy ( Foster et al., 2024 ) Outcome measurement varied substantially across studies. Many relied on self-reported adherence, qualitative accounts, or proxy indicators of engagement, while objective clinical outcomes, such as viral suppression, TB treatment completion, or glycemic control, were inconsistently reported ( Lundahl et al., 2013 ; Malan et al., 2024 ). 3.4 MI implementation facilitators and barriers in South Africa Facilitators of MI implementation included adherence to person-centered care principles, compatibility with brief counselling encounters, and acceptability among both providers and patients ( Miller & Rollnick, 2013 ; DoH, 2023 ). Several studies noted that MI enhanced providers’ confidence in managing ambivalence and resistance, particularly in adherence counselling contexts ( Ticha et al., 2022 ). Common barriers included limited formal training in MI, lack of structured supervision and fidelity monitoring, high workload and time constraints, and inconsistent inclusion into routine service workflows ( Da Silva et al., 2018 ; Ticha et al., 2022 ; Malan et al., 2024 ). MI implementation was often project-based, limiting sustainability beyond the pilot phase ( Mwansa-Kambafwile et al., 2020 ). One pragmatic workflow adjustment that could quickly relieve time pressure for nurses is the integration of MI into existing electronic health record (EHR) systems. This adjustment would enable automated prompts and reminders for MI strategies during consultations, reducing cognitive load and time spent recalling MI techniques and thereby improving efficiency ( Weimann & Petersen, 2017 ). Overall, the results show that MI is primarily utilized in South African PHC as a practical , adapted counselling method integrated into routine services. While studies frequently report improvements in adherence, engagement, and patient experience, the evidence remains fragmented, with considerable variation in intervention design, delivery, and measurement. 4. Discussion This scoping review synthesised evidence regarding the use of Motivational Interviewing (MI) for behaviour change counselling in South African PHC. The results show that MI is predominantly employed as a practical, adapted approach within routine services rather than as a standalone intervention. This approach aligns with the functional realities of South African PHCs, where limited time, high patient volumes, and task shifting necessitate brief, flexible counselling ( Da Silva et al., 2018 ; Ticha et al., 2022 ). MI was most consistently applied within HIV adherence counselling and non-communicable disease (NCD) lifestyle management, with more limited and emerging use in tuberculosis (TB) treatment support. This pattern mirrors national programme priorities and funding streams but additionally highlights missed opportunities for wider application, particularly in TB, mental health, adolescent health, and multimorbidity care ( Mayosi et al., 2012 ; Bradshaw et al., 2022 ). Given that these conditions share common behavioural demands, long-term adherence, sustained self-management, and retention in care, the limited scope of MI use beyond HIV and NCDs amounts to a considerable gap. Across included studies, MI-based counselling was associated with improved medication adherence, enhanced engagement in care, and strengthened patient–provider relationships ( Lundahl et al., 2013 ; Malan et al., 2024 ; Mwansa-Kambafwile et al., 2020 ). These outcomes are consistent with international evidence demonstrating MI’s success in addressing ambivalence and reluctance to change through collaborative, autonomy-supportive communication ( Miller & Rollnick, 2013 ). Notably, several studies reported improvements in engagement, motivation, and trust even where objective clinical outcomes were inconsistently measured, suggesting that MI’s effects may initially manifest through relational and motivational pathways that precede measurable biomedical change ( Ticha et al., 2022 ; Foster et al., 2024 ). However, the review also identified substantial variability in how MI was defined, delivered, and evaluated. Most interventions were described as “MI-informed,” with limited use of structured training, supervision, or fidelity assessment tools. This raises concerns about the dilution of MI’s core components and highlights the risk that MI may be reduced to a general interaction mode rather than implemented as a distinct, evidence-based counselling approach ( Miller & Rollnick, 2013 ; Lundahl et al., 2013 ). The absence of fidelity monitoring adds to the complexity of interpreting outcomes and comparing across studies. Implementation barriers, including limited training, high workloads, and reliance on short-term, project-based initiatives, reveal broader systemic challenges within South African PHC rather than limitations intrinsic to MI itself ( Da Silva et al., 2018 ; Mwansa-Kambafwile et al., 2020 ). Conversely, facilitators such as conformity with person-centred care principles, compatibility with brief consultations, and acceptability to both providers and patients underscore MI’s suitability for PHC when enabling system conditions are present ( Department of Health [DoH], 2016 ; DoH, 2023 ). To summarise, MI shows considerable potential as an expandable counselling method for disease control in South Africa. However, its impact is constrained by inconsistent implementation, insufficient system support, and limited integration into routine PHC practices. 4.1 Strengths and limitations of the review This scoping review has several important strengths. First, it employed a rigorous, transparent methodological approach using the Arksey and O’Malley framework and was reported in line with PRISMA-ScR guidance, thereby enhancing repeatability and methodological credibility. Second, the inclusion of both peer-reviewed and grey literature, including national policy documents and programme reports, enabled a thorough mapping of the use of Motivational Interviewing (MI) in South African primary health care (PHC), extending beyond the academic literature. Third, the review focused explicitly on PHC and community-based public-sector settings, ensuring strong relevance to routine service delivery and health-system implementation. Fourth, by examining MI across multiple disease programs rather than a single condition, the review provides a system-level perspective on behaviour change counselling in a context characterised by multimorbidity. Finally, the explicit consideration of implementation factors, such as workforce training, supervision, fidelity, and workflow integration, improves the review’s utility for decision-makers, managers, and practitioners seeking scalable, sustainable approaches to improve disease control. However, the author acknowledges several limitations. The included evidence base was dominated by qualitative studies, programme evaluations, and small quasi-experimental designs, with few randomised controlled trials conducted in South African PHC settings, limiting causal inference. Selection bias may be present, as many studies relied on convenience samples from single facilities or districts, thereby limiting generalizability. In addition, MI fidelity was rarely assessed, with many interventions described as “MI-informed” rather than formally evaluated against validated competency measures. Outcome reporting was heterogeneous and frequently depended on self-reported adherence or engagement, while objective clinical indicators were inconsistently measured. Follow-up periods were frequently short, limiting assessment of sustained behaviour change. Although the inclusion of grey literature reduced publication bias, some programme reports lacked detailed methodological descriptions. Despite these limitations, the review fulfils its scoping objective by mapping available evidence, identifying gaps, and directing future research and implementation priorities. 4.2 Practice implications • PHC services should move beyond directive information–education–communication approaches (IEC) and adopt Motivational Interviewing (MI) as a structured, evidence-based counseling method that addresses ambivalence and supports sustained behavior change. • PHC clinics and community-based services should operationalize MI by integrating it into existing service points, including adherence counseling, chronic disease reviews, defaulter tracing, ward-based outreach team activities, and differentiated service delivery models, rather than treating it as an additional task. • Nurses, community health workers, health promoters, and adherence counselors require task-appropriate MI training, supported by ongoing supervision and mentoring to maintain competency and adherence under routine workload conditions. • MI operationalizes people-centered care principles and can strengthen therapy adherence, retention, and patient experience, key performance domains under the National Health Insurance contracting and quality assurance mechanisms ( Hanmer & Whittaker, 2020 ). • PHC clinics and community-based services should operationalize MI. MI should be applied across HIV, TB, non-communicable diseases, mental health, and multimorbidity care to maximize its contribution to disease control in South Africa’s PHC system ( UNAIDS, 2023) . 4.3 Recommendations The following recommendations are informed by the findings of this review and consistent with national health system priorities. For policy and governance, South Africa should, • Formally adopt Motivational Interviewing as a core counselling approach within national and provincial guidelines for HIV, TB, NCDs, mental health, and PHC re-engineering ( DoH, 2016 ; DoH, 2023 ). • Position MI as a health system strengthening intervention, explicitly linked to people-centred care, quality improvement, and National Health Insurance performance objectives ( DoH, 2011 ). For Workforce development, the health system should , • Institutionalise MI training within pre-service education, in-service training, and continuing professional development for PHC nurses, community health workers, health promoters, as well as adherence counsellors ( Ticha et al., 2022 ). To ensure training effectiveness, a competency benchmark should be established, utilising a specific fidelity score or skill checklist. This benchmark would serve as an objective measure to signal that training has been effectively implemented and to help implementers consistently evaluate success ( Tricco et al., 2020 ). • Prioritise brief MI competencies suitable for routine PHC consultations, supported by structured supervision and mentoring to maintain skill fidelity ( Miller & Rollnick, 2013 ). For Service delivery and programme integration, the Department of Health should , • Embed MI into routine PHC workflows, including adherence counselling, chronic disease reviews, defaulter tracing, ward-based outreach team activities, and differentiated service delivery models ( Da Silva et al., 2018 ). • Expand MI application beyond HIV and NCDs to TB, mental health, adolescent health, and multimorbidity management to maximise system-wide impact ( Mayosi et al., 2012 ; Bradshaw et al., 2022 ). For Research and evaluation, academic and research institutions should , • Strengthen implementation research using appropriate tools to assess scalability, sustainability, and contextual adaptation of MI in PHC settings ( Tricco et al., 2018 ). • Standardise outcome measurement, incorporating behavioural indicators alongside objective clinical outcomes such as viral suppression, TB treatment completion, and NCD control ( Lundahl et al., 2013 ). • Conduct economic and workload analyses to support policy decisions on investing in counselling capacity within PHC ( Mwansa-Kambafwile et al., 2020 ). 5. Conclusions This scoping review demonstrates that Motivational Interviewing has been implemented in South African primary health care as a flexible, person-centred counselling method, chiefly within HIV and NCD programs. The evidence indicates that MI-based counselling is associated with improved adherence, care engagement, and patient–provider relationships, which are important for disease control in contexts characterised by chronic illness and multimorbidity ( Lundahl et al., 2013 ; Bradshaw et al., 2022 ). Although it has potential, MI is still applied inconsistently, predominantly in short-term projects, and there is limited standardisation in training, supervision, or monitoring. In the absence of comprehensive system-wide integration, the benefits of MI for disease outcomes and PHC performance are unlikely to be fully realised. Establishing MI as a core counselling method may enhance person-centred care, retention, and observance, therewith supporting South Africa’s objectives for universal health coverage and National Health Insurance ( Zuma et al., 2023 ). Institutional review board statement Not applicable. Informed consent statement Not applicable because the study did not involve humans. Data availability statement Extended data Repository name: Mendeley Data [Review of the Implementation of Motivational Interviewing as a Personalised Behaviour Change Counselling Approach for Disease Control in South African Primary Health Care]. https://data.mendeley.com/datasets/t2rkzh976d/2 . This project contains the following extended data: Appendix A. (Search strategy) Appendix B. Figure 1. (PRISMA Flow Diagram) Appendix C. Table 1. (Charting of Data). Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication). • TABLE 1: CHARTING OF DATA (APPENDIX C) Acknowledgements Sincere gratitude goes to the librarian (who does not wish to be named) for providing technical support in identifying relevant studies and conducting an independent review. During the preparation of this manuscript, the author used ChatGPT to polish the language and grammar. 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Zuma K, et al. : Pilot results of Masibambisane: Couples motivational interviewing with mobile breathalyzers to address unhealthy drinking and adherence to antiretroviral therapy in South Africa. JAMA. 2023; 330 (18): 1763–1772. Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 30 Mar 2026 ADD YOUR COMMENT Comment Author details Author details Department of Public Health and health systems, University of Limpopo Faculty of Health Sciences, Polokwane, Limpopo, 0727, South Africa Takalani Grace Tshitangano Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 30 Mar 2026, 15:453 https://doi.org/10.12688/f1000research.178323.1 Copyright © 2026 Tshitangano TG. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Tshitangano TG. Review of the Implementation of Motivational Interviewing as a Personalised Behaviour Change Counselling Approach for Disease Control in South African Primary Health Care [version 1; peer review: 1 not approved] . F1000Research 2026, 15 :453 ( https://doi.org/10.12688/f1000research.178323.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 30 Mar 2026 Views 0 Cite How to cite this report: Marks D. Reviewer Report For: Review of the Implementation of Motivational Interviewing as a Personalised Behaviour Change Counselling Approach for Disease Control in South African Primary Health Care [version 1; peer review: 1 not approved] . F1000Research 2026, 15 :453 ( https://doi.org/10.5256/f1000research.196694.r479515 ) The direct URL for this report is: https://f1000research.com/articles/15-453/v1#referee-response-479515 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 12 May 2026 Dougie Marks , University of Glasgow, Glasgow, Scotland, UK Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.196694.r479515 This article presents a scoping review of the implementation of Motivational Interviewing (MI) as a personalised behaviour-change counselling approach for disease control in South African primary health care and community-based public health settings. The review aims to map how MI ... Continue reading READ ALL This article presents a scoping review of the implementation of Motivational Interviewing (MI) as a personalised behaviour-change counselling approach for disease control in South African primary health care and community-based public health settings. The review aims to map how MI has been used, identify the disease areas and populations targeted, summarise reported outcomes, and identify implementation barriers and facilitators. The article reports that 21 studies met the inclusion criteria from 38 identified records, and concludes that MI has mainly been implemented as brief, MI-informed counselling rather than full-protocol MI, particularly in HIV and non-communicable disease care. The review identifies potentially positive effects on adherence, retention, engagement, and patient–provider relationships, while also highlighting major implementation barriers such as limited training, lack of supervision, poor fidelity monitoring, workload pressures, and project-based delivery. The topic is important and relevant. Behaviour change counselling is highly pertinent to South African primary health care, particularly in relation to HIV, TB, non-communicable disease management, treatment adherence, retention in care, and person-centred care. The article also has a potentially useful implementation focus, moving beyond whether MI “works” in general and asking how it is currently being used in South African PHC. This is a valuable question. However, in its current form, the review has several methodological and evidential weaknesses that need to be addressed before the article can be considered scientifically sound. Major issues that must be addressed 1. The review question and eligibility criteria require tighter operational definition The review states that it includes studies of “Motivational Interviewing or MI-consistent counselling approaches.” This creates a major definitional problem. MI is a specific, theoretically grounded counselling method with identifiable technical and relational components. “MI-consistent counselling” could include a wide range of communication approaches, some of which may not genuinely involve MI. The authors should provide a clear operational definition of what counted as MI, MI-informed counselling, or MI-consistent counselling. For example, did included studies have to mention MI explicitly? Did they need to include training in MI? Did they need to describe specific MI skills such as open questions, affirmations, reflective listening, summaries, eliciting change talk, rolling with resistance/sustain talk, or supporting autonomy? Were any studies excluded because they used generic adherence counselling but not MI? Without this clarification, the review risks overestimating the extent to which MI has actually been implemented in South African PHC. Must address: Define MI and MI-informed counselling clearly, and explain how the distinction was applied during study selection and data charting. 2. The methods are not sufficiently transparent for a scoping review The article states that the full search strategy is provided in Appendix A, and that Appendix C contains the charting table. However, the main manuscript gives limited detail about the actual search strings, database-specific search terms, screening procedure, and data charting process. The PRISMA flow diagram gives the basic numbers, but not enough detail to judge reproducibility. There is also an unclear statement that “inter-rater reliability checks and pilot testing” were conducted, and later that a “contracted independent reviewer” identified sources of bias. This needs clarification. The article appears to be single-authored. It is therefore important to specify who conducted screening, who conducted data extraction, whether any second reviewer was involved, what proportion of records were independently checked, whether disagreements occurred, and how they were resolved. The statement about a “contracted independent reviewer” is especially important because it raises questions about the role of this person in the review process. Was this person involved in screening, data extraction, quality appraisal, bias identification, or manuscript preparation? Were they acknowledged? Were they independent of the author? Must address: Provide a reproducible search strategy in the main text or appendices; clarify screening and extraction procedures; explain the role of any second reviewer or independent reviewer; and state how disagreements or reliability checks were handled. 3. The article makes effectiveness claims that are too strong for the evidence presented The paper is framed as a scoping review, and correctly notes that formal risk-of-bias assessment was not conducted because the aim was mapping rather than effectiveness evaluation. However, the results and conclusions repeatedly imply that MI improved adherence, retention, engagement, and patient–provider relationships. This is not adequately supported in the manuscript as presented. The review does not provide enough study-level detail about intervention design, comparator conditions, sample sizes, outcomes, follow-up periods, effect sizes, or study quality. Many included studies appear to be qualitative studies, programme evaluations, or quasi-experimental designs. The article itself acknowledges heterogeneity, reliance on self-reported adherence, inconsistent objective outcomes, short follow-up periods, and limited fidelity assessment. The authors should therefore soften causal and effectiveness language. Phrases such as “MI improved medication adherence” should be replaced with more cautious wording, such as “included studies reported associations with improved adherence” or “some studies reported perceived or self-reported improvements.” The conclusion that MI “can be scaled up” also requires more caution unless supported by implementation and economic evidence. Must address: Reframe effectiveness claims in line with the scoping review design and the limitations of the underlying evidence. 4. Some citations appear mismatched, weak, or irrelevant to the claims they support A serious concern is that some references do not appear to support the specific claims attached to them. For example, one reference listed as Tichá et al. 2022 concerns fingolimod treatment in multiple sclerosis in the Czech Republic, which appears unrelated to nurses’ perceptions of TB/HIV adherence counselling in South Africa. This suggests a possible referencing error. The manuscript also cites broad international MI reviews and general policy documents in places where South African PHC-specific evidence is needed. Similarly, the recommendation to integrate MI into electronic health record systems appears to be supported by a citation on cloud-based EHRs in South African PHC, but the manuscript does not show evidence that EHR prompts improve MI fidelity, efficiency, or implementation. That recommendation may be reasonable as a speculative implementation idea, but it should not be presented as though it follows directly from the reviewed evidence unless supported by relevant studies. The review also cites some sources in ways that may conflate general disease-burden evidence, policy evidence, and MI implementation evidence. This makes it difficult for the reader to distinguish between contextual background and evidence directly arising from the 21 included studies. Must address: Audit every citation for accuracy and relevance. Remove irrelevant references, correct mistaken references, and ensure that claims about MI implementation and outcomes are supported by included studies rather than by general background literature. 5. The results require a clearer study-level synthesis The results currently summarise broad themes but do not give the reader enough detail about the 21 included studies. The manuscript should include a concise table in the main article or a more detailed summary of the included studies, including author/year, disease area, setting, population, intervention type, provider, MI training/fidelity, outcomes assessed, and main findings. The statement that 81% of included studies used brief MI-informed counselling should be reported more transparently as a count, for example “17 of 21 studies,” if that is the case. The manuscript should also explain how this classification was made. At present, the review often moves between “MI,” “MI-informed counselling,” “brief counselling,” “behaviour change counselling,” and “adherence counselling” without always making clear which studies used which approach. That weakens the synthesis. Must address: Provide a clearer study-level synthesis and distinguish full MI, brief MI, MI-informed counselling, and other counselling approaches. 6. The discussion and recommendations overreach beyond the evidence The recommendations are broadly sensible but sometimes read as policy advocacy rather than evidence-based conclusions from the review. For example, recommending that South Africa should formally adopt MI as a core counselling approach across HIV, TB, NCDs, mental health, and PHC re-engineering may be too strong unless the review demonstrates sufficient evidence across those areas. The paper itself acknowledges that evidence is concentrated in HIV and NCDs, with more limited evidence in TB, mental health, adolescents, maternal health, and multimorbidity. The authors should distinguish between recommendations directly supported by the review and recommendations that are plausible but require further implementation research. Must address: Temper policy recommendations and clearly separate evidence-based conclusions from proposed future directions. Comments on comprehensiveness The review covers important contextual areas, including South Africa’s burden of disease, the limitations of directive information-giving approaches, the relevance of adherence and retention, and the compatibility of MI with person-centred care and task-shifting. It also usefully addresses implementation barriers such as training, supervision, fidelity, workload, and project-based delivery. However, the review would be more comprehensive if it engaged more deeply with the MI implementation literature, especially fidelity, competency, supervision, and adaptation in low-resource or task-shifted settings. The paper should also better distinguish between evidence from South Africa and international evidence used to frame the topic. At present, the literature base feels somewhat uneven: some claims are supported by broad international reviews, some by policy documents, and some by individual South African studies, but the boundaries between these forms of evidence are not always clear. Comments on factual accuracy and citation support No. The main issue is not necessarily that the central argument is wrong, but that the citation practice is not sufficiently reliable. Some references appear mismatched or irrelevant, and several claims require more specific support from the included studies. The authors should perform a full reference audit. Specific examples include: The review should engage with the CAPRISA 058 randomised controlled trial, which appears directly relevant to motivational counselling and ART adherence in South Africa. This study is particularly important because its findings complicate the manuscript’s generally positive interpretation of MI effects. The apparent inclusion of an irrelevant Tichá et al. 2022 multiple sclerosis paper in the reference list. Broad claims about MI improving adherence, engagement, retention, and patient–provider relationships without adequate study-level evidence in the results. Recommendations about EHR-based MI prompts that appear insufficiently supported by the cited literature. Claims about scalability and policy integration that are plausible but stronger than the evidence presented. Comments on language and accessibility The article is generally understandable and uses accessible language. The topic is explained in a way that would be comprehensible to readers interested in primary health care, public health, behavioural counselling, or implementation science. However, the manuscript would benefit from careful editing. There is repetition, especially in the practice implications, where “PHC clinics and community-based services should operationalize MI” appears more than once. Some sentences are overly long or read like inserted planning notes rather than final manuscript text. For example, the objective asking the authors to align each reported outcome with measurable indicators reads more like an instruction than a completed objective. There are also occasional wording issues, such as “observance” where “adherence” would be more appropriate. The language is accessible, but it needs tightening, de-duplication, and a more precise academic style. Comments on conclusions The conclusions are directionally reasonable but somewhat overstated. The review supports the conclusion that MI has potential relevance for South African PHC and that existing implementation appears uneven, project-based, and insufficiently supported by training, supervision, and fidelity monitoring. However, the conclusion that MI is practical and scalable across PHC requires more cautious wording. A more appropriate conclusion would be that the available literature suggests MI may be a promising and acceptable approach for supporting behaviour change in South African PHC, particularly in HIV and NCD contexts, but that stronger implementation research, clearer fidelity assessment, standardised outcome measurement, and longer follow-up are needed before firm conclusions can be drawn about effectiveness, scalability, or system-wide policy adoption. Suggested decision Recommend major revision . The topic is worthwhile and the article has the potential to make a useful contribution, especially if positioned as a mapping of MI-related counselling activity in South African PHC. However, the manuscript requires substantial revision to improve methodological transparency, citation accuracy, definitional clarity, and the proportionality of its conclusions. Essential revisions required for scientific soundness Define clearly what counted as MI, brief MI, MI-informed counselling, and MI-consistent counselling. Provide sufficient search strategy and screening detail to make the review reproducible. Clarify the role of any second reviewer or contracted independent reviewer. Add a clearer study-level synthesis of the 21 included studies. Audit and correct all references and citations. Remove or qualify claims that are not directly supported by the included evidence. Reframe effectiveness and scalability claims more cautiously. Distinguish clearly between findings from the review, background literature, and policy recommendations. Edit the manuscript for repetition, clarity, and consistency of terminology. Ensure that recommendations are proportionate to the strength and scope of the evidence. Is the topic of the review discussed comprehensively in the context of the current literature? Partly Are all factual statements correct and adequately supported by citations? No Is the review written in accessible language? Partly Are the conclusions drawn appropriate in the context of the current research literature? Partly References 1. van Loggerenberg F, Grant A, Naidoo K, Murrman M, et al.: Individualised Motivational Counselling to Enhance Adherence to Antiretroviral Therapy is not Superior to Didactic Counselling in South African Patients: Findings of the CAPRISA 058 Randomised Controlled Trial. AIDS and Behavior . 2015; 19 (1): 145-156 Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Health psychology; behaviour change interventions; motivational interviewing; cognitive behavioural approaches; treatment adherence; primary care and public health; healthcare professional education and training; implementation of psychologically informed interventions in healthcare settings. I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Marks D. Reviewer Report For: Review of the Implementation of Motivational Interviewing as a Personalised Behaviour Change Counselling Approach for Disease Control in South African Primary Health Care [version 1; peer review: 1 not approved] . F1000Research 2026, 15 :453 ( https://doi.org/10.5256/f1000research.196694.r479515 ) The direct URL for this report is: https://f1000research.com/articles/15-453/v1#referee-response-479515 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 30 Mar 2026 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 Version 1 30 Mar 26 read Dougie Marks , University of Glasgow, Glasgow, UK Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Marks D. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 12 May 2026 | for Version 1 Dougie Marks , University of Glasgow, Glasgow, Scotland, UK 0 Views copyright © 2026 Marks D. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This article presents a scoping review of the implementation of Motivational Interviewing (MI) as a personalised behaviour-change counselling approach for disease control in South African primary health care and community-based public health settings. The review aims to map how MI has been used, identify the disease areas and populations targeted, summarise reported outcomes, and identify implementation barriers and facilitators. The article reports that 21 studies met the inclusion criteria from 38 identified records, and concludes that MI has mainly been implemented as brief, MI-informed counselling rather than full-protocol MI, particularly in HIV and non-communicable disease care. The review identifies potentially positive effects on adherence, retention, engagement, and patient–provider relationships, while also highlighting major implementation barriers such as limited training, lack of supervision, poor fidelity monitoring, workload pressures, and project-based delivery. The topic is important and relevant. Behaviour change counselling is highly pertinent to South African primary health care, particularly in relation to HIV, TB, non-communicable disease management, treatment adherence, retention in care, and person-centred care. The article also has a potentially useful implementation focus, moving beyond whether MI “works” in general and asking how it is currently being used in South African PHC. This is a valuable question. However, in its current form, the review has several methodological and evidential weaknesses that need to be addressed before the article can be considered scientifically sound. Major issues that must be addressed 1. The review question and eligibility criteria require tighter operational definition The review states that it includes studies of “Motivational Interviewing or MI-consistent counselling approaches.” This creates a major definitional problem. MI is a specific, theoretically grounded counselling method with identifiable technical and relational components. “MI-consistent counselling” could include a wide range of communication approaches, some of which may not genuinely involve MI. The authors should provide a clear operational definition of what counted as MI, MI-informed counselling, or MI-consistent counselling. For example, did included studies have to mention MI explicitly? Did they need to include training in MI? Did they need to describe specific MI skills such as open questions, affirmations, reflective listening, summaries, eliciting change talk, rolling with resistance/sustain talk, or supporting autonomy? Were any studies excluded because they used generic adherence counselling but not MI? Without this clarification, the review risks overestimating the extent to which MI has actually been implemented in South African PHC. Must address: Define MI and MI-informed counselling clearly, and explain how the distinction was applied during study selection and data charting. 2. The methods are not sufficiently transparent for a scoping review The article states that the full search strategy is provided in Appendix A, and that Appendix C contains the charting table. However, the main manuscript gives limited detail about the actual search strings, database-specific search terms, screening procedure, and data charting process. The PRISMA flow diagram gives the basic numbers, but not enough detail to judge reproducibility. There is also an unclear statement that “inter-rater reliability checks and pilot testing” were conducted, and later that a “contracted independent reviewer” identified sources of bias. This needs clarification. The article appears to be single-authored. It is therefore important to specify who conducted screening, who conducted data extraction, whether any second reviewer was involved, what proportion of records were independently checked, whether disagreements occurred, and how they were resolved. The statement about a “contracted independent reviewer” is especially important because it raises questions about the role of this person in the review process. Was this person involved in screening, data extraction, quality appraisal, bias identification, or manuscript preparation? Were they acknowledged? Were they independent of the author? Must address: Provide a reproducible search strategy in the main text or appendices; clarify screening and extraction procedures; explain the role of any second reviewer or independent reviewer; and state how disagreements or reliability checks were handled. 3. The article makes effectiveness claims that are too strong for the evidence presented The paper is framed as a scoping review, and correctly notes that formal risk-of-bias assessment was not conducted because the aim was mapping rather than effectiveness evaluation. However, the results and conclusions repeatedly imply that MI improved adherence, retention, engagement, and patient–provider relationships. This is not adequately supported in the manuscript as presented. The review does not provide enough study-level detail about intervention design, comparator conditions, sample sizes, outcomes, follow-up periods, effect sizes, or study quality. Many included studies appear to be qualitative studies, programme evaluations, or quasi-experimental designs. The article itself acknowledges heterogeneity, reliance on self-reported adherence, inconsistent objective outcomes, short follow-up periods, and limited fidelity assessment. The authors should therefore soften causal and effectiveness language. Phrases such as “MI improved medication adherence” should be replaced with more cautious wording, such as “included studies reported associations with improved adherence” or “some studies reported perceived or self-reported improvements.” The conclusion that MI “can be scaled up” also requires more caution unless supported by implementation and economic evidence. Must address: Reframe effectiveness claims in line with the scoping review design and the limitations of the underlying evidence. 4. Some citations appear mismatched, weak, or irrelevant to the claims they support A serious concern is that some references do not appear to support the specific claims attached to them. For example, one reference listed as Tichá et al. 2022 concerns fingolimod treatment in multiple sclerosis in the Czech Republic, which appears unrelated to nurses’ perceptions of TB/HIV adherence counselling in South Africa. This suggests a possible referencing error. The manuscript also cites broad international MI reviews and general policy documents in places where South African PHC-specific evidence is needed. Similarly, the recommendation to integrate MI into electronic health record systems appears to be supported by a citation on cloud-based EHRs in South African PHC, but the manuscript does not show evidence that EHR prompts improve MI fidelity, efficiency, or implementation. That recommendation may be reasonable as a speculative implementation idea, but it should not be presented as though it follows directly from the reviewed evidence unless supported by relevant studies. The review also cites some sources in ways that may conflate general disease-burden evidence, policy evidence, and MI implementation evidence. This makes it difficult for the reader to distinguish between contextual background and evidence directly arising from the 21 included studies. Must address: Audit every citation for accuracy and relevance. Remove irrelevant references, correct mistaken references, and ensure that claims about MI implementation and outcomes are supported by included studies rather than by general background literature. 5. The results require a clearer study-level synthesis The results currently summarise broad themes but do not give the reader enough detail about the 21 included studies. The manuscript should include a concise table in the main article or a more detailed summary of the included studies, including author/year, disease area, setting, population, intervention type, provider, MI training/fidelity, outcomes assessed, and main findings. The statement that 81% of included studies used brief MI-informed counselling should be reported more transparently as a count, for example “17 of 21 studies,” if that is the case. The manuscript should also explain how this classification was made. At present, the review often moves between “MI,” “MI-informed counselling,” “brief counselling,” “behaviour change counselling,” and “adherence counselling” without always making clear which studies used which approach. That weakens the synthesis. Must address: Provide a clearer study-level synthesis and distinguish full MI, brief MI, MI-informed counselling, and other counselling approaches. 6. The discussion and recommendations overreach beyond the evidence The recommendations are broadly sensible but sometimes read as policy advocacy rather than evidence-based conclusions from the review. For example, recommending that South Africa should formally adopt MI as a core counselling approach across HIV, TB, NCDs, mental health, and PHC re-engineering may be too strong unless the review demonstrates sufficient evidence across those areas. The paper itself acknowledges that evidence is concentrated in HIV and NCDs, with more limited evidence in TB, mental health, adolescents, maternal health, and multimorbidity. The authors should distinguish between recommendations directly supported by the review and recommendations that are plausible but require further implementation research. Must address: Temper policy recommendations and clearly separate evidence-based conclusions from proposed future directions. Comments on comprehensiveness The review covers important contextual areas, including South Africa’s burden of disease, the limitations of directive information-giving approaches, the relevance of adherence and retention, and the compatibility of MI with person-centred care and task-shifting. It also usefully addresses implementation barriers such as training, supervision, fidelity, workload, and project-based delivery. However, the review would be more comprehensive if it engaged more deeply with the MI implementation literature, especially fidelity, competency, supervision, and adaptation in low-resource or task-shifted settings. The paper should also better distinguish between evidence from South Africa and international evidence used to frame the topic. At present, the literature base feels somewhat uneven: some claims are supported by broad international reviews, some by policy documents, and some by individual South African studies, but the boundaries between these forms of evidence are not always clear. Comments on factual accuracy and citation support No. The main issue is not necessarily that the central argument is wrong, but that the citation practice is not sufficiently reliable. Some references appear mismatched or irrelevant, and several claims require more specific support from the included studies. The authors should perform a full reference audit. Specific examples include: The review should engage with the CAPRISA 058 randomised controlled trial, which appears directly relevant to motivational counselling and ART adherence in South Africa. This study is particularly important because its findings complicate the manuscript’s generally positive interpretation of MI effects. The apparent inclusion of an irrelevant Tichá et al. 2022 multiple sclerosis paper in the reference list. Broad claims about MI improving adherence, engagement, retention, and patient–provider relationships without adequate study-level evidence in the results. Recommendations about EHR-based MI prompts that appear insufficiently supported by the cited literature. Claims about scalability and policy integration that are plausible but stronger than the evidence presented. Comments on language and accessibility The article is generally understandable and uses accessible language. The topic is explained in a way that would be comprehensible to readers interested in primary health care, public health, behavioural counselling, or implementation science. However, the manuscript would benefit from careful editing. There is repetition, especially in the practice implications, where “PHC clinics and community-based services should operationalize MI” appears more than once. Some sentences are overly long or read like inserted planning notes rather than final manuscript text. For example, the objective asking the authors to align each reported outcome with measurable indicators reads more like an instruction than a completed objective. There are also occasional wording issues, such as “observance” where “adherence” would be more appropriate. The language is accessible, but it needs tightening, de-duplication, and a more precise academic style. Comments on conclusions The conclusions are directionally reasonable but somewhat overstated. The review supports the conclusion that MI has potential relevance for South African PHC and that existing implementation appears uneven, project-based, and insufficiently supported by training, supervision, and fidelity monitoring. However, the conclusion that MI is practical and scalable across PHC requires more cautious wording. A more appropriate conclusion would be that the available literature suggests MI may be a promising and acceptable approach for supporting behaviour change in South African PHC, particularly in HIV and NCD contexts, but that stronger implementation research, clearer fidelity assessment, standardised outcome measurement, and longer follow-up are needed before firm conclusions can be drawn about effectiveness, scalability, or system-wide policy adoption. Suggested decision Recommend major revision . The topic is worthwhile and the article has the potential to make a useful contribution, especially if positioned as a mapping of MI-related counselling activity in South African PHC. However, the manuscript requires substantial revision to improve methodological transparency, citation accuracy, definitional clarity, and the proportionality of its conclusions. Essential revisions required for scientific soundness Define clearly what counted as MI, brief MI, MI-informed counselling, and MI-consistent counselling. Provide sufficient search strategy and screening detail to make the review reproducible. Clarify the role of any second reviewer or contracted independent reviewer. Add a clearer study-level synthesis of the 21 included studies. Audit and correct all references and citations. Remove or qualify claims that are not directly supported by the included evidence. Reframe effectiveness and scalability claims more cautiously. Distinguish clearly between findings from the review, background literature, and policy recommendations. Edit the manuscript for repetition, clarity, and consistency of terminology. Ensure that recommendations are proportionate to the strength and scope of the evidence. Is the topic of the review discussed comprehensively in the context of the current literature? Partly Are all factual statements correct and adequately supported by citations? No Is the review written in accessible language? Partly Are the conclusions drawn appropriate in the context of the current research literature? Partly References 1. van Loggerenberg F, Grant A, Naidoo K, Murrman M, et al.: Individualised Motivational Counselling to Enhance Adherence to Antiretroviral Therapy is not Superior to Didactic Counselling in South African Patients: Findings of the CAPRISA 058 Randomised Controlled Trial. AIDS and Behavior . 2015; 19 (1): 145-156 Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Health psychology; behaviour change interventions; motivational interviewing; cognitive behavioural approaches; treatment adherence; primary care and public health; healthcare professional education and training; implementation of psychologically informed interventions in healthcare settings. I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Marks D. Peer Review Report For: Review of the Implementation of Motivational Interviewing as a Personalised Behaviour Change Counselling Approach for Disease Control in South African Primary Health Care [version 1; peer review: 1 not approved] . F1000Research 2026, 15 :453 ( https://doi.org/10.5256/f1000research.196694.r479515) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/15-453/v1#referee-response-479515 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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