Critical conversations with vaccine hesitant patients

ByJoshua Foust
A partner post from the Colorado Department of Public Health & Environment

As COVID-19 vaccines are being allocated across the United States (U.S.), many Americans are ambivalent about or will refuse them. Fortunately, we have ample scientific knowledge regarding how to meet people at their stage of readiness for accepting vaccinations, proactively addressing concerns, facilitating confidence, and building internal motivation for healthy decision making.

Many of those most in need of vaccines, such as communities of color and persons living in poverty, are often the least likely to either have access to or accept vaccinations.2  

A large percentage of Americans are accepting vaccinations, and a small, but vocal percentage of the population will refuse vaccinations regardless of what a health care provider does. For those who are truly ambivalent, health care providers can build trust by being transparent about what we know, as well as taking a nonjudgmental stance toward those who express concern or skepticism. There are unknowns regarding allocation strategies, extended safety, length of vaccine induced immunity, and how to bridge findings to children, adolescents, and pregnant women not included in initial trials. 

One proven tool for facilitating open, honest, and safe conversations is Motivational Interviewing (MI). MI has been a proven engagement strategy for a spectrum of health issues applied in a variety of health care settings. MI is a collaborative conversational style for strengthening a person’s own motivation and commitment to change or healthy decision making.4 Humans become very set in their behavior patterns making ambivalence about any significant behavioral change the norm rather than the exception. While MI may have the ultimate aim of increased vaccination rates, the goal of MI is to build the patient’s confidence rather than persuade or argue the case for vaccinations. People often need to prepare themselves to take action. Time and productivity pressures may motivate providers to jump into action without meeting their patients where they are in their readiness to be vaccinated. 

When not medically contraindicated, providers should respectfully and explicitly state in a personalized manner that that the benefits of vaccination outweigh the risks, and that patients should also continue to use non-pharmaceutical interventions.2 Following this clear, concise presumptive guidance, providers should elicit any concerns patients have about vaccines, ask permission to provide up-to-date information, and then elicit the patient’s response to the new information provided (elicit-provide-elicit). Providers must listen intently to patients and solicit concerns, reflect these back, and help summarize patient’s perspectives. By these means, MI builds health literacy with the understanding that creating patient rapport is a process rather than a one-time directive- it involves exploring rather than telling. The focus is on creating a safe space and asking permission to share what we do and do not know, and help individuals build upon personal strengths and resources. Patients who are provided the opportunity to be ambivalent, and weigh options, will move from intent to actual behavior change at greater rates. Many patients who initially refuse vaccines later agree to them.5

These effective conversations can be quite brief. Studies employing MI for child and youth vaccinations in primary care practices have found improved human papillomavirus (HPV) vaccine initiation and completion. Incorporating MI techniques into clinical visits did not increase visit times. 6 7  Moreover, physicians and other interdisciplinary providers can receive basic training with one to -two  hours of continuing education.

MI is one component in vaccine hesitancy initiatives that should include multiple redundancies in pro-vaccine communications, supportive policy, social context and social norm setting, and shaping the environment.3 MI strategies will assist in building community trust and turning this high willingness/intent into actual vaccinations, particularly for our most vulnerable patients. 

References

  1. National Academies of Sciences, Engineering, and Medicine. Framework for Equitable Allocation of COVID-19 Vaccine. Washington, DC: The National Academies Press; 2020.
  2. Reiter PL, Pennell ML, Katz ML. Acceptability of a COVID-19 vaccine among adults in the United States: how many people would get vaccinated? Vaccine. 2020;38(42):6500-6507.
  3. Brewer NT, Chapman GB, Rothman AJ, Leask J, Kempe A. Increasing vaccination: putting psychological science into action. Psychol Sci Public Interest. 2017;18(3):149-207.
  4. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: The Guilford Press; 2013.
  5. Kornides ML, McRee AL, Gilkey MB. Parents who decline HPV vaccination: who later accepts and why? Acad Pediatr. 2018;18(2S):S37-S43.
  6. Dempsey AF, Pyrznawoski J, Lockhart S, et al. Effect of a health care professional communication training intervention on adolescent human papillomavirus vaccination: a cluster randomized clinical trial. JAMA Pediatr. 2018;172(5):e180016.
  7. Reno JE, O’Leary S, Garrett K, et al. Improving provider communication about HPV vaccines for vaccine-hesitant parents through the use of motivational interviewing. J Health Commun. 2018;23(4):313-320.

Chad D. Morris, PhD
Department of Psychiatry, University of Colorado School of Medicine, Aurora, Colorado

Neill Epperson, MD
Department of Psychiatry, University of Colorado School of Medicine, Aurora, Colorado
Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado