Vaccine Hesitancy and Motivating Change
Vaccine hesitancy is considered by the World Health Organization to be among the top 10 threats to global health.1 Whether due to complacency, lack of confidence, or barriers to convenience, many children go without the recommended vaccinations despite the fact that they can be one of the most cost-effective approaches to preventing disease.

Vaccine hesitancy is a main driver for lower than desired vaccination rates and recent outbreaks of vaccine-preventable illnesses, such as measles, in the United States. While vaccination rates vary from community to community, the vaccine compliance with the 7-vaccine series in children aged 19-35 months was 70.4% nationally in 2017, well below the desired rates for effective herd immunity.2 Rates are even lower in certain settings, such as communities where federally qualified health centers (FQHCs) are often located. 

Think about some recent conversations you have had with a parent about vaccinating their child. Did you observe hesitancy in any of those conversations? What approach did you take to encourage the parent or caregiver to vaccinate their child? Parents often feel hesitant about vaccinating their children, yet their reasons for hesitancy are not often explored much beyond the initial “no” or “not today.”

These hesitancies are rooted in health beliefs, ie, what people believe about health, what causes an illness or disease, and how a disease or illness can be resolved. Health beliefs are developed through a variety of cultural, social, religious, and political influences. By understanding a parent’s health beliefs and engaging parents in a collaborative and supportive manner, we as health care providers can motivate change.

How do we motivate change? There are a variety of ways, but a common method is known as motivational interviewing. This approach focuses on asking questions to understand the patient’s beliefs, addressing their concerns, and finding reasons that will help them desire to change their behavior.

Using this approach, providers collaborate with the parent rather than directly combat their hesitancy. Although it can take time to develop comfort with using motivational interviewing, it can be a powerful tool to help parents succeed in fostering positive health behaviors in their children. Both of us had seen the challenges in promoting pediatric vaccination, so our goal was to see whether motivational interviewing could be an effective tool for providers to use when engaging with parents who are hesitant about getting their child vaccinated.

Our Intervention
We sought to modify vaccine discussions at a local FQHC and observe how this change affected childhood vaccination rates. To accomplish this, we created 2 motivational interviewing-based discussion tools addressing the most common objections that families have toward childhood vaccines—one addressing the core immunization series and the other focused on the seasonal influenza vaccine.

Providers could use this to talk with parents to identify the “why” for the hesitancy and address it with facts. It not only gave the provider questions they could ask but credible information to address those concerns. Our focus in development was not to simply provide another educational tool (many strictly educational efforts fail in this space), but to create a framework and approach to dialogue that gets to the heart of how we make decisions regarding vaccines—our health beliefs.

Then, we trained medical providers and staff. We asked them to change their initial vaccine question to a strong, presumptive recommendation (ex: today, your child is due for 2 vaccines. We will be giving the MMR and varicella vaccines).3

During 4 lunch-hour sessions, we discussed vaccine hesitancy and common vaccine-related health beliefs, provided training in motivational interviewing, introduced the 2 tools, and had them apply what they learned using the tools with simulated parents. We came back in the fall to do another session specifically related to the seasonal influenza vaccine and a version of the tool specifically crafted for conversations about this vaccine.

The staff and medical providers were now all trained on how to talk with parents. Our team frequently checked in on how vaccine discussions were going and provided electronic and printed copies of the tools. The pharmacy team integrated into the FQHC provided support and resources regarding vaccine questions. Several key individuals at the clinic were champions for improving vaccination rates, which was a key contributor to success.

What did we find? We found that vaccination refusals went down, including refusals for the influenza vaccine. Providers also gave us feedback that their approach to conversations about vaccines changed after this intervention.

They began consistently using the presumptive approach and had more conversations with parents about their concerns. The clinic has now asked us to do the same to help with refusals related to the COVID-19 vaccine in adult patients.

How Can You Use Motivational Interviewing to Address Vaccine Hesitancy?
Although we are still learning how we can best address vaccine hesitancy, there are certain things you can do to address this when offering vaccines to parents:
 
  1. Use a presumptive approach. This applies when working in a setting that gives you the information to determine gaps in vaccination coverage. For example, imagine that a child needs an influenza vaccine and tetanus booster. You would say to the parent, “Today, your child will receive 2 vaccines, the influenza and tetanus vaccines.”
  2. For those who express hesitancy, find out the “why” behind hesitancy or refusal. Ask the parent open-ended questions about why they are not interested in their child receiving the vaccine.
  3. Show care and concern. Be empathetic. Even if you don’t agree with their beliefs, it is important to show parents that you care about their concerns.
  4. Address the hesitancy with facts. Provide them with information directly related to their health belief or concern.
  5. Promote self-efficacy. At the end of your conversation, affirmed the parent’s ownership of their decisions regarding vaccines.


About the Authors
Justin W. Cole, PharmD, BCPS, Chair, Pharmacy Practice & Associate Professor, Cedarville University School of Pharmacy

Aleda M. H. Chen, PharmD, PhD, FAPhA, Interim Dean, Associate Professor, Cedarville University School of Pharmacy

References
  1. Ten Threats to Global Health in 2019. The World Health Organization. Accessed January 5, 2021. Available at: https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019
  2. Immunization. Centers for Disease Control and Prevention. Updated November 10, 2020. Accessed January 5, 2021. Available at: https://www.cdc.gov/nchs/fastats/immunize.htm
  3. Immunizations: Vaccine hesitant parents. American Academy of Pediatrics. Accessed January 5, 2021. Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/immunizations/Pages/vaccine-hesitant-parents.aspx