From Vaccine Hesitancy to Vaccine Motivation: A Motivational Interviewing Based Approach to Vaccine Counselling

"The cultivation of trust through MI [motivational interviewing] can lead to a lessening of VH [vaccine hesitancy] and strengthening of vaccine confidence and motivation, especially in marginalized communities in which trust has not been effectively cultivated by healthcare institutions."

Distrust of the medical establishment and related institutions plays a central role in vaccine hesitancy (VH) and indeed in a wide range of health disparities. Communication strategies that address VH by cultivating trust are therefore paramount and timely. One such strategy is motivational interviewing (MI), which is an evidence-based communication style demonstrated to significantly reduce VH. This paper discusses how MI can fundamentally repair distrust and thereby promote increased vaccine uptake, as demonstrated in a series of studies by one of the authors (AG) that informed implementation of public health programmes that improved childhood vaccination rates in Quebec, Canada.

MI guides people toward change through the expression of empathy and by respecting an individual's autonomy. Healthcare providers (HCPs) are the primary implementors of vaccine policies and the most trusted advisors and influencers of vaccination intention at the individual patient level. Training HCPs in MI can be an effective strategy to overcome VH. Many countries have implemented HCP training programmes and population-based MI interventions to improve vaccine uptake. The idea is that understanding individual patient-level drivers of hesitancy allows clinicians to provide tailored, accurate information that reinforces a person's own motivation and confidence in their own decision. 

A set of four guiding principles - Compassion, Acceptance, Partnership, and Evocation (CAPE) -  form the heart and foundation of MI practice. CAPE stands for:
 

• Compassion is about committing to actively pursue the well-being of others and give priority to their needs.
• Acceptance is about appreciating what the other person brings to the conversation and respecting a person's right to change or not to change (autonomy). It is also about empathy, or seeing through the eyes of another, trying to understand their perspective and what matters to them.
• Partnership is about coming alongside the individual and collaborating as equals to solve a problem.
• Evocation is about pulling out the reasons for change that are meaningful to the individual from the individual themselves.

Together, these four principles are called the Spirit of MI. Practicing communication without incorporating the MI Spirit is not practicing MI because the "skills" of MI itself can be used to manipulate others into making behaviour changes. The spirit with which MI is practiced helps build rapport and trusting relationships with patients and clients.

Trust and confidence are foundational for effective partnerships with HCPs that support behavior change and decisions such as vaccination. To that end, this paper describes a 4-step practical framework designed to support HCPs in their dialogue with vaccine-hesitant patients. It can be used by clinicians in busy practices to guide vaccination conversations:
 

1. Engage: Applying the Spirit of MI allows for the creation of safe, judgment-free spaces for open dialogue and free expression of opinions, beliefs, and knowledge gaps. The patient will only be able to move toward a more favourable position on vaccination if he or she has confidence in their provider.
2. Understand what matters most to the patient: By ascertaining an individual's personal causes of hesitation, pertinent information can be identified for use in Step 3. Active listening with curiosity and acceptance can also show that the HCP understands and wants to help.
3. Offer information: Tailor the details to address the patient's specific concerns and to guide the individual toward vaccine intention. As each concern is sequentially identified and addressed, engagement and trust improve as vaccine hesitancy declines. Once all concerns have been addressed in this way, it is time to transition to Step 4.
4. Respect autonomy/planning: Clarify and accept the patient's decision, even if an individual continues to be ambivalent or has strong reasons not to vaccinate. Respecting their autonomy and validating their decision is essential to maintain and continue to build trust in the relationship. This strategy cultivates safety for the individual to return if they reconsider, or for the provider to, with permission, continue the conversation at the next visit.

One metric of MI success is the concept of "change talk", which is defined as everything the patient says that favours change (e.g., "I understand the importance of vaccination." In contrast, "sustain talk" is defined as statements that favour the status quo (e.g., "vaccination won't change anything.") The stronger the change talk ("I will" is stronger than "I might"), the higher the likelihood a person will change.

Evidence is mounting that MI can be helpful in improving vaccine acceptance. Gagneur et al. demonstrated that an MI intervention reduced vaccine hesitancy by 40% and significantly improved vaccine intention and uptake in children aged 0-2 years. The impact was amplified in the most hesitant parents, with the proportion wanting to vaccinate their child increasing from 35% to 66%. In response to these findings, the Quebec government implemented an MI-based provincial programme; early data indicate that the impact of this programme on the level of hesitancy and vaccine coverage is similar to previous studies. See Related Summaries, below, for more details.

The paper concludes that training HCPs in MI aligned communication skills using the 4-step guiding framework outlined here "can help address VH, and build vaccine confidence, and may be an effective strategy to lower the mortality and morbidity associated with...vaccine preventable diseases....Vaccine hesitancy is not merely a matter of knowledge gaps but often rooted in emotions, beliefs, and social influences. Consequently, policymakers and medical societies should take the initiative to implement educational classes focused on improving communication strategies when interacting with vaccine-hesitant patients."