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DIMENSIONS: Motivational Interviewing for Vaccine Hesitancy
Pamela Murray, MD, MHPNeil Copeland, MD Timothy Lefeber, MD
© 2018 BHWP
Training Objectives1) Learn about the MI heart set, processes, skills, and strategies
2) Recognize parental disposition;
3) Demonstrate skill in answering common vaccine specific questions;
4) Demonstrate skill in applying the three Cs intervention approach;
5) Demonstrate skill in using the MI style of communication in conversations with hesitant and vaccine refusing parents.
© 2018 BHWP
Motivational Interviewing
Motivational interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change.
It’s a way of being versus a way of doing.
Vaccine Recommendations
© 2018 BHWP
ACIP Recommendations (2018)
© 2018 BHWP
Why a Presumptive Recommendation?
Who initiated the vaccine recommendation or plan specifically? (n=111)
No plan verbalized (3%; n=3) Parent (13%; n=15)
Provider (84%; n=93)
Presumptive (74%; n=69) Participatory (26%; n=24)
Resists (26%; n=18) Resists (83%; n=20)
Accepts (74%; n=51) Accepts (4%; n=1)
Provides own plan (13%; n=3)
How does the PROVIDER initiate the vaccine recommendation? (n=93)
How does the PARENT respond to the provider’s initiation?
Presumptive recommendation drives consent
Opel et al, Volume 132, Number 6, December 2013
© 2018 BHWP
The Key to MI
Adopt the right “heart‐set.” This includes:
PartnershipActive collaboration
AcceptanceNon‐judgmental
CompassionFocus on well‐being
EvocationStrengths and resources
© 2018 BHWP
Primary Goal of MI
Interact with a person in a way that increases motivation to change and evokes change talk
Change talk is a person’s own statement that favors change
© 2018 BHWP
Four Processes in MI
Engaging
Planning
Evoking
Focusing
© 2018 BHWP
Four Processes in MI: Engaging
The process of positive engagement involves: ① Establishing a trusting and mutually respectful
working relationship② Agreement on treatment goals③ Collaboration on ways to achieve these goals
Engaging
© 2018 BHWP
Four Processes in MI: Focusing
Focusing in MI is an ongoing process of seeking and maintaining direction
Focusing
© 2018 BHWP
Four Processes in MI: Evoking
Evoking is the process of eliciting a person’s own motivation for change by
resolving ambivalence to change
Evoking
© 2018 BHWP
Strategies for Evoking Importance
© 2018 BHWP
Strategies for Evoking Importance
Querying extremes
Looking back
Looking forward
Exploring goals and values
Imagine your child does not get the HPV vaccine, what’s the worst that can happen?
What do you remember about him getting three shots at once when he was a baby?
If you decide on this vaccine, what do you hope will be the benefits to your daughter?
What are your goals for your child’s health?
© 2018 BHWP
Strategies for Evoking Confidence
© 2018 BHWP
Strategies for Evoking Confidence
Reviewing past success
Personal strengths/supports
Hypothetical change
In the past, what has helped you make up your mind when you felt uncertain?
What supports do you have that can help you make this decision ?
Suppose you opt for the recommended vaccines today. Looking forward, what might you see as the
benefits for her?
© 2018 BHWP
Four Processes in MI: PlanningPlanning involves commitment to change and the formulation of a concrete change plan
Planning
© 2018 BHWP
Signs of Readiness for Planning
Increased change talk
Taking steps
Diminished sustain talk
I’m open to getting the vaccine.
I’ll talk about the HPV vaccine with my husband.
I would like my child to be healthier.
© 2018 BHWP
Signs of Readiness for Planning
Resolve
Envisioning
Questions about change
I really do want to do all we can to prevent cancer.
When the time comes for her to engage in intimate relationships, she will be protected.
What’s the best way to explain this to my husband?
© 2018 BHWP
O
A
R
S
Open questions
Affirming
Reflecting
Summarizing
OARS
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The “Expert” TrapWhen a HCP persuades, lectures, or offers excessive scientific data to parents or patients who are: Hesitant, especially when ambivalence
is associated with a core value In discord with the established medical
recommendations Firm about their decision not to
vaccinate
© 2018 BHWP
OARS Coding Sheet
© 2018 BHWP
Open Questions
Difficult to answer with brief replies or simple “yes” or “no” answers
Allow for a fuller, richer discussion Conversational door‐openers that encourage
people to talk, using their own words Keeps the conversation focused on the
individual
© 2018 BHWP
Closed Questions
Do you want your child to be healthy? You do know that boys need the HPV vaccine
too? Are you going to get all three vaccines today,
as I’ve recommended?
What do you need to change to make this an open‐ended question?
© 2018 BHWP
Affirmations
Statements or gestures that recognize a person’s strengths
Lead in the direction of positive change Confidence‐builders Must be genuine and congruent Use sparingly — a little goes a long way
© 2018 BHWP
You are making the best choice for your
child
You want the best for your child
Your commitment to your child’s health is obvious
You are thoughtful in your decision‐making
You are doing an excellent job
© 2018 BHWP
Reflections
Reflective Listening: Is listening to the words that are said and the meaning behind them
Keeps people thinking and talking Demonstrates that you seek to understand what has been shared
Forces you to listen carefully—you can’t reflect if you are not paying attention
© 2018 BHWP
Reflections
Reflections allow the person to: Voice thoughts or feelings they may not have talked about before
Feel understood Feel accepted without judgment Hear their thoughts and feelings restated
© 2018 BHWP
Summarizing
Summaries allow people to: Recall the conversation Think of new ideas Transition from one theme to another Plan their next steps Feel more confident moving forward
© 2018 BHWP
Intervention Schema
PresumptiveRecommendation
Assess ParentalDisposition
1
2
TailoredIntervention3
Acceptor
Cautious Acceptor
Hesitant
Refuser
Vaccinate
AnswerQuestions
Vaccinate
Vaccinate
Vaccinate
ArrangeFollow‐Up
Arrange Follow‐Up
AnswerQuestions/MI
Reassess
MI
Reassess
© 2018 BHWP
Motivation
© 2018 BHWP
Discord Management
“What does it matter?”
“Yes, but…”
“You don’t know what it’s like to be in my shoes.”