CPHA Canvax

Motivational Interviewing: A Powerful Tool for Immunization Dialogue

Arnaud Gagneur

Trying to convince vaccine-hesitant parents to vaccinate their infants with a knowledge-focused intervention may backfire and make them even more hesitant.1 A Cochrane review by Kaufman et al. concluded that face-to-face intervention may not impact vaccine coverage when it is strictly based on providing practical and logistical information regarding vaccination without any consideration of the parents’ beliefs.2 However, a recent Cochrane review, assessing parents’ views and experiences with communication about routine childhood vaccination, showed that parents required more information than what they were actually receiving and that simple, context-specific facts should be provided in a timely manner by a trusted health worker.3 The take-home message, according to the literature, is that while parents want more information, traditional educational methods currently fail to meet their needs. This begs the following question: how do we overcome the challenge of providing adapted factual information on vaccination to parents?

According to the World Health Organization, vaccine hesitancy (VH) is among the top ten threats to global health.4 Effective strategies need to be developed to address this growing problem.1 To date, the educational intervention of promoting vaccinations based on motivational interviewing (MI) techniques is among one of the rarest strategies that have demonstrated their effectiveness to increase infants’ vaccine coverage (VC) and curb parents’ VH.5-9 MI has been described as a promising tool in health promotion10 and the National Advisory Committee on Immunization (NACI) currently recommends its use for vaccination.

1.    A brief definition of Motivational Interviewing (MI)

MI is an interviewing technique that aims to reinforce the motivation and commitment of the person. It is less about the health care professional talking to the patient/caregiver and more about working with the patient/caregiver. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.11

Characteristics of MI are presented in Table 1. An example of a dialogue between a health care worker and a caregiver is provided in Table 2.

Table 1: Description of the spirit, processes and skills used in MI

Table 1: Description of the spirit, processes and skills used in MI

Table 2: Example of traditional approach and use of MI in a dialogue about immunization

Table 2: Example of traditional approach and use of MI in a dialogue about immunization

2.    Examples of successful use of MI in immunization

Dr. Gagneur et al. developed an educational intervention based on the MI approach for parents in maternity wards during their postpartum stay (The PromoVac strategy).5-8 This strategy has been validated during a regional pilot study6-8 (showing an increase of 15% in mothers’ intention to vaccinate, an increase of 7% in infants’ VC at 7 months, and a 9% greater chance of having a complete immunization status during the 0-2 years period among infants whose parents received the intervention in the maternity ward) as well as in a provincial randomized controlled trial (showing a reduction of 40% in VH scores).5,6 Vaccine-hesitant mothers benefited the most from the intervention, and 97% of them reported that they were satisfied with the intervention and would recommend this intervention to all parents.7 Dempsey et al. also demonstrated the effectiveness of a vaccination promotion strategy using MI to increase HPV vaccine uptake in adolescents.9 In 2018, the PromoVac strategy was implemented in all maternity wards in Quebec through a provincial public health program called EMMIE (Entretien Motivationnel en Maternité pour l’Immunisation des Enfants). The preliminary results of the evaluation of this implementation confirmed the results of previous studies with an increase of 11% in parents’ vaccination intention and a decrease of 30% in VH score.12

3.    Relevance of using MI with vaccine-hesitant parents

As we described in the PromoVac strategy, using MI in an educational session fosters a  patient-oriented and, importantly, a tailored session that welcomes parents at their individual level of knowledge while being respectful of their own beliefs.5-8 The use of the MI approach calls for a respectful and empathetic discussion of vaccination and helps build a strong relationship between parents and the healthcare practitioner.4 Parents can freely discuss their concerns and ask questions about vaccination without feeling judged. The intervention is adapted to parents’ needs and is based on their own concerns and questions.6 Healthcare practitioners can, therefore, identify and target parental concerns or misconceptions about vaccination and provide tailored information.6 This is the most prominent distinguishing feature of this approach compared to what has been done in the field of vaccination promotion. This distinguishing feature may explain why this intervention with MI is the first to have such positive results in curbing VH and improving VC.5-8 As opposed to currently available interventions, the educational session with MI is adapted to parents’ individual needs and is based on their own concerns and questions about vaccinating their child. Using MI techniques, healthcare professionals help parents explore their own ambivalence, find their own arguments for change, and make their own informed decision about vaccinating their child or not. In a study on parents’ decisional process in vaccination, Paulussen et al. showed that most parents did not actively process the information provided on benefits and drawbacks prior to deciding whether to have their child vaccinated.13 A parent’s positive attitude towards vaccination and high vaccination intention may, therefore, be susceptible to non-informed and informed counterarguments. By eliciting and exploring a parent’s personal reasons for vaccination, the MI approach enhances his or her personal motivation to vaccinate via a robust decisional process. Moreover, MI is a short intervention and could easily be integrated into usual vaccination consultation once the healthcare practitioners are trained.

MI is a powerful tool to increase vaccine acceptance and curb VH and should be integrated with the training of immunization providers and health care workers involved in immunization counselling. There are several training materials on using MI applied to immunization that are currently available - https://www.who.int/immunization/programmes_systems/vaccine_hesitancy/en/.14, 15

  1. Dubé È, Gagnon D, MacDonald NE, SAGE Working Group on Vaccine Hesitancy. Strategies intended to address vaccine hesitancy: Review of published reviews. Vaccine. 2015; 33(34):4191-4203. doi: 10.1016/j.vaccine.2015.04.041.
  2. Kaufman J, Ryan R, Walsh L, Horey D, Leask J, Robinson P, Hill S. Face-to-face interventions for informing or educating parents about early childhood vaccination. Cochrane Database Syst Rev 2018;5:CD010038. doi: 10.1002/14651858.
  3. Ames HM, Glenton C, Lewin S. Parents' and informal caregivers' views and experiences of communication about routine childhood vaccination: a synthesis of qualitative evidence. Cochrane Database Syst Rev. 2017; 2:CD011787. doi: 10.1002/14651858.CD011787.
  4. World Health Organization. Ten threats to global health in 2019. https://www.who.int/emergencies/ten-threats-to-global-health-in-2019
  5. Gagneur A, Battista MC, Boucher F, Tapiero B, Quach C, De Wals P, Lemaître T, Farrands A, Boulianne N, Sauvageau C, Ouakki M, Gosselin V, Gagnon D, Petit G, Jacques MC, Dubé È. Promoting vaccination at maternity wards using a motivational interview reduces hesitancy and enhances intention to vaccinate: a multicenter pre- and post-design RCT-nested study. Euro Surveill. 2019 (in press).
  6. Gagneur A, Gosselin V, Dubé È. Motivational interviewing: A promising tool to address vaccine hesitancy. Vaccine. 2018; 34(44):6553-6555. doi: 10.1016/j.vaccine.2017.10.049.
  7. Gagneur A, Lemaître T, Gosselin V, Farrands A, Carrier N, Petit G, Valiquette L, De Wals P. A postpartum vaccination promotion intervention using motivational interviewing techniques improves short-term vaccine coverage: PromoVac study. BMC Public Health. 2018; 18(1):811. doi: 10.1186/s12889-018-5724-y.
  8. Lemaître T, Carrier N, Farrands A, Gosselin V, Petit G, Gagneur A. Impact of a vaccination promotion intervention using motivational interviewing techniques on long-term vaccine coverage: the PromoVac strategy. Hum Vaccin Immunother. 2018. doi: 10.1080/21645515.2018.1549451.
  9. Dempsey AF, Pyrznawoski J, Lockhart S, Barnard J, Campagna EJ, Garrett K, Fisher A, Dickinson LM, O’Leary ST. 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. doi:10.1001/jamapediatrics.2018.0016
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  11. Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: 2008.
  12. Gagneur A, Bergeron J, Gosselin V, Guay M, Dubé È, Sanson J, Sicard N, Auger D. Preliminary results of EMMIE program: Increase of parental vaccine intention and reduction of vaccine hesitancy. Canadian Immunization Conference. Ottawa, Canada. December 4th, 2018.
  13. Paulussen TG, Hoekstra F, Lanting CI, Buijs GB, Hirasing RA. Determinants of Dutch parents’ decisions to vaccinate their child. Vaccine. 2006; 24(5):644-51.
  14. Gagneur A, Bergeron J, Gosselin V, Farrands A, Baron G. A complementary approach to the vaccination promotion continuum: An immunization-specific motivational-interview training for nurses. Vaccine. 2019 May 6;37(20):2748-2756. doi: 10.1016/j
  15. Gagneur A, Gosselin V, Bergeron J, Farrands A, Baron G. Development of motivational interviewing skills in immunization (MISI): a questionnaire to assess MI learning, knowledge and skills for vaccination promotion. Hum Vaccin Immunother. 2019 Mar 4. doi: 10.1080/21645515.2019.1586030