Overview
Definition:
Vaccine hesitancy is a delay in acceptance or refusal of vaccines despite availability of vaccination services
It is complex and context-specific, varying across time, place, and vaccines
Motivational interviewing (MI) is a collaborative, goal-oriented style of communication with particular attention to the language of change
It is designed to strengthen personal motivation for and commitment to a specific goal by exploring and resolving ambivalence.
Epidemiology:
Global vaccination coverage has plateaued for some essential vaccines, with significant regional variations
In India, while vaccination rates are generally good, pockets of hesitancy exist, influenced by socio-economic factors, misinformation, and distrust
Studies indicate that parental concerns regarding vaccine safety and effectiveness are key drivers of hesitancy.
Clinical Significance:
Vaccine hesitancy poses a major threat to public health by reducing herd immunity, increasing the risk of outbreaks of preventable infectious diseases, and potentially reversing decades of progress in child health
For pediatricians, addressing vaccine hesitancy effectively is crucial for ensuring optimal child health outcomes and fulfilling their role in preventative care and patient education.
Understanding Vaccine Hesitancy
The 6 C Model:
The 6 C's of vaccine hesitancy: Confidence (trust in vaccine efficacy, safety, and the system), Complacency (low perceived risk of disease), Convenience (accessibility and ease of vaccination), Communication (information from various sources, including misinformation), Constraints (barriers like cost, time, or policy), and Collective Responsibility (perceived individual vs
community benefit).
Common Concerns:
Safety concerns (autism links, side effects, overload)
Efficacy doubts (vaccines not working, natural immunity is better)
Distrust in pharmaceutical companies, government, or healthcare providers
Misinformation spread through social media
Religious or philosophical objections.
Factors Influencing Hesitancy:
Demographics (education level, income)
Socio-cultural beliefs
Media influence and misinformation
Personal experiences with healthcare
Political polarization
Provider communication style.
Introduction To Motivational Interviewing
Core Principles:
MI is guided by four processes: Engaging (building rapport and trust), Evoking (drawing out the patient's own motivations and reasons for change), Focusing (clarifying the desired direction of change), and Planning (collaborating on a plan for change)
It is built on the spirit of partnership, acceptance, compassion, and evocation.
Key Skills Omi:
OARS: Open-ended questions (e.g., "What concerns do you have about the vaccines?")
Affirmations (recognizing strengths and efforts)
Reflections (mirroring and validating the patient's statements, e.g., "So you're worried that the vaccines might be too much for your baby's system?")
Summaries (tying together what has been said and highlighting ambivalence or commitment).
Stages Of Change:
MI is particularly effective for individuals in pre-contemplation (not thinking about change) and contemplation (considering change) stages
The goal is to help them move towards preparation and action.
Motivational Interviewing Strategies For Vaccine Hesitancy
Building Rapport And Trust:
Start by listening empathetically and acknowledging the parent's concerns without judgment
Use open-ended questions to explore their feelings and beliefs about vaccines
Validate their feelings, e.g., "It's understandable to have questions about something as important as your child's health." Prioritize establishing a collaborative relationship.
Exploring Ambivalence And Values:
Gently probe for reasons *for* and *against* vaccination
"What are the good things about vaccinating your child? What are the not-so-good things?"
Help parents articulate their core values (e.g., protecting their child, being a good parent) and explore how vaccination aligns with or conflicts with these values
"You mentioned wanting to protect your child from serious illness
how do you see vaccines fitting into that goal?"
Eliciting Change Talk:
Encourage parents to express their own desires, abilities, reasons, and need (DARN) for change
Examples: "What makes you consider vaccinating at all?", "If you were to vaccinate, what would make it easier for you?", "What are the risks you see for your child if they *don't* get vaccinated?".
Addressing Misinformation Carefully:
Avoid directly confronting or debating misinformation
Instead, reflect their understanding and gently offer accurate information as support for their concerns
"I hear you've read about vaccine safety online
It's true that there's a lot of information out there, and it can be hard to sort through
Would you be open to hearing about what current research says about [specific concern]?" Focus on evidence-based sources and clarify the process of vaccine safety monitoring.
Collaborative Planning And Commitment:
Once ambivalence is reduced and desire for vaccination is evoked, collaboratively plan the vaccination schedule
Discuss practical barriers and solutions
"Given our discussion, what feels like the next best step for you and your child regarding vaccinations?" Set realistic goals and schedule follow-up.
Pediatric Specific Considerations
Age Appropriate Communication:
Tailor language and explanations to the parent's comprehension level
For older children, involve them in the discussion about their health and vaccines in an age-appropriate manner.
Developmental Milestones:
Discuss how vaccines protect against diseases that can cause significant developmental delays or disabilities, linking vaccination to the child's future health and potential.
Parental Anxiety Management:
Recognize that parental anxiety about medical procedures for their child is common
Use a calm, confident demeanor
Explain the procedure and what to expect
Offer comfort measures for the child during and after vaccination.
Key Points
Exam Focus:
MI is a patient-centered, collaborative approach to resolving ambivalence about behavior change, applicable to vaccine hesitancy
OARS (Open-ended questions, Affirmations, Reflections, Summaries) are the core skills
Focus on evoking change talk and aligning with patient values.
Clinical Pearls:
Start with empathy and listening
Never argue with a hesitant parent
Focus on their child's well-being and parental goals
Information is more effective when it supports their own articulated reasons for change
Offer choices and collaborate on a plan
Follow up is crucial.
Common Mistakes:
Being confrontational or dismissive of concerns
Presenting a one-sided, fact-heavy lecture
Not listening actively
Failing to explore parental values
Forcing a decision without collaboration
Not addressing underlying barriers to access or convenience.