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Fisher-Chavez D, Eunice Choi E, Prapasiri S, Martinez M. Let’s talk about COVID-19 vaccines: coaching for provider confidence. HPHR. 2023;73. https://doi.org/10.54111/0001/UUU2
Vaccine hesitancy to the COVID-19 vaccine global threat. Misinformation and polarization make conversations about the vaccine challenging for healthcare providers. We created a presentation for healthcare providers emphasizing motivational interviewing, a technique which has been shown to motivate positive change including overcoming vaccine hesitancy. We also provided the most up to date COVID-19 vaccine information. We assessed the helpfulness of this presentation and provider confidence in a pre- and post-presentation survey. Providers felt that our presentation was helpful, and there was a statistically significant increase (22.6%) in provider confidence in talking to people who are hesitant about getting the COVID-19 vaccine. In summary, giving providers information about motivational interviewing and providing up to date information about the vaccine significantly increased provider confidence. We recommend that similar presentations be used in other medical settings to increase confidence in difficult conversations.
Just before the COVID-19 pandemic, the World Health Organization designated Vaccine Hesitancy as a threat to global health.1 Defined as “the reluctance or refusal to vaccinate despite the availability of vaccines”, vaccine hesitancy has many causes: low health literacy, fear of needles and potential side effects, mistrust of government and science.2, 3, 4, 5, 6 The politicization of COVID-19 vaccines along with ready access to social media created an environment for rapid dissemination of misinformation and polarization of beliefs related to the vaccines.7, 8, 9, 10 There is a spectrum of patients with vaccine hesitancy. At one end, patients may have questions that are quickly answered by a conversation with a care provider. At the other end of the spectrum, patients may be adamantly opposed to COVID-19 vaccines based on a deep-rooted belief regarding safety, efficacy and mistrust of government, science or medicine.2, 11, 12, 13
Vaccine hesitancy is evident in the rate of vaccination. Even though the COVID-19 vaccine has been shown to reduce cases, hospitalizations, and deaths caused by COVID-19, the CDC estimates that 79.2% of Americans have received only one COVID-19 vaccine, with 20.8% having received no vaccine.14 Additionally, less than half of the US population has received their first booster dose, and only 34% have received their second booster.14 In New Mexico, while 80.3% of adults over 18 years of age have received their primary series of COVID-19 vaccines completed, only 24.3% of the same group have received the COVID-19 booster despite its availability.15
Provider communication may impact patient opinions about the vaccine making effective communication with vaccine-hesitant patients critical.8, 12, 16, 17, 18 Vaccine hesitancy may be exacerbated when a provider uses a directing style, especially if the patient has strong personal beliefs.19 Motivational interviewing is a collaborative, non-confrontational style that has demonstrated positive behavioral outcomes.16, 20, 21, 22 There is strong evidence for the use of motivational interviewing by healthcare providers across a wide range of challenging encounters, including treatment adherence and general vaccine hesitancy.20, 23, 18, 24 Many health professionals are attempting to develop motivational-interviewing-based interventions for addressing COVID-19 vaccine hesitancy.19 We were not able to find studies analyzing the effect of training in motivational interviewing on provider confidence.
In response to this, we developed a presentation outlining 8 motivational interviewing steps towards a successful conversation regarding the COVID-19 vaccine. This was presented to healthcare providers including physicians, residents, advanced practitioners, and medical students. In the presentation, we discussed motivational interviewing and provided updated information about the COVID-19 vaccine including links to evidence-based information for patients. We hypothesized that a presentation given to healthcare providers would increase provider confidence in talking to vaccine-hesitant individuals. In this study, we aimed to 1) assess the helpfulness of such an educational presentation using a pre- and post-presentation RedCap surveys and 2) evaluate the confidence level of healthcare providers before and after the presentation.
Using Microsoft PowerPoint, we developed a 45-minute educational presentation on how to talk to patients with vaccine hesitancy. The presentation emphasized the use of motivational interviewing methods including information sharing and relationship building in discussing the COVID-19 vaccines with vaccine-hesitant patients. The presentation was given on 12 different occasions to groups of healthcare providers, including physicians, residents, advanced practitioners, and medical students. The presentation was given by 3 different presenters who changed based on presenter availability. Throughout the course of the study from September 2021 to October 2022, we adjusted the presentation based on feedback, to better suit presenter styles, and to provide the most up-to-date information as vaccination knowledge, regulations, and policy changed.
With institutional review and approval (UNM HPRO 21-272), the audiences of the 12 presentations were asked to complete a survey before and after the presentation using the RedCap® survey system. The pre- and post- presentation surveys were accessed via a QR code at the beginning and end of the slideshow. Each question on the survey required either short-answer, true/false, or scaled multiple choice responses. Scaled multiple choice questions assessed provider confidence before the presentation, and helpfulness of the presentation after on a scale of 1 to 5. An answer of 1 indicated not at all confident or helpful, and an answer of 5 indicated being extremely confident or helpful. After each presentation we interacted with the audience, answering questions and clarifying specific points from the presentation. Specific pre- and post- presentation questions are outlined in table 1.
The data collected from the pre- and post-presentation surveys were analyzed using SAS 9.4 (Cary, NC). The outcome variables, such as helpfulness and confidence, were dichotomized for the purpose of data analysis. For helpfulness, 3) somewhat helpful, 4) helpful and 5) very helpful were aggregated as helpful, whereas 1) not at all and 2) slightly helpful were categorized as not helpful. Confidence was also aggregated in the same fashion. We used Chi-squared and Fisher to examine the association between the pre- and post-presentation responses.
Figure 1. List of topics in didactic presentations
Table 1. Provider levels and survey responses
| Pre (n=166) | Post (n=125) | p-value |
Providers Attending physician Advanced practice provider Resident or fellow Medical student Medical assistant Other clinic staff |
47 (28.5%) 42 (25.5%) 22 (13.3%) 52 (31.5%) 1 (0.6%) 1 (0.6%) |
25 (20.2%) 29 (23.4%) 18 (14.5%) 49 (39.5%) 1 (0.8%) 2 (1.6%) |
0.477* |
Presentation was… Helpful Not helpful |
|
118 (94.4%) 7 (5.6%) |
|
How confident do you feel in your ability to talk to someone who is hesitant to get a COVID-19 vaccine? Confident Not confident |
130 (78.3%) 36 (21.7%) |
120 (96.0%) 5 (4.0%) |
<0.001
|
If you counsel someone to get the COVID-19 vaccine and they decline the vaccine, you have failed. False True |
152 (92.1%) 13 (7.9%) |
123 (98.4%) 2 (1.6%) |
0.017* |
If you dispel all of the myths about the COVID-19 vaccine, your patient will want the vaccine. False True |
159 (95.8%) 7 (4.2%) |
117 (94.4%) 7 (5.7%) |
0.575 |
Table 2. Comments and suggestions
Comments/Suggestions |
“Awesome job! I definitely feel more comfortable even if a patient still refuses the vaccine.” “Also wondering about political stance on vaccine. These seem to be a big group of people not getting the vaccine. They want to keep their rights… but they’re not using logic in their choices.” “Your approach to engaging people is very good.” “We have to be honest and provide all of the data, not just the data that supports a preconceived narrative.” “Very helpful presentation with great resources.” |
Figure 2. Helpfulness by various providers
Figure 3. Post-presentation provider confidence
A total of 291 survey responses were collected—166 before the presentation and 125 after the presentation. As shown in Table 1, the distribution of provider job-titles remained the same between pre-presentation and post-presentation (p=0.477), with medical students being the majority of pre- and post-presentation respondents (31.5% and 39.5%, respectively). The overwhelming majority (94.4%) of the survey respondents found the presentation to be helpful. The feedback collected via a short-answer survey item on the helpfulness of the presentation were mostly positive. For example, one comment stated “I definitely feel more comfortable if a patient still refuses the vaccine.” Another comment read “very helpful presentation with great resources.” Multiple responses commented that “[our presentation’s] approach to engaging people is very good.” We also received constructive criticism. One respondent criticized our lack of information on political stances surrounding the vaccine, stating, “[a patient’s] political stance on vaccine… these seem to be a big group of people not getting the vaccine.” Another suggestion we received was that “[providers] have to be honest and provide all of the data, not just the data that supports a preconceived narrative.”
The proportion of survey respondents who reported feeling confident talking to people who are vaccine-hesitant showed a statistically significant increase, from 78.3% before the presentation to 96.0% after the presentation for a 22.6% increase (p<0.001, Table 1). Conversely, there was a 81.6% decrease in responders who reported not feeling confident talking to someone who is vaccine hesitant. Before the presentation was given, almost all survey respondents (92.1%) responded that it is not a failure if a patient refuses the vaccine after being counseled. There was a statistically significant 6.8% increase in this response after the presentation (p=0.017). Similarly, a high portion of survey respondents (95.8%) reported that they did not believe that dispelling all myths about the COVID-19 vaccine would make a patient want the vaccine. While not statistically significant, the proportion who answered false to this statement remained high (94.4%) after the presentation (p=0.575).
Talking to vaccine hesitant patients is difficult. Multiple sources recommend using motivational interviewing that promotes collaborative communication between provider and vaccine-hesitant patient. This is in contrast to a more directing style of communication.19, 23, 25, 26, 27 However, the practical difference between the two approaches is subtle. Contrary to directing styles of communication, motivational interviewing centers around the provider maintaining impartiality, safeguarding the patient’s autonomy, offering evidence-based information to empower the patient in making informed decisions.19, 20, 22, 23 Our presentation highlighted these subtle differences, and provided example conversations using motivational interviewing with vaccine-hesitant patients.
The helpfulness of the presentation was assessed both qualitatively and quantitatively in the scaled multiple-choice section and short answer suggestions/comments sections, respectively. Our qualitative and quantitative data show that the presentation was overwhelmingly well-received, strongly suggesting a demand for such informational presentations on motivational interviewing as a tool to build trust and share information. Additionally, we received constructive criticism that we plan to use to improve future presentations and studies. One provider explained that vaccine hesitant patients “want to keep their rights, but they’re not using logic in their choices” due to their political stance. Numerous research investigations have consistently demonstrated that individuals with conservative political leanings tend to exhibit higher levels of resistance towards vaccination.16, 27, 28, 29, 30, 31, 32 While our study did not directly address the political aspect of COVID-19 vaccine hesitancy, we did emphasize protecting patient autonomy by maintaining neutrality, which is a key aim of motivational interviewing. Nevertheless, in the future we plan to incorporate more information on politically inclined conversations. In future presentations we will emphasize that these conversations can be deescalated if providers 1) ask permission to talk about a subject, 2) share information by using ask-tell-ask and 3) build trust over time and 4) respect patient’s autonomy. For example, a conversion might end with “thanks for sharing your thought with me, I respect your viewpoint, but I worry about you getting ill without a COVID Vaccine. Let’s agree to disagree.”
It is well-established in the literature that health care provider recommendations have a major influence over the acceptance of vaccines.16, 23, 28, 33 Without a doubt, primary care providers are influential in patients’ receptivity of the vaccine. Providers’ attitude and perception towards vaccine safety shapes the recommendation practices.17, 25, 26, 33 Given the association between a providers’ attitudes and their vaccine recommendations, it is troubling to find that apprehension of the COVID-19 vaccination is common amongst some medical students.34 There is a need to bolster provider confidence on recommendation practices. However, there is little research that directly measures the level of confidence of health care providers on leading difficult conversations with vaccine hesitant patients. Our presentation proved to be an effective tool that showed a statistically significant increase in provider confidence. We found a 22.6% increase in provider confidence level from pre- to post-presentation. Equipping healthcare providers with effective communication tools that enable patient transformation in line with their values and objectives constitutes a vital and essential stride in the continuous endeavor to stimulate changes pertaining to COVID-19 vaccine hesitancy.
Our informational presentation on using motivational interviewing to talk to vaccine hesitant patients showed a statistically significant increase in provider confidence. There have been numerous research articles suggesting motivational interviewing on promoting vaccine acceptance. Breckenridge and Fogarty defined motivational interviewing and sited examples of how it could be used.9, 10 This study adds a helpful tool that focuses specifically on strengthening provider confidence level on initiating difficult conversations about the COVID-19 vaccine. Some of the limitations include that there was only one multiple choice survey question each regarding the helpfulness of the presentation and the confidence level of the health care providers. Studies exploring reasons providers might or might not feel confident in vaccine conversations would have been useful. Additionally, we updated the presentation to reflect rapidly changing information throughout the 14-month study period, and used three different presenters, which may have impacted the consistency of the presentation. We were also unable to correlate the pre- and post- survey responses with individual respondents. This may have induced potential bias in the analysis of our study.
Despite the ongoing prevalence of COVID-19 infection and hospitalization, some patients remain hesitant about receiving the COVID-19 vaccine. Vaccine hesitancy exists as a spectrum ranging from never wanting to receive the vaccine to agreeing to get the vaccine. Many providers feel uncomfortable talking to vaccine-hesitant patients. Building a trusting relationship with patients is key to a successful conversation. This includes asking permission to discuss the topic, managing your expectations, determining where patients are on the vaccine-hesitancy spectrum, using the ask-tell-ask method, opening the conversation with one positive, asking the patient to list specific concerns, managing their concerns, recommending the vaccine, harm reduction, leaving the door open, and celebrating success. While we hope that the patients will eventually want to be vaccinated, the goal of each conversion build trust so that patients will accept information and make informed decisions. Misinformation has been cited as a key factor in vaccine hesitancy.4, 6, 7 Patients will believe information from sources they trust. Provider can be that source if they build relationships.
After presenting these 8 steps to attending physicians, residents, advanced practitioners, and medical students, we found that respondents found the presentation to be helpful and that their confidence in speaking to vaccine-hesitant patients increased. This indicates that similar educational materials may help providers increase their confidence in talking to vaccine-hesitant individuals. We recommend that similar practice be adopted in many specialties across a variety of clinical settings in order to increase provider confidence in engaging in difficult conversations with COVID-19 vaccine hesitant patients.
Dr Melissa Martinez has served as a paid consultant for Seqirus a vaccine company that does not produce COVID vaccines. No other authors have conflicts to declare.
Devon Fisher-Chavez is a 4rd year medical student at the University of New Mexico School of Medicine. His research areas include vaccine hesitancy and patient education. He received formal training in biology and literature at the University of New Mexico
EunHo Eunice Choi is a 3rd year medical student at the University of New Mexico School of Medicine. Her research areas include public health and medical ethics. She received her formal training as a biostatistician at the University of New Mexico.
Dr. Surasri Prapasiri is an assistant professor in the Department of Internal Medicine at the University of New Mexico School of Medicine, and a medical director at the University of New Mexico Westside Clinic. His research focus includes quality improvement in primary care and social determinant of health and coding and documentation.
Dr. Melissa Martinez is a Family physician and a professor in the Department of Internal Medicine at the University of New Mexico School of Medicine. She has a special interest in immunizations and completed a Vaccine Science and Policy Fellowship with the American Academy of Family Physicians, served on the National Vaccine Advisory Committee and co-chairs the New Mexico Immunizations Practices Advisory Committee.
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