4. Motivational Interviewing Part 2 - Understanding & Addressing Vaccine Hesitancy

In part 2 of this two-part podcast, Mustafa Alavi, MD and Christina Wells, MD, MPH, FAAFP continue their discussion with Rachel Caskey, MD, MA and Amy Christison, MD. They explain major factors that influence vaccine hesitancy and ways to apply motivational interviewing techniques to address these concerns. 

They remind us, although people get their information from multiple sources, enormous amount of research have confirmed year after year after year that, in fact, having a physician or health care provider recommend a vaccine is actually one of the most influential pieces of information. And so, though it doesn't feel like it all the time, by recommending the vaccine or continually recommending the vaccine is very effective at eventually leading to change.  

Join this panel as they discuss some of the do’s and don’ts to having meaningful conversations with your patients.

Objectives:

-          Discuss how to address vaccine hesitancy with motivational interviewing principals

-          Identify different reasons for vaccine hesitancy for various patients

-          Explain the 3Cs model of the vaccine hesitancy 

Visit us at illinoisvaccinates.com/podcasts.

Chapters

• 0:00 Introduction
• 1:36 Episode Begins

Transcript

Welcome to Beyond the Needle A Physician's Guide to Increasing COVID19 Vaccination Rates. Brought to you from the Illinois Academy of Family Physicians through the Illinois Vaccinate or I-VAC grant. I am Carl Lambert, a family physician and a member of IAFP, and I'm an assistant professor of family medicine at Rush University Medical College.

I-VAC is a joint effort administered by the Illinois Chapter of American Academy of Pediatrics, ICAAP, the Extension for Community Health Outcomes, ECHO Chicago, and the Illinois Academy of Family Physicians. I-VAC funding for this podcast series is provided by the Office of Disease Control through the Illinois Department of Public Health. The goal of I-VAC is to ensure Illinoisans are being immunized against COVID-19 at every opportunity and that providers are prepared to immunize all eligible age groups. Support for providers is available through bootcamps, learning collaboratives, do it yourself toolkits and IVAC podcasts. For more information, visit IllinoisVaccinates.com. 

CME credit is available for each podcast through the Illinois Academy of Family Physicians. Information on how to receive credit can be found on the Illinois Vaccinates website under podcasts.  

In this podcast series, we will empower the primary care clinician to feel confident in implementing COVID-19 vaccination so their patients can receive the vaccine at a routine visit. 

You will hear from a variety of primary care clinicians and staff from across the state who have become experts on COVID-19 and the COVID-19 vaccine and implementation.  As primary care clinicians, this is the kind of work we've been doing throughout our careers. For centuries, we've been trusted allies in preventive health for individuals, families and communities. We will share the highs and the lows of our experiences and lessons learned throughout the pandemic. Thank you for joining us as we come together to vaccinate against COVID-19.   

Mustafa Alavi, MD

Thank you for joining us as we come together to vaccinate against COVID-19.  Hi, everyone. Welcome to our next podcast. In a series addressing vaccine hesitancy with motivational interviewing Again, my name is Dr. Mustafa Alavi. I'm a full scope delivering family physician at Erie Family Health Centers.

Christina Wells, MD

And I'm Christina Wells, a family medicine physician at the University of Illinois Mile Square Health Center. And I'm also a board member of the Illinois Academy of Family Physicians. Today, we are going to be talking about vaccine hesitancy. We know that we have all encounter for different reasons why patients are unwilling to get a vaccine. And vaccines, as we know, are important.

Vaccine hesitancy, which is influenced by many different factors. Complacency, convenience, and confidence.  Complacency is that perceived risk. Vaccine preventable diseases are low. So, I'm not really at risk for this. And the vaccine is not deemed and necessary. Preventative action or other life or health responsibilities are seen as more important at that point in that person's life. Convenience is the extent to which physical availability, affordability, willingness to pay, geographical accessibility the ability to understand such as language and health literacy and the appeal of immunization services affects the uptake among individuals.

And then confidence is that trust in vaccines in the system that delivers them. And then the policy makers who decide which vaccines are needed and when. And so, as we understand some of those factors behind vaccine hesitancy, today, we have two wonderful guests with us who are going to take us down the road and help us to understand vaccine hesitancy.

We have both Dr. Rachel Caskey and Dr. Amy Christison. And can you guys introduce yourselves and then help us understand how we can address vaccine hesitancy in our normal, everyday practice?

Rachel Caskey, MD, MAPP

Thank you, Dr. Wells. I'm Rachel Caskey. I'm an associate professor of internal medicine and pediatrics at the University of Illinois at Chicago and a health services researcher. I've spent a lot of time studying vaccine uptake, vaccine hesitancy and so forth. It's a pleasure to be here.

Amy Christison, MD

And my name's Amy Christison. I'm an associate professor in the Department of Pediatrics at the University of Illinois College of Medicine at Peoria. And I'm a general pediatrician. But also, my focus is on childhood obesity. And I like to train others on skills related to motivational interviewing.

Rachel Caskey, MD, MAPP

So, Dr. Christison, let's get going. Let's talk about vaccine hesitancy. Everyone listening to this podcast has experienced vaccine hesitancy, in your clinical practice, perhaps with friends, family members, neighbors. This is something we tend to experience both in our professional life and in our personal life. There are innumerable examples, but some of the most common would-be parents concerned about too many vaccines.

It might overwhelm my baby's immune system, distrust of vaccines. It could be distrust of the health care system at large, perhaps distrust of the government or of large pharmaceutical companies. How many times have we heard I don't get the flu shot because it causes the flu? Right. So, this belief that vaccines can cause disease. I hear a lot of younger healthy adults saying, well, I don't need because I don't get sick.

I just I never get sick. So that's not something I need. And certainly safety, that's a common concern. Can we trust that these vaccines have truly been studied for safety, particularly if I'm giving something to maybe my younger infant and so forth? So that's just some common hesitancy, hesitance right now to start that over. So those are some common concerns that are shared by patients, either about themselves or vaccinating their children.

Dr. Christison has your answer. Any similar stories?

Amy Christison, MD

Oh, definitely. I think all of us have heard those stories. And I want to just say that they're really not coming from a bad place. You know, I've gone through decades now of taking care of families, administering vaccines during well-child visits. I remember when people were really concerned and still are about maybe the effects of MMR. And does it really cause autism or doesn't it?

That was really big in the nineties. You know, as I was first starting practice and I think we encounter this all the time and sometimes it's a little uncomfortable to know how to react. But the one thing, especially as a pediatrician that I really try to keep in mind is that the concerns that parents especially have when it comes to administering vaccines to their children and people, their concerns about just getting a vaccine and having a problem with it, it really comes from a place of love.

Like, I think parents want the best for their kids. They don't want harm to befall them. They don't want harm to befall their loved ones in their family. And that's why, you know, a lot of these concerns and conversations are happening. People are worried about risk, but more than anything, they just want what is the best for their families.

And we want to make the right choice. So, I don't think these are bad people who are coming from a bad place they are really coming from a good place. And they're just concerned they might be frightened. You know, they have lots of different experiences with health care and health care systems. So, they all have backstories about where they're coming from as they're kind of thinking about vaccinations in general and then specifically about the COVID vaccine itself.

I love sharing the story of one of my very favorite patients in weight management, and I've actually seen her since she was 12 and she is going to be 18 and she's graduating the top of her class. One of my favorite patients in this last year. She was about 17 and we had this conversation about how she felt about the COVID vaccine.

Again, I'm seeing her for weight management and something that we know is that children who have obesity have higher risks due to infections and so I've been very concerned for my patients. I've had quite a few of them hospitalized in the ICU when they've gotten really sick. So, it's a conversation I love to have with my patient. And she said, you know, my mom really wants me to get the shot and I'm not getting that I'm just there's no way I'm getting it.

I said, okay, that that's fine. You know, I'm really interested in understanding why you're concerned about this shot. I want to hear about this, and she said, well, first of all, you can't trust Johnson and Johnson to even make baby powder that safe. And second of all, I'm just going to give you one word, Tuskegee. Should I say more?

And this young lady, again, one of my favorites. I'm like, yeah, yeah, I hear you. You know, historically, you know, it's not like there's a lot of trust being built right there. Right. And then she goes on and on and she's such a well-read, such a bright and knowledgeable young lady that has a lot to share about history.

And how it concerns her based upon what she understands about history and different folks and their interaction with health care and institutions.

So, I could have chosen to really respond in different ways. Dude, I'm the expert. Like, you know, I published this article that showed that people like you who have extra weight are going to be in the ICU. Doesn't that scare you? I kind of responded a lot of ways. But what I heard here was a very knowledgeable, bright, educated young lady who had a lot of concerns, and she wanted to share that with me.

And boy, I could really understand this, that, you know, there's a lot of reason for distrust. And I hear that. And I think that right now it sounds like you just need a bit more trust about the situation before you would be even ready to consider doing this vaccine. And then she went, well, you know, I could go with the maturity, but I'm not old enough.

I feel a little bit better about this. And so, she started done exploring what could be different or what might trigger her to go ahead and maybe make a change and the reasons why. And we explored that a little bit. So rather than wrestling with her, I give her a bunch of data and evidence about why she should make that choice.

I think it was really important to really actively listen and acknowledge and normalize as so many people experience the same sort of skepticism. I get that. And with that, it just erupted into a really great conversation with her. And by the way, the time I saw her two months later, she came to me. I would bring it up and she said, hey, I got my shot.

I said, Oh, okay. Wow. So, you know what was different that made you decide that? And then she kind of shared what was going through her head. And so I think it's really refreshing to know that, first of all, we're not giving up our patients on our patients when we're just acknowledging and going alongside and just listening for their concerns that we just they just need to be heard out and they need to feel validated about what their concerns are, because the real fears and real concerns and real experiences.

And I feel like when we come alongside them, acknowledge normalize it because these feelings and these situations normalize where other people are thinking the same thing. It really helps for further conversations and maybe even opening the door for when they're ready.

Rachel Caskey, MD, MAPP

I love that approach you took, and you really just didn't push back, and you stopped, and you listened for the reasons, and it sounds like whether you knew it was going to influence her decision to get vaccinated or not. It probably was really meaningful to her that you just listened, and it sort of acknowledged or affirmed her reasons.

Is this something you do frequently for vaccine hesitation or for those that are worried about vaccination?

Amy Christison, MD

Yeah, I, I think that's a really great question and it's generally my response. So, you know, I think that in my field, if there was anything that anybody is always ambivalent about, it's about losing weight and in fact, our motivations for wanting to try to get healthier our drive for that kind of changes from day to day, week to week, an hour to hour.

And I think all of us can relate to that. So, I'm really used to, I think, listening to people and their concerns and what makes them feel ambivalent about making a choice And so I think that active listening and about their own concerns, their hesitancies, their ambivalence helps kind of understand even maybe what's behind some of those concerns and statements.

So, you know, just to highlight some of the things that I shared about my responses to my patients, a lot of what I shared was just what we call reflective statements. It's kind of probing or maybe testing a hypothesis about what's behind their concern or statement that there's kind of a driver. It could be fear, or it could be skepticism.

It could be distrust; it could be a lot of things that's behind it. It could be risk aversion. Right. You know, I'm really afraid that if I act on something and choose to do something and it causes harm, it'll be my fault or his just letting it happen from inaction or it could be that because they've been hearing so much on the news or on their social media about adverse event acts that it gets amplified in their head as like, this is going to happen to me.

And so being able to normalize what their concerns are that this is something that other people are concerned about, too, that what's behind this might be that they're afraid that that same thing might happen to them because they're hearing so much of it. And that reflective statement alone can make a person feel really affirmed and heard and feel for their experiences and their attitudes.

And I feel like it's a very powerful way to respond to our patients Thank you.

Rachel Caskey, MD, MAPP

That is a really helpful approach to talking to people about their concerns around vaccines. And I want to circle back to one of the things you mentioned early on, Dr. Christison, and that is really that often the fear is coming from a very good place, particularly when it's a parent about a child or even perhaps an adult about an elderly parent.

It's coming from a place of love and concern. And they there's fear that making a decision to vaccinate if it caused harm is much worse than just doing nothing. And so, I think that's really important. And I feel like that's a helpful way to ground this for clinicians, is to remember people are not bringing these concerns to you to upset you.

They're not trying to anger us. Right. They have genuine concerns that are authentic for them. And it's OK to just acknowledge those, even if we think they make more sense, even if we completely disagree. I think it's really important to acknowledge and acknowledge that. I've always told trainees fear sits so much deeper than logic. So much deeper. And we have all met highly intelligent, educated people that have what feels like terribly irrational fears around vaccines or other interventions.

And so, we are just I think it's great to affirm it. I would need it as a human not to take off your clinician hat I hear what you're saying. I hear your concerns and just know that it's coming from a good place. I think it's also important to remember that one even just one very brief, reflective statement, acknowledging those concerns can increase the odds of change.

Maybe not today. It might be in the future. But even in the midst of an extremely busy clinical visit, a very quick reflective statement acknowledging the concerns and perhaps reminding your clinic that you have a clinical recommendation for vaccination. But leave it at that and then let the patient take that with them and continue the conversation later Wow.

Mustafa Alavi, MD

That was great. Dr. Carson. Dr. Christiansen, this really is going to help reframe how I approach my future conversations with my patients and just to summarize for the audience here. So regardless of the reason why someone would be hesitant to be vaccinated, the core principles your approach, that sounds like it's the same active listening, that it's not a patient in front of you who is in, quote unquote, antibiotics, or it is a real patient with real concerns and fears and making one reflective, reflective statement and normalizing their concerns and reasons can go a long way in building that relationship with that patient and making meaningful change in the future.

Christina Wells, MD

All right. Thank you so much for that summary, Dr. Alavi. It is. You know, I've really learned myself, learned a lot today. And not only do I think that I can utilize this information in discussing things like vaccine hesitancy, but I can use it in a lot of things that I encounter in my clinical practice on a day-to-day basis.

Christina Wells, MD

So, I want to thank you again, Dr. Christison and Dr. Caskey. Do you have any additional thoughts or closing statements that you like to leave with us today?

Rachel Caskey, MD, MAPP

I want to comment on one more topic that we have not mentioned too much about, and that is where people get their information about vaccines. And I know it can sometimes be very frustrating when patients come in talking about what they read on Instagram or watched on TikTok or any other sort of media that perhaps is less accurate than we would like for vaccine information.

And though that is extremely common, certainly everyone gets information from lots of varied sources these days. I do just want to remind everyone listening that enormous amount of research have confirmed year after year after year that, in fact, having a physician or health care provider recommend a vaccine is actually one of the most influential pieces of information. And so, though it doesn't feel like it all the time, by recommending the vaccine or continually recommending the vaccine is very effective at eventually leading to change.

And we are trusted as sources of vaccine information, even though it does not always feel that way on a daily basis.

Amy Christison, MD

I'm grateful every day about being able to practice medicine because it's really about these relationships we are privileged to build with our patients and families. Longitudinally. And it's really, really bottom line about these relationships that you have with your families. That is the basis of this trust. You have a track record with that they see for a reason.

And I would say never underestimate the power of that relationship. And it's come back time and time again over the decades, my own practice and stories of my adult patients coming back to me and the stories that they talk about our conversations. And I'm so grateful because we have had and built that relationship And I really, truly, truly feel grateful for the fact that we are in that position to be able to serve the people we get to serve every day.

So, yeah, don't underestimate the strength of the relationship you have with your patients and families.

Christina Wells, MD

Well, thank you so much. This has been so awesome. I have learned a lot. I know this would be so helpful and beneficial to all who are going to listen to this podcast. So, we thank you again, Dr. Caskey and Dr. Christison, for taking up your time and sharing your expertise with us today. We thank. I want to thank my co-host, Dr. Alavi, for joining me today.

And thank you, audience for joining us for another podcast. Have a wonderful day.

Carl Lambert, MD

Thank you to our expert faculty and to you, our listener, for tuning in to this episode. If you have any comments, questions, or ideas for future topics, please contact us directly at podcast@ilvaccinates.com for more episodes of Beyond the Needle. Please visit Illinoisvaccinates.com/podcasts. You'll find links to resources, transcripts, speaker disclosures, a survey to gather your feedback and instructions to claim CME Credit.

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