Motivational Interviewing

Building vaccine confidence takes time and trust. Client-facing staff and others working directly with community members seeking to dispel fear, misinformation, and disinformation will usually need to engage and explore people's hesitancy before sharing accurate information. One helpful way to do this is using some of the techniques found in Motivational Interviewing.

Motivational Interviewing (MI) is an evidence-based treatment that is used by a wide variety of clinicians to explore ambivalence and enhance motivation to change. Nonclinicians, such as community health or outreach workers seeking to overcome vaccine hesitancy and build vaccine confidence in communities, can also successfully use many of the techniques of MI to make a positive impact. MI principles include: 

MI uses key skills referred to by the acronym OARS to assist in building rapport and trust, and ideally, eliciting change. The suggested techniques through OARS include: 

  • Open-Ended Questions – These are questions that go beyond a “yes” or “no” and allow the person to share in detail their thoughts and feelings. For example, instead of asking “Do you plan on getting the COVID-19 vaccine?” client-facing staff may ask, “What are your thoughts on the COVID-19 vaccine?”
  • Affirmation – While you may not agree with what someone else has said, you want to be sure to affirm their right to think and feel it in a way that is authentic and conveys to them they are being understood. For example, if someone shares that they heard that the vaccine causes infertility, instead of saying “That’s wrong” a client-facing staff member can say, “That is a common concern for many people and can be a scary thought if someone is interested in having children.” 
  • Reflection – Involves rephrasing a statement to capture the meaning and feeling. For example, if someone says, “I heard that after a lot of people took the shot, they had heart attacks” the client-facing staff member might say, “It sounds like you have heard some information that could lead you to be fearful of getting the shot. Is that right?”
  • Summarizing – This is generally done after spending time exploring and listening, and is utilized to consolidate what has been heard and to check in that you have heard and interpreted it correctly. It can also be a time to point out discrepancies between two thoughts that may be at odds with one another. For example, “It sounds like you have seen a lot of videos online that say the vaccine is dangerous and that has made you fearful of getting vaccinated. At the same time, you know several people in your community who have died from COVID-19 and you are afraid of getting the virus. Is that right?”

Using MI Techniques in Salt Lake City 

At the International Rescue Committee (IRC) in Salt Lake City, staff members called Refugee Community Liaisons (RCLs) have found creative ways to include MI techniques in their work to prevent the spread of COVID-19. One example is how staff are using the MI principles and techniques in Cultural Orientation (CO), which is in a group setting. COs, as indicated by the Cultural Orientation Resource Exchange, are sessions for refugees resettled in the U.S. to obtain “...vital knowledge, skills, and attitudes needed to adapt to their new lives and achieve self-sufficiency.” Using MI through CO sessions can be done through the following approach: 

  1. During CO, a health engagement client-facing staff member introduces themselves and their role.
  2. The client-facing staff member then talks briefly about their work trying to stop the spread of COVID-19, including their work to stop the disproportionate impact on refugee and immigrant communities.
  3. The client-facing staff member then provides brief information about the COVID-19 vaccine. 
  4. The client-facing staff member then begins asking Open-Ended Questions. For example, “What are reasons people may want to get the vaccine? What are reasons people may not want to get the vaccine? If you received the vaccine and feel comfortable sharing, we would love for you to tell us about your experience.” 
  5. As people respond, the client-facing staff member uses the techniques of Affirmation and Reflection to allow people to feel heard, understood and to build trust.
  6. Client-facing staff members summarize the conversation with a special emphasis on anything that may have been a personal positive experience.
  7. After summarizing, client-facing staff members share information related to the vaccine and are sure to include where they got the information and why it is trusted. Client-facing staff members then make themselves available afterward for more questions, to hand out in-language information, or to assist with scheduling a vaccination appointment and transportation. For those unsure or not ready, the client-facing staff member asks if it is okay to follow up in a few weeks' time. For clients who agree to a future check-in, RCLs can make follow-up calls and note further concerns expressed.

To best interact with clients, it is important to remember that clients are at different stages in the vaccination journey. It is equally important to not “push” individuals, rather meet people where they are, making sure they have relevant, accurate information in their preferred language. From the conversations IRC Salt Lake City had with vaccinated individuals, most responses were related to a desire to protect their family. With an MI approach, more people were ready to talk and some were ready for vaccination after exploring these thoughts on family protection. In one case, the Salt Lake City team spoke with a hesitant client who remained uncertain due to the concern that their brother’s DNA changed from the vaccine. Although nothing was instantly changed, it was a very positive interaction which allowed the client to feel like they were getting the information they needed and still had choice and agency, feeling safe to ask questions. 

Benefits and Challenges to Motivational Interviewing

The benefits to motivational interviewing include the ability to:

  1. Meet clients where they are. It is not an issue of a lack of information; rather, sending the same messages is not always effective. This MI approach adapts to changing contexts.
  2. Listen not tell. Allowing people to engage in conversations the way they see is best through a non-intimidating, non-forceful approach allows clients to be heard and understood.
  3. Target and Tailor. Opening up honest questions and concerns. Individuals in the community might think of the agency as an authority figure. This approach takes a bottom-up approach as staff members are there to listen and understand real concerns.

There are also implementation challenges. The agency must have the time and space to conduct these activities. You need to have someone who is able to meet (in-person safely or over the phone). This is typically a 1-1 approach which is labor and time-intensive. Additionally, you need to be flexible and be able to modify approaches within various languages. In one of the group CO sessions for Salt Lake City, it was primarily Kinyarwanda speakers so individuals were able to communicate easily. However, when there were multiple languages in a group, there was cross dialogue with different interpreters (in one session, this was a mix of English, Arabic, Kinyarwanda, Dari and Burmese speakers), adding to the complexity of exchanging thoughts. The Salt Lake City office adapts and addresses the concerns per language simultaneously, despite the challenges that can persist for cross-dialogue. 

Ultimately, it is important to keep in mind a listening mindset. Staff members are there to listen. As indicated by IRC Salt Lake City, this approach redefines roles through a “paradigm shift” alongside the changing context of COVID-19. Speak with, not at. Listen, not tell.

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