Stephan L Foster PharmD CAPT Ret USPHS Professor University of Tennessee College of Pharmacy Liaison Member CDC Advisory Committee on Immunization Practices ACIP Objectives At the end of this session the active participant will ID: 779582
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Motivational Counseling for Vaccine Hesitant Patients
Stephan L. Foster, Pharm.D.CAPT (Ret) U.S.P.H.S.Professor University of Tennessee College of PharmacyLiaison Member CDC Advisory Committee on Immunization Practices (ACIP)
Slide2ObjectivesAt the end of this session, the active participant will:
Understand why some patients/parents are hesitant to receive vaccinesUtilize the techniques of motivational interviewing when discussing vaccines with hesitant patientsGiven a patient scenario, identify statements made by the patient that can be used in motivational counseling
Slide3Consultative Methods
TraditionalProvide InformationI am the expertLecturesI need to educateI tell the patientI do disease managementProcessLengthyRepetitive/BoringPatient
may or may not understand
Interactive
Verify Understanding
Patients do not have to hear things they already understand
Short - Fill in gaps
Every one is different
Interactive - patient actively involved
Verbalizes or demonstrates understanding
Slide4Predictors of Change
ImportanceConfidence in productRapport with provider
Slide5Reasons for Vaccine Hesitancy
Your thoughts?
Slide6Reasons patient delay or refuse vaccinations
Smith PJ, Humiston SG, Marcuse EK,et al. Parenteral Dely or refusal of vaccine doses., childhood vaccination coverate at 24 months of age and the health belief model. Public Health Rep. 2011;126(Suppl 2):135-146
Slide7Flu Excuses
I got the flu from the flu shotI never get the fluIt’s too late in the seasonI do not like shotsVaccine does not workOnly old people die from the fluI can take Echinacea, vitamin C, ……Flu is not a serious diseaseI am not at risk for fluI had the vaccine last year and got the fluI don’t believe in the flu vaccineIf I have symptoms, I will stay home and not spread it.Vaccine is not safeThe government_______________It weakens my immune systemI am on _____ medicine and should not get the vaccineVaccine strengthens the virus
Slide8Specific ConcernsToo many shots
Additives ThimerosalMMR and AutismAssociation with high-risk behaviorInfluenza not seriousVaricella is harmless
Slide9Why Some Parents HesitatePerceived Risk
False BeliefsOverwhelmed/Does not understandCan control child’s susceptibilityUnreliable vaccine information and negative mediaPrefer inactivity to negative outcomesHerd ImmunityAlternate Medical BeliefsDirect experience with adverse effectsProvider attitudes
Slide10Motivational Interviewing(Counseling)
Many evolving definitionsOriginated in addiction counselingDefinitionPatient centered, guided method of counseling by exploring and resolving ambivalence and resistance.Provide information exchange with patient to facilitate a change in behavior
Slide11Berger and
Villaume, 2013
Slide12Do Not Argue
Slide13Goal: Patient Centered Care
Understand biomedical, social, and psychological factors relating to illnessPerceive the patient as a person and they have the right to decide - RespectIndividualized careInvolve patients in decision making – shared decisionBe aware of your own response and unintended behaviorsShow you care“Patients do not care how much you know until they know how much you care”
Slide14Change TalkAsk about disadvantages about not changing
“What concerns do you have about not taking the flu shot”Ask about advantages about changing“How can getting the flu shot help you”Ask about being successful in changing“What do you think would help you in making the decision to get vaccinated”Ask about the intention to change“You said that you will consider getting the flu shot. When do you think that time will come?”
Slide15TechniquesOpen-ended questions
Reflective ListeningDo not reinforce resistance talk“Sounds like you may consider vaccination if it did not cause the flu.”Affirmation of positive statements“I am pretty sure if you were convinced the needle does not cause pain, you would consider getting the vaccination.”Summarize
Slide16Open Ended Words
How Why What When Where
Slide17Open-Ended Questions
How can I help you with ___?Help me understand ___?How would you like things to be different?What are the good things about ___ and what are the less good things about it?When would you be most likely to___?What do you think you will lose if you give up ___?What have you tried before to make a change?What do you want to do next?
Slide18Reflective Listening
Repeating or rephrasingListener repeats or substitutes synonyms or phrases, and stays close to what the speaker has saidParaphrasingListener makes a restatement in which the speaker’s meaning is inferredReflection of feelingListener emphasizes emotional aspects of communication through feeling statements. This is the deepest form of listening.
Slide19Reflective Listening“So
you feel…”“You’re wondering if…”“It sounds like….”“What I hear you saying…”“So on the one hand it sounds like …. And, yet on the other hand….”“It seems as if….”“I get the sense that….”“It feels as though…
Slide20Affirmation of Positive Statements
“I appreciate that you are willing to meet with me today.”“You are clearly a very resourceful person.”“You handled yourself really well in that situation.”“That’s a good suggestion.”“If I were in your shoes, I don’t know if I could have managed nearly so well.”“I’ve enjoyed talking with you today.”
Slide21Normalizing
Lets patients know it is not uncommonPhrases“A lot of people are concerned about changing their [insert risky/problem behavior].”“Most people report both good and less good things about their [insert risky/problem behavior].”“Many people report feeling like you do. They want to change their [insert risky/problem behavior], but find it difficult.”That is not unusual, many people report having made several previous quit attempts.”“A lot of people are concerned about gaining weight when quitting.”
Slide22Steps to Counseling
Develop rapport with empathy and asking permissionProvider: “Since we are starting influenza season, I would like to see if I can offer you an influenza vaccination today?” Patient: “No thank you, I do not want to get the vaccine this year.”Provider: “You have always received the vaccine in the past. Something must have happened to make you not want the vaccine. Can we talk about it?”
Slide23Steps to CounselingRespond by reflecting and reframing
Patient: “I was told by a friend that the vaccine does not always protect against the flu and is not really necessary.”Provider: “This friend of yours does not think the vaccine is very effective and therefore is not needed. What level of protection would be important to you before you would consider the vaccine?”
Slide24Steps to CounselingAsk permission to provide information
Patient: “I do not know. I guess I have not thought about it like that.”Provider: “Would you mind if I shared some information with you and then you could tell me what you think?
Slide25Steps to CounselingProvide the information and ask for feed back
Listen and reflectPatient: “Sure. What do you have?”Provider: “As you already know, no vaccine, or medication, is 100% effective. Also the ability for the vaccine to work depends upon many factors as explained in this information sheet.”
Slide26www.immunize.org
How effective is influenza vaccine? Protection from influenza vaccine varies by the similarity of the vaccine strain(s) to the circulating strains, and the age and health of the recipient. Healthy people younger than age 65 years are more likely to have protection from their influenza vaccination than are older, frail individuals. It is important to understand that although the vaccine is not as effective in preventing influenza disease among the elderly, it is effective in preventing complications and death. In general, the immunity following influenza vaccination rarely lasts longer than a year.
Slide27Steps to CounselingAsk the patient for feedback in a non-judgmental way
Provider: So what is your opinion about getting the vaccine now?”Support the patients decisionSummarize and plan next stepsGive vaccineWait until next visit
Slide28Steps to CounselingPossibilities
Patient says yesGive vaccine todayPatient wants to wait or think about itReassure patients decisionLet patient know that disease does not waitPatient says “No!”Ask permission to readdress this issue at the next patient visit.
Slide29Handouts (IAC)
Slide30Slide31Slide32Slide33Role Play
Pick your partner
Slide34CaseA parent of a 13 year-old female is hesitant about her receiving a HPV vaccine. Patient does not want to have this given.
You need to convince her that she needs this important vaccine to prevent human papillomavirus disease
Slide35CounselingOpen-Ended Question
“Sounds like you already made your decision. Help me understand why you do not want to give this vaccine to your daughter”Parent“Since she is not sexually active, I do not see why she should get it at this time.”
Slide36CounselingReflective Listening
“You are right. I see your point that she is not active at this time. A lot of people feel the same way you do. However are you aware that this vaccine is only preventative? If given after exposure, it is too late. Would you mind if I share some important information about HPV with you?”Parent“That would be fine.”
Slide37Counseling
Provide informationVerballyWritten
Slide38CounselingAsk for response
“Now that you have seen this, how do you feel about the vaccination now?”Parent:“You have shown me some new information, however I still want to think about it”
Slide39CounselingAccept patient’s decision
“I understand that this is a lot to think about and you need a little more time. I really think this is important for your daughter. Please let me know if there is more information I can provide.” Ask permission to revisit“Can we schedule another time to discuss this again?” or “If it is OK with you, can we talk more at your next visit?”
Slide40Case DiscussionThere are wrong techniques to use with motivational interviewing, however there is no one way to perform it. You have to flow with the patient.
Slide41Questions?