Development of PIVOT with MI: A Motivational Interviewing-Based Vaccine Communication Training for Pediatric Clinicians

Abstract

Delay or refusal of childhood vaccines is common and may be increasing. Pediatricians are parents’ most trusted source for vaccine information, yet many struggle with how to communicate with parents who resist recommended vaccines. Evidence-based communication strategies for vaccine conversations are lacking. In this manuscript, we describe the development and perceived usefulness of a curriculum to train clinicians on a specific vaccine communication strategy as part of the PIVOT with MI study, a cluster randomized trial testing the effectiveness of this communication strategy on increasing childhood vaccination uptake among 24 pediatric practices in Colorado and Washington. The communication strategy is based on the existing evidence-based communication strategies of a presumptive format for initiating vaccine conversations and use of motivational interviewing if hesitancy persists. Focus groups and semi-structured interviews with pediatric clinicians helped inform the development of the training curriculum, which consisted of an introductory video module followed by 3 training sessions. Between September 2019 and January 2021, 134 pediatric clinicians (92 pediatricians, 42 advanced practice providers) participated in the training as part of the PIVOT with MI study. Of these, 92% viewed an introductory video module, 93% attended or viewed a baseline synchronous training, 82% attended or viewed a 1^st refresher training, and 77% attended or viewed a 2^nd refresher training. A follow-up survey was administered August 2020 through March 2021; among respondents (n=100), >95% of participants reported that each component of the training program was very or somewhat useful. These data suggest that the PIVOT with MI training intervention is a useful vaccine communication resource with the potential for high engagement among pediatric clinicians.

Introduction

Vaccine-hesitant parents (VHPs) are a large (10–30%),^1–5 heterogeneous group of parents who refuse and/or delay at least 1 recommended vaccine for their children⁶ and represent an important population for interventions aimed to improve vaccine acceptance.⁷ Pediatricians have consistently been shown to be the most trusted source of vaccine information for VHPs.^1,6,8–10 The quality of a provider’s recommendation has consistently been associated with increased uptake of childhood and adolescent vaccines.^11–18 Opel et al. have shown that the communication format used to initiate the vaccine recommendation matters: a presumptive (e.g., “Anna is due for three shots today.”) rather than a participatory (e.g., “How do you feel about vaccines today?”) format was associated with increased parental vaccine acceptance of childhood vaccines,^19,20 a finding confirmed in a randomized controlled trial (RCT) testing this type of introductory format for HPV vaccine.²¹ However, many providers lack confidence in communicating with parents who have concerns about vaccines² or perceive their discussion wi ll do little to change a parent’s mind.²² To address these barriers, some have explored the feasibility and efficacy of using Motivational Interviewing (MI) when parents resist the vaccine recommendation. In common use since the 1980s, MI is an evidence-based, patient-centered framework for behavior change^23–27 that is effective even when delivered in a single session.^25,28 The 3 essential elements of MI—having a conversation, leveraging inherent motivation for behaviors, and making the conversation person-centered—make it well suited for use with VHPs given their known vaccine communication preferences of open conversations with trusted messengers.^6,10

A major gap in our understanding of how to effectively communicate with parents in the early childhood vaccine context is the lack of experimental evidence for specific strategies. Though experimental evidence has emerged in the adolescent vaccine context, data in the early childhood vaccine context supporting specific communication strategies like the format of the vaccine recommendation remains observational and from small sample sizes.²⁹

We are currently conducting a cluster RCT in Washington and Colorado to evaluate the effect of a provider communication strategy that combines these 2 communication strategies—the Presumptively Initiating Vaccines and Optimizing Talk with Motivational Interviewing (PIVOT with MI) intervention—on child immunization status as well as on parent and provider experience.³⁰ The PIVOT with MI intervention involves having providers use the presumptive format to initiate the childhood vaccine recommendation with all parents followed by use of MI if a parent verbally resists the recommendation. This tiered approach involving 2 complementary communication strategies has the potential to have the additive effect of improving parental vaccine acceptance and provider self-efficacy while preserving a highly-rated parent visit experience. The objectives of this manuscript are to describe the development of the training curriculum for the PIVOT with MI study, the training program participation, and the perceived usefulness of the training program’s components.

Methods

PIVOT with MI is a cluster-randomized trial among 24 pediatric practices in two practice-based research networks (PBRNs) in Colorado and Washington.³⁰ Some of the initial content for the curriculum was based on prior work done by study team members, including formative work regarding a presumptive initiation style for introducing vaccinations^19,20 and a cluster-randomized trial of a motivational interviewing-based communication training to increase uptake of HPV vaccine.^31,32 The theoretical basis for the PIVOT with MI curriculum was developed based on insights from behavioral economics and decision psychology³³ applied to the vaccine encounter³⁴ and is described in detail elsewhere.³⁰

Curriculum Planning

The educational portion of the PIVOT with MI curriculum incorporated several approaches based on adult learning theory³⁵ shown to be effective in changing provider behavior,^36,37 including interactive and tailored educational outreach,³⁸ trainee rehearsal and coaching,³⁹ audit and feedback,⁴⁰ booster learning sessions,³⁹ and change agents.⁴¹ Because we planned to implement PIVOT with MI across diverse populations, including among Spanish-speaking parents, we also drew upon evidence regarding culturally adapting behavioral interventions in community settings.^42,43

A priori, we planned for the curriculum to include 4 components. The first component would be an online video module introducing the PIVOT with MI communication strategy, its rationale, and a model vaccine visit utilizing it. The second component would be an in-person interactive provider training session including: a) a brief didactic session on vaccine hesitancy, how the PIVOT with MI strategy addresses vaccine hesitancy, and practice data on vaccination coverage and vaccine hesitancy prevalence; b) baseline assessments of provider skills using the presumptive format and MI; and c) modeling of the PIVOT with MI intervention followed by provider rehearsal through role-playing and coaching by the study team. The third component would include provider reference sheets with brief and accessible summaries of the communication behaviors the comprise PIVOT with MI, along with example statements for key steps in the PIVOT with MI communication strategy. The fourth component would be two refresher trainings at 3–6 and 9–12 months after the baseline training that included a question and answer session regarding barriers to implementing the PIVOT with MI intervention, with example interactions conducted by the study team and transcripts from videotaped visits showcasing proper versus improper use of MI. We also planned to enlist a study champion at each practice to aid in carrying out study activities.

Curriculum Development

To inform curriculum development, we conducted two in-person provider focus groups involving 6 providers in Washington and 11 in Colorado at the start of the development process (November 2018) to elicit provider input on the format, length, and content of the above curriculum components as well as to identify design and acceptability issues. Study team members reviewed moderator notes and transcribed audiotapes from the initial provider focus groups to inform the initial drafts of the intervention’s components. We heard general support for the preconceived 4 components of the training curriculum as long as the training sessions were relatively short (30–45 minutes) and were focused on a specific set of techniques, such as which MI techniques were useful and how they could specifically be integrated into a vaccine conversation.

Next, a draft video module was developed in collaboration with CU Productions (https://cuproductions.tv/). The objectives of the online module were to introduce the presumptive format and 5 key motivational interviewing techniques adapted to the vaccine discussion in preparation for the in-person trainings. The script was iteratively developed by the study team based on common scenarios as discussed in the provider focus groups and sent to CU Productions where a storyboard was created.

We then conducted 2 additional focus groups in July 2019 that included a set of 5 providers in Washington and 7 in Colorado who were not involved in the prior focus groups to provide feedback on the storyboard. The study team again reviewed moderator notes and transcribed audiotapes to iteratively identify and address design, content, and format issues to the storyboard raised by focus group participants. A revised storyboard was then returned to CU Productions for final creation of the video module. The final online video module was 18 minutes long, animated, and used professional voice actors playing a pediatrician and a model parent. The module began by introducing the presumptive format followed by evidence supporting the use of motivational interviewing if push back from a parent persists. The theoretical basis for both the presumptive format and motivational interviewing were also presented. The 5 specific motivational interviewing techniques included in the module (and the subsequent trainings) included: 1) open-ended questions; 2) affirmations; 3) reflections; 4) “asking permission to share” (sometimes referred to “elicit-provide-elicit”); and 5) autonomy support. There were two demonstrative scenarios to illustrate both presumptive and motivational interviewing techniques:

1. refusal of hepatitis B vaccine because of concerns that the child was not at risk of disease, and

2. refusal of measles-mumps-rubella vaccine because of concerns that it could cause autism.

With each of these, the techniques were labeled as the animated doctor demonstrated how to use them in conversation.

The in-person trainings, including the baseline training and the two refresher trainings, were developed by the study team as Power Point presentations and were designed to be interactive. Because of the SARS-CoV-2 pandemic, a subset of the in-person trainings were done using online remote platforms. Recorded versions were created for providers who could not participate in person due to scheduling conflicts. The baseline training consisted of 29 slides and included the following objectives: 1) Understand how to use the presumptive format to initiate the vaccine discussion; 2) Demonstrate skill in using the presumptive format; 3) Identify parental disposition toward vaccination; 4) Understand core MI spirit, skills, and strategies for working with VHPs; and 5) Demonstrate skill in using MI with VHPs. Content included slides on the evidence supporting a presumptive initiation format and MI, a brief video demonstrating use of the presumptive format, five “Presumptive Pearls” (tips for use of a presumptive vaccine initiation discussion), the aforementioned 5 MI techniques introduced in the online module, and instructions for a PIVOT with MI Role Playing Activity for participants. The first and second refresher trainings used a combination of content from the baseline training to reinforce the training (e.g., the “presumptive pearls” and MI techniques) and new content, including a videotaped mock clinic encounter followed by an interactive “debrief” on what was said and what could have been said, additional “tips and tricks” for presumptive initiation and motivational interviewing, and review of a script from a videotaped clinical encounter with a VHP, again followed by an interactive “debrief.” Additionally, the second refresher training ended with tips from clinicians gathered informally in the first refresher training (e.g., “‘Asking permission to share’ has been a game changer. It has really changed the conversation. If there is one MI skill I try to implement each time I do MI, it’s this one.”).

While the training sessions were being developed, the study team incorporated important points from the trainings into the provider tip sheets. All participating providers were given a laminated version of the final tip sheet (Figure 1).

Figure 1.

Incentives and Evaluation

Clinicians from the formative focus groups were provided with a $100 gift card for participation. Physicians who completed all of the trainings were eligible to receive Maintenance of Certification Part 4 credit via the American Board of Pediatrics and Continuing Medical Education (CME) credit via Seattle Children’s Hospital CME office.

We tracked participation in the trainings through sign-in sheets for in-person activities and by roll call through the chat function for online portions. Participants who were unable to join the live trainings but completed the recorded trainings informed the study team upon completion. Attestation forms were collected once all study activities were completed. To obtain CME and MOC credit, after viewing the module and completing all trainings, providers were required to answer an online survey (REDCap) using Likert scales. In addition to assessing several secondary study outcomes (presented elsewhere), the survey assessed perceived usefulness of the different training components (very useful, somewhat useful, not very useful, not at all useful, did not view or attend).

The online module was released for viewing by clinicians in September 2019. Baseline trainings for the majority of practices occurred from September 2019 – February 2020 (3 practices in Washington were delayed in starting the intervention while awaiting approval from their health system). First refreshers took place between January – July 2020 and second refreshers from July 2020 – January 2021.

Results

There was a total of 92 physicians and 42 APPs in the intervention practices (Colorado: 61 total; Washington: 73 total). Among those who provided demographic information in a follow up survey (n=100), 73% of participants identified as female, and the majority were White, non-Hispanic; 77% were MD/DO (Table 1). Participation in the online module and in-person trainings was high (Table 2). Overall, 92% of providers completed the online video module (range [between unique clinics]: 75–100%; Colorado: 92%, Washington: 92%), 93% completed the baseline training (range: 75–100%; Colorado: 90%, Washington: 96%), 82% completed the 1 st refresher (63–100%; Colorado: 75%, Washington: 88%), and 77% completed the 2^nd refresher (range: 50–100%; Colorado: 74%, Washington: 79%).

Table 1.

Characteristics of Clinicians Participating in the PIVOT with MI Vaccine Communication Training Intervention (n=100).

Characteristic	Survey Respondents (%)
Gender
Male	27
Female	73
Ethnicity
Hispanic	3
Not Hispanic	96
Unknown	1
Race
White	87
Black/African American	0
Asian	8
American Indian/Alaska Native	0
Native Hawaiian/Pacific Islander	0
More than 1 race	4
Unknown	1
Type of provider
MD/DO	77
PA/NP	23
Years practicing at current office
<1 year	1
1–5 years	38
6–10 year	17
11–15 years	11
16–20 years	16
>20 years	16
Unknown	1
Number of patients ≤ 2 years old seen per week (self-report)
<20	24
21–30	48
31–40	17
> 40	11

Abbreviations: PIVOT with MI, Presumptively Initiating Vaccination and Optimizing Talk with Motivational Interviewing; MD, Medical Doctor; DO, Doctor of Osteopathy; PA, Physician Assistant; NP, Nurse Practitioner.

Table 2.

Clinician Participation in the PIVOT with MI Training by Practice and Overall (n=134).

Clinic	Number of Clinicians	Viewed Video Module		Attended or Viewed Baseline		Attended or Viewed 1st Refresher		Attended or Viewed 2nd refresher
		n	%	n	%	n	%	n	%
WA01	25	22	88%	25	100%	21	84%	19	76%
WA02	10	10	100%	10	100%	10	100%	10	100%
WA03	3	3	100%	3	100%	3	100%	3	100%
WA04	8	8	100%	7	88%	6	75%	6	75%
WA05	14	13	93%	13	93%	12	86%	10	71%
WA06	13	11	85%	12	92%	12	92%	10	77%
CO01	7	7	100%	7	100%	7	100%	6	86%
CO02	12	10	83%	10	83%	6	50%	5	42%
CO03	15	13	87%	14	93%	11	73%	12	80%
CO04	11	11	100%	11	100%	11	100%	11	100%
CO05	2	2	100%	2	100%	2	100%	2	100%
CO06	14	13	93%	11	79%	9	64%	9	64%
Total	134	123	92%	125	93%	110	82%	103	77%

Abbreviations: PIVOT with MI, Presumptively Initiating Vaccination and Optimizing Talk with Motivational Interviewing; WA, denotes practice based in Washington; CO, denotes practice based in Colorado.

Among clinicians who stated at initiation of the study that they desired CME credit (n=120), 95 completed the module plus trainings and received credit (79%). Among physicians who stated at initiation of the study that they desired MOC Part 4 credit (n=91), 69 completed all requirements and were awarded MOC credit (76%).

Among clinicians who completed the follow up survey (n=100), the four components of the intervention were generally considered highly useful, with greater than 95% of clinicians who viewed or attended each component reporting all of them as at least very or somewhat useful (Figure 2). More specifically, 53% considered the online module to be very useful (42% somewhat, 2% didn’t use or view), 73% very and 23% somewhat useful for the baseline training (3% didn’t use or view), 55% very and 40% somewhat useful for the 1^st refresher (4% didn’t use or view), and 46% very and 38% somewhat useful for the second refresher (12% didn’t use or view).

Figure 2.

Perceived Usefulness of the Training Components of the PIVOT with MI Intervention (n=100).

Abbreviations: PIVOT with MI, Presumptively Initiating Vaccination and Optimizing Talk with Motivational Interviewing.

Discussion

In this manuscript, we describe the development of, participation in, and perceived usefulness of a motivational interviewing-based vaccine communication training program for pediatric clinicians. The training program was based on a conceptual framework and developed with clinician input. Completion of the program qualified clinicians for both CME and MOC Part 4 credit. Participation in the training program was high. Overall, clinicians perceived the various components of the training curriculum as useful.

Evidence-based techniques for communicating with parents about childhood vaccines are sorely needed. Two recent Cochrane reviews examining the evidence for communicating with parents about childhood vaccines concluded that the evidence was of low quality and suggested that face-to-face communication had little or no impact on parental attitudes about vaccines or child immunization status.^44,45 While this is perhaps an overstatement of the problem – every primary care pediatrician can describe success stories of conversations that convinced parents to vaccinate their children – it does speak to the need for evidence about how to train clinicians to have those conversations in the most effective and efficient ways. There are many communication training programs in existence, but most have not been developed with the rigor of the one we present in this manuscript, and none are effective in a randomized trial. Additionally, we had very high participation rates for the evaluation of our curriculum. Investigators in similar studies should consider our methods when designing intervention trials of this nature, specifically our use of financial incentives for interviews and focus groups and making survey response a requirement for receiving MOC credit.

Communication dynamics have been shown to be a key influential factor affecting health behavior,⁴⁶ but most resources developed for clinicians when they encounter VHPs do not account for these dynamics. Instead, these resources are primarily based on the so-called Information Deficit Model,⁴⁷ which assumes that vaccine resistance is due to a lack of knowledge and that the solution is to provide more information. It has been known for many decades, though, that simply providing information often does not influence behavior and may even create a dynamic in which an individual is actually less receptive to information a clinician may impart.^48–50 By training providers to use communication techniques based on principles of MI when parents voice resistance to a presumptive vaccine recommendation, we seek to avoid this negative dynamic and thus better equip providers to change the vaccination behavior of VHPs.

The development of PIVOT with MI and almost all baseline trainings took place prior to the onset of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic, while much of the delivery of refresher trainings took place during the pandemic, and this may have impacted some of our findings. For example, perceptions of the curriculum as “very useful” declined from the baseline training to the first refresher training and even further to the second refresher training. This could represent pandemic fatigue, displeasure with a virtual format, the lack of need for refresher trainings, or potentially a combination of all of these. Further evaluation of both this intervention and future interventions should pay particular attention to the pros and cons of in-person versus virtual training sessions and the need of refresher trainings.

There are some limitations to the evaluation of the curriculum presented here. First, respondents may have differed from non-respondents. Second, our findings regarding usefulness of the intervention may reflect social desirability bias. Finally, although we attempted to incorporate adult learning theory techniques to promote long-term adoption of the techniques we were teaching, perceived usefulness may not reflect ultimate adoption and sustained use of the communication skills taught within the curriculum.

Conclusions

The PIVOT with MI curriculum was developed to combine two promising communication techniques for increasing uptake of recommended childhood vaccines. Provider participation was high, as was perceived usefulness, findings which bode well for future dissemination of this intervention. This vaccine communication curriculum represents one of the few being tested in a large, randomized trial. Further evaluation will determine the effectiveness of this promising intervention.