Motivational Interviewing for Maternal Immunizations: Intervention Development

Abstract

Background and Objective:

Vaccine uptake during pregnancy remains low. Our objectives were to describe 1) development and adaptation of a clinician communication training intervention for maternal immunizations and 2) obstetrics and gynecology (ob-gyn) clinician and staff perspectives on the intervention and fit for the prenatal care context.

Methods:

Design of the Motivational Interviewing for Maternal Immunizations (MI4MI) intervention was based on similar communication training interventions for pediatric settings and included presumptive initiation of vaccine recommendations (“You’re due for two vaccines today”) combined with motivational interviewing (MI) for hesitant patients. Interviews and focus group discussions were conducted with ob-gyn clinicians and staff in five Colorado clinics including settings with obstetric physicians, certified nurse midwives (CNMs), and cliniciantrainees. Participants were asked about adapting training to the ob-gyn setting and their implementation experiences. Feedback was incorporated through iterative changes to training components.

Results:

Interview and focus group discussion results from participants before (n=3), during (n=11) and after (n=25) implementation guided intervention development and adaptation. Three virtual, asynchronous training components were created: a video and two interactive modules. This virtual format was favored due to challenges attending group meetings; however, participants noted opportunities to practice skills through role-play were lacking. Training modules were adapted to include common challenging vaccine conversations and live-action videos. Participants liked interactive training components and use of adult learning strategies. Some participants initially resisted the presumptive approach but later found it useful after applying it in their practices. Overall, participants reported that MI4MI training fit well with the prenatal context and recommended more inclusion of non-clinician staff.

Conclusions:

MI4MI training was viewed as relevant and useful for ob-gyn clinicians and staff. Suggestions included making training more interactive, and including more complex scenarios and non-clinician staff.

Introduction

The Centers for Disease Control and Prevention (CDC) recommends influenza and Tdap (tetanus, diphtheria, and acellular pertussis) vaccination during pregnancy to protect both the pregnant person and the child from risks of influenza and pertussis.^1–7 Despite these recommendations, U.S. vaccination coverage during pregnancy was only 55% for influenza, 54% for Tdap, and 31% for both vaccines during the 2020–21 influenza season.⁸ Receiving a provider recommendation for vaccination during pregnancy is associated with vaccine acceptance, whereas the lack of a recommendation is a known barrier.^9–13 However, recent CDC data found only 60% of people received a provider offer or referral for both Tdap and influenza vaccines during pregnancy.⁸

Obstetrics and gynecology (ob-gyn) clinicians (including physicians and certified nurse midwives) identify several patient concerns as barriers to vaccination including questions about the safety of vaccination and risks for the baby, issues related to trust of vaccines and the medical system, and questions about the need for and effectiveness of influenza and Tdap vaccines.^8,14–16 A nationally representative survey of U.S. ob-gyn clinicians identified commonly used messages to communicate vaccine safety and risks of not getting vaccinated during pregnancy, but evidence for the effectiveness of those messages is lacking.¹⁶ Noting that a provider recommendation is associated with vaccine acceptance and that vaccine hesitancy and specific patient concerns continue to be barriers, strengthening clinician communication skills may be a promising way to increase maternal immunization.

Motivational interviewing (MI) is an evidenced- based communication framework for behavior change that emphasizes having a person-centered conversation and building upon an individual’s inherent motivation for behaviors.^17–22 MI has proven effective for improving immunization acceptance when used in the postpartum period and in communicating with vaccine hesitant parents about pediatric vaccines.^23,24 A randomized-controlled trial of a clinician communication training intervention instructing on how to make a strong recommendation for vaccination and apply brief MI techniques to vaccine conversations resulted in increased adolescent human papillomavirus (HPV) vaccination rates and improved clinician confidence in communication skills.²³

To test the feasibility and fit of a similar clinician communication training intervention in the prenatal care context, we proposed the Motivational Interviewing for Maternal Immunizations (MI4MI) intervention.²⁵ Because some concerns about vaccination during pregnancy are distinct from pediatric vaccine concerns, ob-gyn clinicians may have different communication approaches and experiences than pediatric clinicians. General approaches to risk of clinical interventions vs non-intervention are unique during pregnancy, affect both the health of the pregnant person and the baby (sometimes not in the same way), and often shift after delivery.²⁶ Vaccination decisions during pregnancy may differ between first and subsequent pregnancies²⁷ and ob-gyn clinicians may underestimate their influence on patient vaccination decisions.²⁸ Further, the context of prenatal care is unique in many ways and interventions previously developed for pediatric contexts may need to be adapted significantly for maternal immunizations. While vaccination has been central to pediatric care for many decades, development of vaccination infrastructure in obstetric settings is more recent and less robust.^29,30 Our objectives in this study were to describe 1) development and adaptation of a clinician communication training intervention for maternal immunizations and 2) obstetrics and gynecology (ob-gyn) clinician and staff perspectives on the intervention and fit for the prenatal care context.

Methods

In this manuscript we describe the development, adaptation, and fit of the MI4MI intervention implemented in ob-gyn clinics as part of a larger study.²⁵ Clinic recruitment began in late 2019 and continued through October 2020. Two clinics that initially agreed to participate and provided feedback before intervention implementation later declined participation due to clinic demands associated with the onset of the COVID-19 pandemic. Additional clinics were recruited to reach a total of five participating clinic sites for implementation. We targeted five participating clinics to achieve our goal sample size for chart reviews of patient vaccination status (analysis ongoing). The providers at these clinics included obstetric physicians, certified nurse midwives (CNMs), and clinician-trainees providing prenatal care. Non-clinician staff were able to participate in all aspects of the MI4MI training intervention, but training content and recruitment was tailored toward clinicians. This study involved qualitative interviews and focus group discussions with ob-gyn clinicians and staff and was approved by the Colorado Multiple Institutional Review Board.

Intervention Development and Adaptation

The MI4MI intervention was based on similar clinician communication training interventions for HPV and early childhood vaccinations.^23,31 These previously developed interventions taught clinicians to use a presumptive recommendation for vaccination, (“Today you’re due for two vaccines”) followed by the use of brief MI skills with hesitant patients/parents. These brief MI skills include asking permission to share information, providing autonomy support, and using open-ended questions, affirmations, and reflection statements (Table 1). The pediatric interventions included introductory video presentations for participants to view before attending two in-person training sessions at their clinic. In addition to incorporating some general vaccine hesitancy information from pediatric interventions, MI4MI intervention content addressed common barriers to vaccination during pregnancy and vaccine concerns of pregnant patients identified from existing literature. Clinician feedback from interviews before and during implementation informed further adaptation of MI4MI intervention content and format.

Table 1:

Motivational Interviewing (MI) Skills Included in MI4MI Training Intervention

Brief MI Skills	Explanation	Example
Open-ended questions	Explore and understand a patient’s stance on vaccination	“What have you heard about these vaccines?”
Affirmation	Show support and appreciation for a patient by highlighting positive attributes	“I can tell you’re being very thoughtful about this decision”
Reflection	Confirm understanding of a patient’s viewpoint and help patient better understand their own motivations	“It sounds like you are concerned about side-effects from the flu vaccine AND you want to keep your baby healthy”
Ask permission to share	Improve patient receptivity by asking first before presenting more information	“Would it be ok if I share with you what I’ve learned about using these vaccines during pregnancy?”
Autonomy support	Letting patient know they are in control.	“Ultimately this decision is up to you.”

To understand the context of vaccination conversations and strategies in pregnancy, we first conducted interviews with a total of three ob-gyn clinicians before developing the MI4MI intervention (Figure 1). Clinicians were recruited by email from ob-gyn clinics that had agreed to participate in the MI4MI intervention. The interviews were conducted via online videoconferencing and each lasted 45–60 minutes. Study team members (SB and JC) with background in vaccine hesitancy and communication conducted the interviews using semi-structured guides. Topics included feedback on proposed intervention components, clinician experience communicating with pregnant patients about vaccines, and factors unique to ob-gyn settings that should be considered in intervention development including organizational and contextual considerations. The pre-intervention interviews were recorded and summary notes compiled by study team members (SB, JC, MF). Summary notes were reviewed for important themes to inform initial development of the MI4MI intervention delivery format and content of the introductory video and first interactive training module. Throughout the study, participants in an interview or focus group discussion received an electronic gift card in appreciation for their time.

Figure 1:

Timeline of Study Activities and MI4MI Intervention Implementation

During implementation of the MI4MI intervention, we conducted midpoint interviews with 11 clinicians and staff members (6 CNMs, 1 resident physician, 1 attending physician, 1 medical assistant, 1 nurse, and 1 practice coordinator) from participating ob-gyn clinics (Figure 1). We attempted to continue interview recruitment until thematic saturation was reached. We were unsuccessful in recruiting participants from one resident physician clinic and had higher participation among our two midwife clinics. Midpoint interviews lasted 30–60 minutes and were conducted by phone or videoconferencing using semi-structured interview guides. Midpoint interviews were conducted by three researchers (SB, JC, MF) who had relationships with participants as members of the study team. Topics included feedback on the content and format of the first two MI4MI training components (introductory video and first interactive module, Figure 1), and content and format suggestions for the upcoming second interactive module. Summary notes were compiled and reviewed for themes in real time to inform development of the second interactive module.

Experiences with the intervention and fit for the prenatal context

Midpoint interviews (as described above) and post-intervention focus group discussions (conducted after implementation of the introductory video and the first and second interactive modules) were also used to understand clinician and staff experiences with the MI4MI training and fit for the prenatal context. One post-intervention focus group was conducted for each clinic with a total of 25 participants across five clinics (8 resident physicians, 7 CNMs, 3 nurses, 2 medical assistants, 2 attending physicians, 1 family nurse practitioner, 1 ultrasound technician, and 1 practice manager). Participant attendance at focus groups was reflective of training participants across our two midwife clinics, two resident physician clinics, and one traditional ob-gyn (non-midwife/non-trainee) clinic. Post-intervention focus groups were conducted by three study team members (SB, JC, MF) using videoconferencing and lasted 45–60 minutes. Semi-structured focus group discussion guides were used, and topics included feedback on the content and format of MI4MI training components, virtual training approach, and fit of the intervention with the ob-gyn setting. We limited focus groups to one per clinic but sought robust discussion and thematic saturation by allowing ample time for each session and by probing for comments from quieter participants throughout the session.

Qualitative Analysis

Midpoint interviews and post-intervention focus groups were recorded, transcribed verbatim, and entered into ATLAS.ti 8.0 (Scientific Software Development GmbH, Berlin, Germany) for coding and analysis. Coding used a mixed inductive and deductive strategy, drawing on concepts known before data collection (interview/focus group discussion guide topics, specific training components) and concepts expressed by interview/focus group participants. Two trained qualitative analysts (SB, JC) read transcripts and debriefed periodically to achieve data immersion and develop consensus on an initial code list. They then independently double coded a subset of transcripts, reviewed, and edited coding until agreement was achieved on a final list of codes and code definitions. After coding the remaining transcripts, team members reviewed coded data to identify emergent themes using a grounded theory approach. Decisions about which themes were most relevant were based upon multiple participants and/or participants from multiple clinics voicing a theme and reflected consensus among team members (SB, JC) after independently analyzing coded data.

Results

Intervention development and adaptation

Participants in the pre-intervention interviews reported that both time and motivation are a challenge for ob-gyn clinicians and staff, and therefore training materials should be succinct and include an incentive to complete, such as Maintenance of Certification (MOC) or Continuing Medical Education credits (CME). Due to the nature of ob-gyn work, participants expressed it would be difficult to reach all clinicians and staff during a scheduled meeting time for training, and therefore asynchronous and virtual trainings were preferable but would need to be highly engaging. Suggested methods of engagement included interactive elements such as clicking items on-screen, real-life video examples, as well as sound bites and key facts that are easy to remember for use in patient conversation.

One practice conveyed that many ob-gyn clinicians already have experience using the presumptive approach and motivational interviewing. They noted that this training may contain repeat information for experienced clinicians and encouraged targeting less-experienced clinicians, trainees, and other clinic staff. In describing the prenatal care context, participants noted that pregnancy care is longitudinal and development of trust is essential. They highlighted that their relationship with a patient strongly influences vaccine conversations, and that sometimes there is a lack of continuity of care. Because of this, interview participants stressed the importance of knowing the outcomes of previous vaccine conversations with other clinicians.

The MI4MI training components are outlined in Table 2 (visual examples in Supplement 1). A 22-minute animated introductory video incorporating the above issues was created to describe the processes and conversational techniques included in the overall MI4MI training intervention. The video included communication techniques for use with all patients, instructing the viewer to first presume that all patients will accept maternal vaccines before introducing additional strategies to help with those patients who remain hesitant or do not accept recommended vaccines. The video describes the spectrum of vaccine acceptance and then shares information about the presumptive approach, including language that puts vaccination as the expected course of action, or the presumed choice. Next, the video describes the use of brief MI skills (Table 1) during vaccine conversations and explains why these strategies work with vaccine hesitant patients. Several example scenarios demonstrate a presumptive vaccine recommendation and MI skills. Learning styles used in this video include visual (seeing a video and mock interactions), auditory (listening to examples), and interpersonal (encouraging role play with colleagues).

Table 2:

MI4MI Communication Training Intervention Components

Component, Format and Duration	Content	Instructional methods
Introductory video: Animated online video 22 minutes	• Background on vaccine hesitancy, communication •Presumptive approach for vaccine recommendation (“Today you’re due for two vaccines”) • Brief Motivational Interviewing (MI) skills introduced	• Didactic/explanatory • Example conversations (audio, written) • Adult learning styles: visual, auditory, interpersonal
Interactive module 1: Asynchronous virtual learning module 45–60 minutes	• Background on vaccine hesitancy • Evidence for vaccine communication techniques in non-ob-gyn settings • Presumptive approach • Brief MI skills defined and explained	• Didactic/explanatory • Example conversations (audio) • Adult learning styles: visual, auditory, linguistic, logical, intrapersonal, interpersonal
Interactive module 2: Asynchronous virtual learning module 30–45 minutes	• Review of presumptive approach and Brief MI skills	• Example conversations (video scenarios) • Adult learning styles: visual, auditory, linguistic, logical, intrapersonal, interpersonal

Both interactive training modules were developed using an interactive content creation platform (Genially) and presented on an online learning platform (Canvas) in an asynchronous virtual format. The first interactive module presented more detailed content about concepts discussed in the introductory video including vaccine hesitancy, use of the presumptive approach, and brief MI techniques. Voiceover scenarios throughout the module demonstrated how to use these communication techniques. Strategies to engage adult learners^32–35 included visual (seeing diagrams, slides, and repeated images), auditory (listening to examples), linguistic (pause for practice), logical (breaking information into flow charts and steps to follow, matching example text to specific skills), intrapersonal (time to reflect and/or practice out loud or in their head), and interpersonal (encouraging role play with colleagues).

The second interactive module reviewed the communication skills previously presented, emphasizing the importance of the presumptive approach for recommending vaccination and providing various examples of its use. The module reviewed the MI skills from prior training components, presenting additional brief examples of their use and extended patient scenarios to demonstrate skills in context of a full conversation. Strategies to engage learners included visual (seeing role-play scenarios), auditory (listening to role play examples), linguistic (pause for practice, identify phrases from the videos that correspond to specific MI skills), logical (breaking information into steps to follow, re-playing sections of mock videos to illustrate use of communication techniques), intrapersonal (time to reflect and/or practice out loud or in their head), and interpersonal (encouraging role play with colleagues). Across the five study clinics combined, a majority of participants initially engaged in the project completed all training components.

Presumptive approach concerns

After the introductory video and before completing additional training sessions, one clinic expressed concerns about the concept of the presumptive approach. In a meeting with the study team prior to midpoint interviews, this practice noted that they have been trained in using shared clinical decision-making to build strong patient-provider relationships in prenatal care. They were concerned that using a presumptive approach would not fit their otherwise collaborative and participatory style, but they also expressed interest in learning more about MI skills and completing additional MI4MI training components. We later heard from this clinic that participants had tried incorporating the presumptive approach into their practice style and were successful using it in vaccine conversations.

Experiences with the intervention and fit for the prenatal context

Participants in midpoint interviews and post-intervention focus groups overall described positive experiences with the MI4MI training intervention format. Feedback on individual training components is summarized in Table 3 with illustrative quotations in Table 4. Participants found the structure and length of the introductory video and interactive modules to be appropriate and appreciated the ability to engage with educational materials at their own pace. Some participants did not like the animated graphics in the video, and feedback that many participants preferred live-acting examples was incorporated in development of the second interactive module. Repetition of core concepts was received positively, and we continued to review basic MI skills in each training component. Participants appreciated engagement techniques that forced learners to click or type a response, so these approaches were emphasized in the second interactive module. Most people did not like the idea of talking through practice phrases and responses independently during the modules and would have liked more collaborative ways to practice communication skills, such as role-play opportunities. One participant described this as a limitation of virtual training:

Table 3:

Participant Feedback on MI4MI Intervention by Training Component

	Format	Content	Instructional methods
Introductory video: feedback after viewing video and module 1	• Length appropriate • Some thought cartoon graphics “silly”	• Content clear • Presumptive approach came on too strong (note: concerns resolved for most participants after interactive module 1)	• Liked example conversations, specific phrases/language • Would like video examples, live-acting
Interactive module 1: feedback after viewing video and module 1	• Length appropriate • Liked ability to self-pace • Some thought module could be shorter • Would like to have role play	• Content clear • Some would like more interactive parts • Some did not connect with presumptive style	• Reinforced skills from video • Was interactive enough • Matching skills to example phrases reinforced understanding • Did not like practicing phrases on their own (virtual role-play) • Prefer forced interactive component of clicking/typing response
Interactive module 2 suggestions: suggestions for changes after viewing video, module 1	• Would like options for role-play	• Would like examples of specific topics (influenza, autism, preservatives) • Would like advanced scenarios, showing when conversations don’t go well	• Would be alright to review skills again • Would like video examples
Interactive module 2 feedback: for future MI4MI iterations	• Important to train whole clinic team	• Relevant to prenatal context • Relevant even for those with experience • Noted how they could adapt skills to their style • Communication approach fits longitudinal nature of prenatal care	• Good to repeat skills again • Better seeing scenarios in live-acting videos • Interactive components helpful when you must click, are forced to interact

Table 4:

Quotations Illustrating Participant Experiences with MI4MI Training Intervention, Fit with Prenatal Care, and Suggestions for Improvement

Presumptive approach

“Our practice was a little nervous about the presumptive technique, just kind of even more so the way it was presented in the video. Once we had actually talked with you guys about it, I think we all felt a little bit better, but the way that it’s in the video, the particular example is very presumptive. She just said, “You’re getting these vaccines today.” I think we were all a little bit like, “Oh, we usually don’t approach that way” “And I mean I feel like our practice does like I just don’t feel like we are pushing. We’re very very respectful of our patients’ viewpoint.”

Format

“Well, I think, there definitely is some benefit to in person learning of concerns or questions that my peers bring up that I haven’t necessarily thought about. Though, I think that might be, if that’s a way to get that information to share virtually, I think that would be helpful to improve the virtual format.” “I think in general there was a lot of repetition. Which, on one hand could can feel like wasted time but on the other hand I think is really important to reinforce information. And so some of the concepts of how to phrase questions for those principles I think more easily settled into my memory. I couldn’t rattle them all off right now but I remember the concepts of it really well.” “I think anytime you’re learning it’s great to be able to use you know… those different skills and people who learn by listening or reading and so I think you know maybe those more tactile steps are helpful for those of us who learn it… with a different learning style.” “I do think the interactive piece and having to constantly click is a good way to keep attention and to ensure that it wasn’t just being played in the background but that you had to actively participate in it, so I do think that was helpful to remain focused.” “I think it was more, because I found it hard to practice by myself. I think it’s hard to and I don’t know what the solution to that would be, but I didn’t find that part super helpful, just ‘cause I don’t know. I think it’s better for me actually, to practice when I’m in a real-life situation.”

Content

“I thought the video was really helpful in talking about language. Showing one way of it being done and how changing the language can make it a different experience. I thought that was really helpful and useful.” “I thought that seeing, just like actual conversations or acted out conversations about how to like implement the different strategies was helpful rather than just kind of like seeing it in writing.” “I kind of wanted something new. I don’t know it made it to me it made it seem like your audience wasn’t smart. […] It was fine, but I just thought it was a little, little too basic.” “You know, it doesn’t always go like the scenario. But it’s good but it’s good to have that example nonetheless. Yeah and… I think you guys did use good examples of like somebody who has fear around a vaccine or has myths about a vaccine in their head and how to address that. That’s certainly something I would say we encounter in our patients.” “I felt like it was really good, like the scenarios were good, I felt like I could understand and relate to those more, and I think the hardest part about motivational interviewing is, when you’re in it, remembering to use all those tools. And so seeing it seen it like actual in an actual interaction seen that more times like repeated helped me to really think about that and try to incorporate those tools when I’m speaking to patients.”

Fit with prenatal context

“I think doing this in the in the OB setting is pretty ideal because we see patients that have certain at certain intervals and so you can like [she] said you can kind of tee them up, you know, all through their second trimester, and then you hit third and you just like they’re prepped for this. But it also of course starts a great conversation with them, they have their baby and then you talk about the baby’s vaccine so I think that, you know, something like this should be almost pushed more in an OB visit...” “I think that’s the reason why it would be really helpful to get the clinic staff, kind of trained as well because we only get like it’s a 20 minute visit to address all of these things, and we really only spend like 10 minutes of that with them. And so being able to have that from multiple people, I think would be helpful in the counseling.”

“It’s so necessary, but so far from what real in person training would do, right? I’ve had similar training in medical school on motivational interviewing where live in person role play, as cheesy as it is, has been really helpful.”

Overall, the virtual format was described as helpful for enabling a flexible schedule for completion of training and a self-paced approach to each module. Some people, however, expressed fatigue with online work and found it harder to prioritize the training due to the virtual format. Participants emphasized the importance of training the whole clinic team. Nurse and medical assistant staff who participated supported this approach and encouraged incorporation of more content targeted to their job roles.

Ob-gyn clinicians and staff found MI4MI training content clear and easy to understand. They particularly appreciated inclusion of example conversations and phrases they could adapt to their own style and use with patients. During midpoint interviews, participants requested more challenging patient scenarios, such as how to get a conversation started with someone refusing vaccines and how to transition from a presumptive approach to MI skills when a patient expresses hesitancy. They also requested examples of specific common vaccine concerns, such as the false belief that influenza vaccination makes people sick. The second interactive training module incorporated some of these requested topics and presented extended conversations featuring more resistance from the patient; however, participants still noted that real life conversations don’t always go as smoothly as the examples. As described above, some participants shared concerns about using a presumptive approach for vaccine recommendations and these discomforts were repeated in midpoint interviews and post-intervention focus groups. After viewing the interactive modules in addition to the introductory video, some of these concerns were allayed with one participant noting:

“I felt like the initial video… only gave examples where it said like, “You’re gonna be getting two shots today” and I think that’s where all of us hesitated because we were like, “Wait, wait, wait. That’s not gonna fly with our patients.” Then when you do the module and you see that’s actually a very small part of what MI is and that is one approach…”

Participants found the MI4MI intervention fit well with prenatal care settings. Several participants noted that the concepts presented were similar to communication skills they had learned before but still appreciated the additional training in the context of prenatal vaccines. Others found new skills that filled a gap for them:

“I definitely felt like, “Oh, yeah, I need some more of these skills of when patients refuse.”… I already feel like I can’t convince people otherwise. They already have their opinions. It’s those patients… that are wavering that I probably need some better skills to help educate them and things like that. I kind of have my standard spiel, and I give it and people decide and then I move on.”

Participants highlighted that the MI4MI approach fits well with the longitudinal nature of prenatal care communication approach and pointed out ways different skills could be used to continue a vaccine conversation across visits. Some clinicians had concerns that learning and applying these communication skills would not address the problem of limited time during patient encounters. The importance of including nurses and medical assistants in training was noted again as a potential solution to ease the time burden on clinicians by shifting some vaccine communication to other staff.

Discussion

Using an iterative approach to incorporate clinician feedback, we developed the MI4MI intervention to train ob-gyn clinicians in using specific vaccine communication skills to increase vaccine acceptance. The MI4MI training intervention was implemented virtually with asynchronous online educational sessions to accommodate scheduling challenges for ob-gyn clinics. Both the content and format of training components were adjusted in response to participant feedback about common anticipated patient concerns and preferred ways of interacting with example scenarios. Participants in the training overall described mostly positive experiences with the MI4MI training and found it well-suited to prenatal care contexts.

Noting that previous versions of similar vaccine communication training interventions for pediatric vaccinations were implemented in person^23,31, using an asynchronous virtual format was the most significant adaptation made in developing MI4MI. As others have noted, virtual learning platforms allow learners to set the pace and facilitate sharing content in a variety of formats, but simply moving teaching materials online does not ensure achievement of educational goals.^32,36 Consideration of different learning style frameworks and use of adult learning techniques are important for effective virtual clinician education interventions^32–35 and we received positive participant feedback on the attention to different learning styles within our modules.

We also experienced some challenges in designing scalable virtual training for communication skills including the need to make learning social and to incorporate opportunities for practice.³⁶ Simulation methods and virtual reality have become more common in teaching non-technical health care skills like patient-provider communication and represent a potential substitute for in-person role-play.^37,38 Interactive virtual simulation scenarios have been shown to be effective in teaching patient-provider and interprofessional communication skills^39,40, including in studies focused on general MI skills and on influenza vaccine hesitancy.^41,42 Noting that our participants requested more complex example vaccine conversations, future efforts to offer practice maternal immunization conversations may benefit from more robust virtual platforms that customize scenarios and contexts to adapt to the learner over time.⁴³ Another way to increase interaction with colleagues while allowing for asynchronous scheduling would be to have participants record simulated or actual vaccine conversations and then provide peer feedback on one another’s recordings.⁴⁴ Future implementation of MI4MI might incorporate simulated patient scenarios that require and respond to participants’ use of communication skills.

Prior to developing and after implementing MI4MI, participants noted that training in communication skills may not be new for experienced clinicians and encouraged consideration of a broader audience for this training. Concerns that most clinicians have already learned communication techniques were balanced with appreciation for seeing new ways to apply skills to the topic of maternal immunizations and examples of specific phrases and common vaccine conversation scenarios. Overall, our findings suggest that even experienced ob-gyn clinicians can learn from the MI4MI intervention. Emphasizing how the training is novel and how it adapts MI skills to the vaccine context may be important for future recruitment and engagement.

We responded to pre-implementation suggestions for a broader audience by working with two clinics with clinician-trainees and inviting both clinicians and non-clinician staff to participate in the intervention. Prior interventional studies to improve maternal immunization have largely focused on clinicians, and those that included non-clinician staff often emphasized immunization delivery practices (e.g., standing orders) rather than communication.^45–48 Engaging non-clinician staff in communication training and implementation can address concerns about time constraints by empowering staff members who often introduce the topic of vaccines at a clinic visit. To fully realize potential benefits of engaging all clinic staff members, maternal immunization communication training interventions should include content to bolster knowledge among non-clinician staff (e.g., facts about vaccination, responses to common questions) and approaches tailored to their job role and workflow (e.g., introducing and recommending vaccines, initiating and handing off a conversation when needed).

Several studies have demonstrated the effectiveness of a presumptive or announcement approach to introducing pediatric vaccines,^23,49–52 and additional literature shows that receiving a strong provider recommendation is an important determinant of maternal vaccine uptake.^9,53,54 Some participants in our study noted that a presumptive recommendation seemed to contradict their prevailing practice style of shared clinical decision-making. Shared clinical decision-making engages patients in medical choices alongside their clinical team and has been described as acknowledging the importance of both medical expertise and the patient’s expertise in their personal experience and preferences.^55,56 Shared clinical decision-making is often applied when there are multiple potentially recommended treatment options or when a decision is preference-sensitive.^55,56 Influenza and Tdap vaccination are standard recommended preventive care during pregnancy^2,3,57 and forgoing or limiting vaccines is not recommended; therefore, a presumptive approach may be a more accurate way to introduce the topic of vaccination by making clear which choice is recommended based on medical expertise. Prior studies of pediatric vaccine conversations have shown that a participatory approach to introducing vaccines (more similar to shared clinical decision-making) is less effective at promoting vaccine uptake.^50–52

Participants with concerns about the presumptive recommendation still expressed interest in learning MI techniques for vaccine communication. Noting that MI features a more collaborative style, future maternal vaccine communication training interventions should clearly explain why a presumptive approach is recommended to introduce vaccines and how shifting to MI when patients express hesitancy supports a philosophy of working with patients to reach a decision together. Study participants who initially had concerns later reported success reworking the presumptive recommendation to fit their communication style; however, we lack data about whether these adjustments maintained fidelity to the concept of a presumptive rather than participatory conversation structure.⁵⁰ Additional study is needed to determine if continued adaptation of the presumptive approach can improve fit in the prenatal care context or if this approach is truly less suited or less effective for maternal vaccination.

Limitations of this study include our small sample of participants from five urban ob-gyn clinics in Colorado and uneven representation of participating clinics in midpoint interviews. These findings may not be generalizable to all prenatal care settings, although there were participants from both CNM and physician clinics and from sites with and without trainees. Because we conducted interviews and focus groups both during and after MI4MI implementation, we were unable to incorporate all participant feedback in developing this first version of the intervention. The effectiveness of this MI4MI training intervention has not yet been established, thus interpretation of the results presented here are limited to providers perceptions and fit within the prenatal care context. In addition, a more thorough dissemination and implementation evaluation of the intervention is currently ongoing; reach, adoption, implementation, clinic context, and individual participant factors will be described more fully in future manuscripts. The COVID-19 pandemic presented numerous challenges to delivering prenatal care and to conducting this study. We are unable to know how participants’ recommendations for adapting this training to the ob-gyn context and their perceptions of the MI4MI program may have differed in absence of COVID-19. Additional analysis is underway to understand the role of COVID-19 and other contextual factors in MI4MI intervention implementation.

Conclusion

By incorporating perspectives of ob-gyn clinicians and staff, we developed and adapted a communication training intervention (MI4MI) to fit the prenatal care context. Training was presented virtually to address scheduling challenges among ob-gyn clinicians. Adult learning techniques and interactive features were used successfully to encourage engagement with training materials. Aspects to improve in future use of this training include clearly communicating the rationale for a presumptive approach to vaccine recommendations, creating opportunities for participants to practice MI4MI skills, and including and adapting content for staff in non-clinician job roles (e.g., nurses, medical assistants).

Supplementary Material

1

Supplement 1: MI4MI Provider/Staff Training Modules

Abbreviations:

CDC

Centers for Disease Control and Prevention

CNM

certified nurse midwife

MI

motivational interviewing

MI4MI

Motivational Interviewing for Maternal Immunizations

ob-gyn

obstetrics and gynecology

Tdap

tetanus, diphtheria, and pertussis