key: cord-0715283-xdvyoq2e
authors: Zolezzi, Monica; Paravattil, Bridget; El-Gaili, Taysier
title: Using motivational interviewing techniques to inform decision-making for COVID-19 vaccination
date: 2021-10-02
journal: Int J Clin Pharm
DOI: 10.1007/s11096-021-01334-y
sha: c884bb14ff4375f9cb30e027e8aa5bfa12bf7b6f
doc_id: 715283
cord_uid: xdvyoq2e

Motivational interviewing is a patient-centered communication style used to enhance a person’s internal motivation for attitudinal change by exploring and solving inherent ambivalences. In the face of rising COVID-19 vaccine hesitancy, pharmacists and other health care professionals may use motivational interviewing to enable individuals making informed decisions with regards to the COVID-19 vaccines. The purpose of this article is to integrate theory with practice by describing a scenario that illustrates how motivational interviewing skills and strategies can be used to reduce COVID-19 vaccine hesitancy.

• Pharmacists are well positioned to improve people's understanding of the COVID19 vaccine and influence on decision-making among those who are vaccine-hesitant. • While educating the public, pharmacists can use motivational interviewing techniques to explore people's ambivalence regarding the COVID-19 vaccine.

Vaccination programs have contributed substantially to the decline in mortality and morbidity of infectious diseases [1] . The coronavirus disease pandemic that emerged in 2019 (COVID- 19) continues to impact all aspects of life worldwide from countless lives being lost to the cause of unprecedented social distress. Although several strategies have been implemented to tackle the spread of this infection, vaccination as opposed to natural infection offers the most viable and optimistic option in achieving herd immunity [2, 3] . Vaccine hesitancy, defined by the World Health Organization (WHO) as the "delay in acceptance or refusal of vaccines, despite availability of vaccine services", is within the top ten global health threats of 2019 [4] [5] [6] . Despite the promising efficacy and safety of COVID-19 vaccines, many continue to remain opposed to getting vaccinated [7] . Educational strategies that focus not only on increasing the public's knowledge and awareness, but also that evoke health behaviour change, have been recommended to decrease vaccine hesitancy [4, 5, 8, 9] . Motivational interviewing (MI) is a patient-centered communication style used to enhance a person's internal motivation for attitudinal change by exploring and solving inherent ambivalences [10] . Evidence suggests that pharmacists are well positioned to utilize the MI approach to help people overcome ambivalence towards immunizations [11] [12] [13] .

The underlying framework, often referred to as the "spirit" of MI, is based on partnership, acceptance, compassion, and autonomy [14] . The goal is to engage the person in a collaborative working relationship, allowing the individual to feel involved in the decision to change within a respectful and non-judgmental atmosphere, and to resist the urge to dictate the problem and the solution. As outlined in Table 1 , the core communication skills consistent with the spirit of MI that are used by practitioners to build rapport and establish a therapeutic relationship with patients are represented by the acronym OARS: Open questioning, Affirming, Reflective listening, and Summarizing [10] MI has traditionally been employed with people who are experiencing ambivalence or resistance toward behavioral change and are disengaging from treatment services. Thus, eliciting "change talk" is an important aspect of MI, as it is a consciously directive strategy used for resolving ambivalence. This guiding style is preferred over the authoritative, practitioner-led strategy of educating, advising, or convincing, which can have the opposite effect resulting in further resistance and defiance from the individual [10] . As outlined in Table 1 , change talk involves 4 steps: Displaying empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy. Changing attitudes and behaviours or adopting new ones depend on how important the change is to the individual as well as how confident and prepared they are in adopting change. Using the "importance/confidence ruler" also facilitates change talk and allows practitioners to learn about facilitators and barriers to guide the individual towards change and make it easier to tailor an appropriate action plan. In this article a case vignette is used to illustrate a common scenario and how the pharmacist can use MI to increase knowledge, reduce perceived misconceptions, change attitudes, and enable informed decision-making with regards to the COVID-19 vaccines.

A pharmacist working in a community pharmacy is approached by Mrs. VD, a 54 year-old teacher working at a local international school. She asks the pharmacist for vitamin D, zinc, vitamin C, and ivermectin. When asked the Open-ended questioning: These type of questions cannot be answered with "yes" or "no" statements. Posing a question that provides an opportunity for the individual to craft a response so that clinicians understand his/her perception of the issue being discussed Example: "I understand you have some concerns about the COVID19 vaccines.

Can you tell me about them?" Versus: "Are you concerned about getting vaccinated?"

Displaying empathy: Involves a partnership and consultation with the individual, honoring his/her expertise and perspectives, whereby the atmosphere is conducive rather than coercive to change. In this phase, "change talk" is initiated by listening more than telling, eliciting rather than installing, so that intrinsic motivation for change is enhanced by drawing on the individual's own perceptions, goals, and values. A simple way to do that is to: Use reflective listening skills to accurately portray empathy Create open and respectful exchange with the individual Avoid judging, criticizing or blaming the individual Affirming: Acknowledging the person's strengths and offering encouragement towards a change goal. This helps to build rapport and fosters confidence in the person's ability to change behavior Example: "You have clearly been very resourceful coping with the difficulties during the COVID19 pandemic."

Developing discrepancy: Guiding the individual to be aware of his/her current status, and where he/she would like to be in the near future, examining readiness for change by: Helping the individual to explore the pros and cons of change Developing disagreement in their presentation of their "facts" Developing awareness of the consequences of their behavior 

The case vignette presented illustrates how pharmacists may use the MI approach to communicate with those who are hesitant to take the COVID-19 vaccine. The focus should revolve around collaboration, drawing on their personal beliefs by listening to their fears, thoughts, and opinions. Time constraints has been reported as a main barrier to using MI in community practice [13, 15] . Brief interventions based on MI may be a simpler alternative, where the aim is starting a conversation by using mostly open questions and empathic listening statements. A question as simple as "What are your personal health and safety goals around COVID-19 and this pandemic?" is a good starting point [9, 16] Staying current with the myths surrounding the COVID-19 vaccine is almost as important as staying up to date on the evidence on vaccine efficacy and safety [2, 7, 9, [16] [17] [18] [19] . Current conspiracy theories over-emphasize on the risks associated with the vaccine itself rather than on those related the COVID-19 illness. Studies exploring attitudes towards COVID-19 vaccines undertaken in several countries report the safety of the vaccine as the most prominent reason for vaccine hesitancy [20] [21] [22] [23] . Table 2 provides evidence-based information to respond to the most common myths and concerns about the COVID-19 vaccines. Dispelling evidence

The concept of using mRNA as a novel therapeutic tool dates to the early 1990s [24] . Vaccine safety monitoring systems exist and are tasked to continuously identifying adverse events not encountered in clinical trials [18, 25] The vaccine will alter my DNA

The mRNA is not designed to integrate with host DNA, nor can it typically do so given its rapid degradation. In the COVID-19 vaccine, once the immune response is initiated against the spike protein, mRNA is degraded by the cells [17] [18] [19] 25 ] I will react to the vaccine because I have allergies

Severe allergic reactions are rare, with an estimated rate of 11 cases per million doses of the vaccine [26, 27] . As a result, post-vaccination observation has been made mandatory: 30 min for those with a history of severe allergic reactions and 15 min for everyone else [17, 18, 25] . Some of the vaccines have polyethylene glycol, which has been implicated in some of the allergic responses to the vaccine [28] 

The COVID-19 vaccine does not contain the live virus, and vaccines are unable to trigger the full disease. An individual who has received the vaccine will not test positive for COVID-19 in the absence of infection [18, 25] 

The ingredients for the majority of the currently used vaccines have been published [29] . Vaccines usually contain lipids that help deliver the mRNA into the cells and other common ingredients that help maintain the pH and stability of the vaccine [28] . Despite theories circulated on social media, they do not contain microchips or any form of tracking device [17] 

The COVID-19 vaccines were tested for their ability to prevent severe illness and death from COVID-19 [17] . It is not clear whether they also protect against asymptomatic infection and spread. As such, even after being fully vaccinated, it is important to keep wearing a mask around others, washing hands and practicing physical distancing [17, 30] 

A few clinical trials have explored the possibility that supplements may be effective in COVID-19. Unfortunately, most of the scientific evidence is unconvincing [31, 32] . The researchers found that people receiving the supplements, whether individually or combined, had no improvement in symptoms or a faster recovery when compared with otherwise similar patients receiving neither supplement

Ivermectin tablets are only approved to treat people with intestinal infections caused by parasitic worms. There are currently insufficient data to support use of ivermectin in COVID-19 patients to treat or to prevent COVID-19. In addition, it can interact with other medications and potentially cause harm [33] 

Published estimates of the risk of vaccine-induced thrombotic thrombocytopenia (VITT) from countries with moderate to high data quality range from 1 case per 26,500 to 1 case per 127,300 first doses of AstraZeneca/COVISHIELD administered [34] . The European Medicines Agency states that this side effect is very rare, and that the overall benefits of the vaccine in preventing COVID-19 outweigh the risks of VITT [35] 

Getting the COVID-19 vaccine will not affect the fertility of women who are seeking to become pregnant, including through in vitro fertilization methods [36] . Also, women trying to become pregnant do not need to avoid pregnancy after receiving a COVID-19 vaccine [37] I am pregnant, harmful substances in the vaccine could affect the baby Studies have shown that pregnant women have an increased risk of getting severely ill if contracting COVID-19 [38, 39] . Studies have also shown that pregnant women who experience severe COVID-19 symptoms have a higher risk of complications during and after pregnancy [39, 40] . A recent study reported that adverse outcomes occurred at similar rates in vaccinated women as those that occurred in other studies of unvaccinated women [41] Several professional societies suggest that the vaccine can be taken during breastfeeding as it is not thought to pose a risk to the breastfeeding infant [42] . Recent reports have shown that breastfeeding people who have received COVID-19 mRNA vaccines have antibodies in their breastmilk, which could help protect their babies [37, 42] 

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