Improving Provider Communication about HPV Vaccines for Vaccine-Hesitant Parents Through the Use of Motivational Interviewing

"[I]mproving providers' ability to communicate with the considerable proportion of parents that are HPV vaccine-hesitant can lead to increased adolescent HPV vaccine utilization and a significant public health benefit."

In the United States (US) specifically, but even in other countries with higher vaccination rates, human papillomavirus (HPV) vaccine hesitancy is a common barrier to vaccine acceptance. Provider recommendations have been shown to be a critical component to HPV vaccination compliance; however, research demonstrates that providers often fail to communicate effectively about HPV vaccines. In response, this group of researchers developed a multi-faceted, 5-component communication intervention (see Related Summaries, below); the current manuscript focuses on an assessment of one specific component of the intervention, motivational interviewing (MI).

MI is described here as "an empirically developed, guiding style of communication that emphasizes the evocation and reinforcement of intrinsic motivation (i.e., change talk) within a compassionate, collaborative, and autonomy supportive relationship." This is an evidence-based mechanism for effecting patient behaviour change; so, within MI discussions, "assessment of the barriers to change is evocative, tailored only to specific parental concerns, and solution-focused." It works by engaging vaccine-hesitant parents without making them feel attacked, hopefully facilitating a willingness to consider new viewpoints.

The researchers hypothesised that MI could potentially help providers with 3 problems often encountered when discussing HPV vaccination with vaccine-hesitant parents:

1. Lack of time - MI techniques can be incorporated into conversations that providers are already having.
2. Low self-efficacy - MI teaches a guiding style of communication that provides tangible, specific strategies for leading a conversation with vaccine-hesitant parents.
3. Encountering psychological resistance - MI techniques provide a means for facilitating a discussion about HPV vaccines while acknowledging the legitimacy of parents' concerns and affirming their autonomy in decision-making.

The 8 clinics that participated in the larger randomised trial (RCT) in central Colorado, US are discussed in this manuscript. For the MI component of the intervention, the research team worked with a member of the Motivational Interviewing Network of Trainers (MINT, 2017) to develop an HPV-vaccine-specific MI training programme for healthcare providers and staff. The training instructed providers and staff to uniformly use a "presumptive" approach that assumed a parent would vaccinate when initially bringing up the HPV vaccine with parents and to discuss HPV vaccination in the same manner as other adolescent vaccines needed at the visit, followed by the use MI techniques to facilitate further conversation if parents expressed vaccine hesitancy. The MI training consisted of 3 parts: (i) a 40-minute background video; (ii) a 1-hour, in-person training session focused on describing and demonstrating the techniques related to frequently encountered barriers; and (iii) a second 1-hour, in-person training session where providers role-played different MI techniques. The trainings culminated with the circulation of an "MI Tip Sheet".

After training was complete, the 8 participating intervention clinics received regular reminders during the intervention (February 2015-January 2016) to incorporate the MI strategies (along with the other communication toolkit items provided as part of the larger intervention) when they encountered parental HPV vaccine hesitancy. Each clinic also had a staff member who was the "study champion" and met with research staff.

Eight serial surveys were administered via email throughout the intervention as a means of process evaluation. Across the 8 surveys, the proportion of providers who reported using MI when discussing HPV vaccine with parents ranged from 72% to 90%. At the end of the intervention period, 88% of providers considered MI useful or very useful to help parents resolve ambivalence about vaccination. With typical parents, providers reported spending significantly less time discussing the HPV vaccine during clinical visits at the end of the study than at baseline (before MI training). For vaccine-hesitant parents, the time spent discussing the vaccine was similar between baseline and post-intervention. A clinically significant higher proportion of providers disagreed or strongly disagreed that "when parents wish to delay or refuse HPV vaccination for their child, there is not much I can say to change their minds" at the end of the study compared to baseline (67% vs. 53%, p = .081), indicating higher self-efficacy for addressing parental HPV vaccine hesitancy. However, there was little change between baseline and post-intervention in 2 other measures of reported self-efficacy.

Towards the end of the intervention period, 8 focus groups were conducted at different intervention sites with providers and staff to elicit feedback on toolkit components, usage, and recommended changes. "Based on focus group interviews, a majority of the providers and staff found that MI was the most effective tool when attempting to educate and lead vaccine-hesitant parents to vaccinate against HPV in comparison to other intervention tools" in the broader intervention (e.g., fact sheets, decision aids, web application). Some of the reasons providers and staff cited for MI's effectiveness with HPV-vaccine-hesitant parents included more personalised vaccine recommendations, a collaborative conversation style, and active listening. Focus group feedback indicated that all providers planned to continue to use MI in the future.

The researchers conclude that, overall, the integration of MI training into the provider communication intervention was successful and resulted in positive outcomes. Nevertheless, the research team encountered challenges along the way that revealed practical implications for designing and implementing future MI interventions:

• While process evaluation is a critical component to ensuring the success of a health communication intervention, evaluation alone does not ensure the fidelity or accomplishment of intervention goals - particularly when identified, potentially critical changes are not easy to implement.
• While MI was received positively by providers and staff, a significant time investment was needed in order to become proficient in the techniques.
• In-person MI training is necessary but could potentially be supplemented with online sessions.

Suggestions for future studies are outlined, including investigating the usefulness of MI in other vaccination settings such as schools, which are a primary site of adolescent vaccination in many countries.