Best shot: A motivational interviewing approach to address vaccine hesitancy in pediatric outpatient settings

Published:September 13, 2022DOI:


      • A motivational interviewing education session may decrease vaccine hesitancy in parents of children 0-12 months of age.
      • Providers identified motivational interviewing as a feasible tool to use during a well child visit.
      • Regular screening for vaccine hesitancy can be helpful in identifying and addressing concerns of caregivers.
      • The COVID-19 pandemic negatively impacted the number of well child visits seen.



      Vaccine hesitancy in parents and childhood vaccine refusal is increasing. A standard of care to address this problem has not been identified.


      To identify if the use of motivational interviewing by pediatric providers during routine well child visits, when compared to standard of care, would increase vaccine rates in children 0–12 months of age. Factors associated with vaccine hesitancy were also investigated.


      A quasi-experimental study was completed on a convenience sample of pediatric providers (N = 6) and caregivers of children 0–12 months of age (N = 66). Four providers were trained to use motivational interviewing. During the well child visit the Parent Attitudes About Childhood Vaccines survey was completed, and the motivational interviewing intervention was implemented. Clinic's data were compared with other clinic data of non-trained providers.


      Vaccine refusal/delays rate was 11.4% among caregivers. Vaccine refusal rate decreased after the intervention (9.00% pre-intervention and 6.40% post-intervention). An ordinal regression identified caregivers with higher vaccine hesitancy scores and more children were more likely to delay or refuse vaccines, while caregivers ≥30 years or with high income were less likely to delay/refuse vaccines. A difference in difference analysis identified that an additional 2.6% of children received vaccines when seen by trained providers compared to non-trained (β = −0.330, OR = 0.719, p = 0.470).


      Findings indicate a condensed motivational interviewing education session may be clinically significant in decreasing vaccine hesitancy among this population.

      Applications to practice

      A more robust study to confirm these findings is recommended prior to practice implementation.


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        • Alrowaili G.Z.
        • Dar U.F.
        • Bandy A.H.
        May we improve vaccine timeliness among children? A cross sectional survey in northern Saudi Arabia.
        Journal of Family and Community Medicine. 2019; 26: 113-117
        • Beard F.A.
        • Hull B.P.
        • Leask J.
        • Dey A.
        • McIntyre P.B.
        Trends and patterns in vaccination objection, Australia, 2002-2013.
        Medical Journal of Australia. 2016; 204: 275e1-275e6
        • Braun C.
        • O’Leary S.T.
        Recent advances in addressing vaccine hesitancy.
        Current Opinion in Pediatrics. 2020; 32: 601-609
        • Brewer N.T.
        • Chapman G.B.
        • Rothman A.J.
        • Leask J.
        • Kempe A.
        Increasing vaccination: Putting psychological science into action.
        Psychological Science in the Public Interest. 2017; 18: 149-207
        • Centers for Disease Control and Prevention
        Thimerosal and Vaccines.
        (Retrieved 10/13/2021, from)
        • Chopra M.
        • Bhutta Z.
        • Blanc D.C.
        • Checchi F.
        • Gupta A.
        • Lemango E.T.
        • Victora C.G.
        Addressing the persistent inequities in immunization coverage.
        Bulletin of the World Health Organization. 2020; 98: 146-148
        • Cole J.
        • Berman S.
        • Gardner J.
        • McGuire K.
        • Chen A.M.
        Implementation of a motivational interviewing-based decision tool to improve childhood vaccination rates: Pilot study protocol.
        Research in Social and Administrative Pharmacy. 2021; 17: 619-624
        • Cole J.W.
        • Chen A.M.
        • McGuire K.
        • Berman S.
        • Gardner J.
        • Teegala Y.
        Motivational interviewing and vaccine acceptance in children: The MOTIVE study.
        Vaccine. 2022; 40: 1846-1854
        • Díaz Crescitelli M.
        • Ghirotto L.
        • Sisson H.
        • Sarli L.
        • Artioli G.
        • Bassi M.
        A meta-synthesis study of the key elements involved in childhood vaccine hesitancy.
        Public Health. 2020; 180: 38-45
        • Dubé E.
        • Gagnon D.
        • MacDonald N.E.
        Strategies intended to address vaccine hesitancy: Review of published reviews.
        Vaccine. 2015; 33: 4191-4203
        • Dubé È.
        • Ward J.K.
        • Verger P.
        • MacDonald N.E.
        Vaccine hesitancy, acceptance, and anti-vaccination: Trends and future prospects for public health.
        Annual Review of Public Health. 2021; 42: 175-191
        • Edwards K.M.
        • Hackell J.M.
        Countering vaccine hesitancy.
        Pediatrics. 2016; 138: e1-e14
        • Gagneur A.
        • Lemaitre T.
        • Gosselin V.
        • Farrands A.
        • Carrier N.
        • Petit G.
        • De Wals P.
        Promoting vaccination at birth using motivational interviewing techniques improves vaccine intention: The PromoVac strategy.
        Journal of Infectious Diseases and Therapy. 2018; 6: 1-7
        • Garcia É.
        • Nery Teixeira Palombo C.
        • Waldman E.
        • Sato A.
        Factors associated with the completeness of the vaccination schedule of children at 12 and 24 months of age in a Brazilian medium-size municipality.
        Journal of Pediatric Nursing. 2021; 60: 1-8
        • Gilkey M.B.
        • McRee A.
        • Magnus B.E.
        • Reiter P.L.
        • Dempsey A.F.
        • Brewer N.T.
        Vaccination confidence and parental refusal/delay of early childhood vaccines.
        PLoS One. 2016; 11: 1-12
        • Glanz J.M.
        • Newcomer S.R.
        • Jackson M.L.
        • Omer S.R.
        • Bednarczyk R.A.
        • Shoup J.
        • Daley M.F.
        White paper on studying the safety of the childhood immunization schedule in the vaccine safety datalink.
        Vaccine. 2016; 34: A1-A29
        • Hargreaves A.L.
        • Nowak G.
        • Frew P.M.
        • Hinman A.R.
        • Orenstein W.A.
        • Mendel J.
        • Bednarczyk R.A.
        Adherence to timely vaccinations in the United States.
        Pediatrics. 2020; 145: 48-58
        • Hill H.A.
        • Elam-Evans L.D.
        • Yankey D.
        • Singleton J.A.
        • Kang Y.
        Vaccination coverage among children aged 19–35 months — United States, 2017.
        Morbidity and Mortality Weekly Report. 2018; 67: 1123-1128
        • Hornsey M.J.
        • Fielding K.S.
        Attitude roots and jiu jitsu persuasion: Understanding and overcoming the motivated rejection of science.
        The American Psychologist. 2017; 72: 459-473
        • Immunization Practices Advisory Committee
        Immunizations practices advisory committee (IPAC) 13th meeting 11–13 June 2019: Final meeting report & recommendations.
        (Retrieved June 4, 2021, from)
        • Jarrett C.
        • Wilson R.
        • O’Leary M.
        • Eckersberger E.
        • Larson H.J.
        Strategies for addressing vaccine hesitancy – A systematic review.
        Vaccine. 2015; 33: 4180-4190
        • Kaufman J.
        • Ryan R.
        • Walsh L.
        • Horey D.
        • Leask J.
        • Robinson P.
        • Hill S.
        Face-to-face interventions for informing or educating parents about early childhood vaccination.
        Cochrane Database of Systematic Reviews. 2018; 1-104
        • Kempe A.
        • Saville A.W.
        • Albertin C.
        • Zimet G.
        • Breck A.
        • Helmkamp L.
        • Szilagyi P.G.
        Parental hesitancy about routine childhood and influenza vaccinations: A national survey.
        Pediatrics. 2020; 146: 1-12
        • Larson H.J.
        • Clarke R.M.
        • Jarrett C.
        • Eckersberger E.
        • Levine Z.
        • Schulz W.S.
        • Paterson P.
        Measuring trust in vaccination: A systematic review.
        Human Vaccines & Immunotherapeutics. 2018; 14: 1599-1609
        • Lee S.
        • Bae- Shaaw Y.H.
        • Gogineni H.
        • Worley M.M.
        • Law A.V.
        Triple strength utility of the modified drug adherence work-up (m-draw) tool in a veterans affairs outpatient diabetes clinic.
        Research in Social and Administrative Pharmacy. 2020; 16: 914-920
        • Lemaitre T.
        • Carrier N.
        • Farrands A.
        • Gosselin V.
        • Petit G.
        • Gagneur A.
        Impact of a vaccination promotion intervention using motivational interview techniques on long-term vaccine coverage: The PromoVac strategy.
        Human Vaccines & Immunotherapeutics. 2019; 15: 732-739
        • Limaye R.J.
        • Opel D.J.
        • Dempsey A.
        • Ellingson M.
        • Spina C.
        • Omer S.B.
        • O’Leary S.T.
        Communicating with vaccine-hesitant parents: A narrative review.
        Academic Pediatrics. 2021; 21: S24-S29
        • Mbaeyi S.
        • Fisher A.
        • Cohn A.
        Strengthening vaccine confidence and acceptance in the pediatric provider office.
        Pediatric Annals. 2020; 49: e523-e531
        • McNally V.V.
        • Bernstein H.H.
        The effect of the COVID-19 pandemic on childhood immunizations: Ways to strengthen routine vaccination.
        Pediatric Annals. 2020; 49: e516-e522
        • Mical R.
        • Martin-Velez J.
        • Blackstone T.
        • Derouin A.
        Vaccine hesitancy in rural pediatric primary care.
        Journal of Pediatric Health Care. 2021; 35: 16-22
        • Miller W.
        • Rollnick S.
        Motivational interviewing: Helping people change.
        3rd ed. Guilford Press, New York2013
        • Miller W.R.
        • Rollnick S.
        The effectiveness and ineffectiveness of complex behavioral interventions: Impact of treatment fidelity.
        Contemporary Clinical Trials. 2014; 37: 234-241
        • National Academies of Sciences, Engineering, and Medicine
        The critical public health value of vaccines: Tackling issues of access and hesitancy: Proceedings of a workshop.
        The National Academies Press, Washington, DC2021
        • Office of Disease Prevention and Health Promotion
        Immunization and infectious diseases.
        (Retrieved March 16, 2021, from)
        • Olson O.
        • Berry C.
        • Kumar N.
        Addressing parental vaccine hesitancy towards childhood vaccines in the United States: A systematic literature review of communication interventions and strategies.
        Vaccines. 2020; 8: 1-25
        • Opel D.J.
        • Mangione-Smith R.
        • Taylor J.A.
        • Korfiatis C.
        • Wiese C.
        • Catz S.
        • Martin D.P.
        Development of a survey to identify vaccine-hesitant parents: The parent attitudes about childhood vaccines survey.
        Human Vaccines. 2011; 7: 419-425
        • Opel D.J.
        • Robinson J.D.
        • Spielvogle H.
        • Spina C.
        • Garrett K.
        • Dempsey A.F.
        • O’Leary S.T.
        “Presumptively initiating vaccines and optimizing talk with motivational interviewing” (pivot with MI) trial: A protocol for a cluster randomised controlled trial of a clinician vaccine communication intervention.
        BMJ Open. 2020; 10: 1-9
        • Opel D.J.
        • Taylor J.A.
        • Mangione-Smith R.
        • Solomon C.
        • Zhao C.
        • Catz S.
        • Martin D.
        Validity and reliability of a survey to identify vaccine-hesitant parents.
        Vaccine. 2011; 29: 6598-6605
        • Opel D.J.
        • Taylor J.A.
        • Zhou C.
        • Catz S.
        • Myaing M.
        • Mangione-Smith R.
        The relationship between parent attitudes about childhood vaccines survey scores and future child immunization status: A validation study.
        JAMA Pediatrics. 2013; 167: 1065-1071
        • Pivetti M.
        • Melotti G.
        • Mancini C.
        Vaccines and autism: A preliminary qualitative study on the beliefs of concerned mothers in Italy.
        International Journal of Qualitative Studies on Health and Well-Being. 2020; 15: 1-15
        • Reno J.E.
        • O’Leary S.T.
        • Pyrzanowski J.
        • Lockhart S.
        • Thomas J.
        • Dempsey A.F.
        Evaluation of the implementation of a multicomponent intervention to improve health care provider communication about human papillomavirus vaccination.
        Academic Pediatrics. 2018; 18: 882-888
        • Rodriguez N.J.
        Vaccine-hesitant justifications: “too many, too soon,” narrative persuasion, and the conflation of expertise.
        Global Qualitative Nursing Research. 2016; 3: 1-10
        • Rollnick S.
        • Miller W.R.
        • Butler C.C.
        Motivational interviewing in health care: Helping patients change behavior.
        The Guilford Press, New York, NY2008
        • Rosengren D.B.
        Building motivational interviewing skills: A practitioner workbook.
        2nd ed. Guilford Publications, Inc., New York, NY2018
        • Schmidt L.K.
        • Andersen K.
        • Nielson A.S.
        • Moyers T.B.
        Lessons learned from measuring fidelity with the motivational interviewing treatment integrity code (MITI 4).
        Journal of Substance Abuse Treatment. 2019; 97: 59-67
        • Smith P.J.
        • Humiston S.G.
        • Marcuse E.K.
        • Zhao Z.
        • Dorell C.G.
        • Howes C.
        • Hibbs B.
        Parental delay or refusal of vaccine doses, childhood vaccination coverage at 24 months of age, and the health belief model.
        Public Health Reports. 2011; 126: 135-146
        • Spencer J.P.
        • Trondsen Pawloski R.H.
        • Thomas S.
        Vaccine adverse events: Separating myth from reality.
        American Family Physician. 2017; 95 (Retrieved from): 786-794
        • Sweileh W.M.
        Bibliometric analysis of global scientific literature on vaccine hesitancy in peer-reviewed journals (1990–2019).
        BMC Public Health. 2020; 20: 1-15
        • Tauil M.
        • Sato A.
        • Waldman E.A.
        Factors associated with incomplete or delayed vaccination across countries: A systematic review.
        Vaccine. 2016; 34: 2635-2643
        • Vogel M.
        • Beger C.
        • Gausche R.
        • Jurkutat A.
        • Pfaeffle R.
        • Körner A.
        • Kiess W.
        COVID-19 pandemic and families’ utilization of well-child clinics and pediatric practices attendance in Germany.
        BMC Research Notes. 2021; 14: 1-3
        • Williams J.T.
        • O’Leary S.T.
        • Nussbaum A.M.
        Caring for the vaccine-hesitant family: Evidence-based alternatives to dismissal.
        The Journal of Pediatrics. 2020; 224: 137-140
        • World Health Organization
        Ten threats to global health in 2019.
        (Retrieved April 17, 2021, from)