Case Study 38-1: Motivational Interviewing for Vaccine Hesitancy

A Clinical Communication Model for Health Misinformation

Overview

Vaccine hesitancy — defined by the World Health Organization as a reluctance or refusal to vaccinate despite the availability of vaccines — represents one of the most consequential intersections of health misinformation and individual behavior change. COVID-19 brought this issue to unprecedented public attention, but hesitancy has been an ongoing challenge in public health communications for decades, affecting uptake of childhood vaccines, flu vaccines, and other preventive interventions.

This case study examines the application of Motivational Interviewing (MI) — an evidence-based clinical communication model developed by William Miller and Stephen Rollnick — to conversations about vaccine hesitancy. It draws on clinical research, public health practice, and communication science to illustrate both the promise and the limits of MI as a tool for addressing health misinformation in one-on-one conversations.

Background: What Is Vaccine Hesitancy?

The WHO's Strategic Advisory Group of Experts on Immunization (SAGE) defines vaccine hesitancy as existing on a continuum between total acceptance and total refusal. The "3 C" model identifies three contributors to hesitancy:

Confidence: Trust in the effectiveness and safety of vaccines, the system that delivers them (including healthcare providers and government), and the motivations of policymakers who recommend them.

Complacency: Perception that the preventable disease is low-risk, making the vaccine unnecessary.

Convenience: Physical and structural factors affecting access to vaccines (availability, affordability, geographic access, language, cultural appropriateness).

Many communication interventions, including MI, are most relevant to the confidence dimension. Hesitancy driven primarily by complacency or convenience requires different interventions (risk communication and access improvement, respectively). Identifying which "C" is driving a patient's hesitancy is the first step in tailoring the communication approach.

What Is Motivational Interviewing?

Motivational Interviewing (MI) is a collaborative, goal-oriented communication style designed to strengthen personal motivation for change by exploring and resolving ambivalence. Developed originally for substance use counseling, MI has been adapted for a wide range of health behavior contexts.

Four core principles structure MI:

Partnership: The practitioner and patient are collaborative partners in the conversation, not expert and passive recipient. The practitioner's expertise is in the communication process, not in making the patient's decision for them.

Acceptance: The practitioner accepts the patient's autonomy — their right to make their own health decisions — without approving of all choices. Acceptance does not mean agreeing that hesitancy is justified; it means treating the patient as a capable adult whose decision is ultimately theirs.

Compassion: The practitioner actively prioritizes the patient's wellbeing and interests, not their own persuasion goals or statistical outcomes.

Evocation: The practitioner draws out the patient's own motivations, values, and reasons for change rather than importing external arguments. "Change talk" — the patient's own articulation of reasons to change — is more persuasive than the practitioner's arguments.

Research Base for MI in Vaccine Contexts

Multiple systematic reviews and randomized controlled trials have examined MI for vaccine hesitancy, with consistent findings:

Increasing HPV vaccine uptake: A 2018 RCT by Dempsey et al. (published in Pediatrics) found that MI-trained primary care providers achieved significantly higher HPV vaccine initiation rates compared to providers using standard recommendation approaches.

Reducing hesitancy scores: Studies using validated hesitancy measures (including the SAGE Working Group's VHS scale) consistently find that MI-based conversations reduce hesitancy scores compared to control conditions.

Influenza vaccination: Multiple studies in community and clinical settings have found that brief MI interventions (as short as 10-15 minutes) increase influenza vaccine uptake in hesitant populations.

COVID-19 contexts: Research during the COVID-19 pandemic found MI-informed interventions effective at increasing vaccination intentions, though effect sizes varied by population and by the specific hesitancy concerns being addressed.

The general finding is that MI outperforms confrontational or purely informational approaches for hesitant patients, but is most effective when practitioners are trained in MI skills rather than simply reading about them.

A Clinical Conversation: Before and After MI

The following illustrates the difference between standard confrontational and MI-informed approaches to a vaccine hesitancy conversation.

Scenario

Dr. Chen is seeing Maria, a 34-year-old patient who has declined COVID-19 vaccination at her last two appointments. Maria expresses uncertainty about vaccine safety, mentions she has heard about side effects, and feels that she is healthy enough not to need the vaccine.

Confrontational Approach (Not MI)

Dr. Chen: "Maria, I really need to talk to you about the COVID vaccine again. I know you've been hesitant, but you really should get it. The safety data is overwhelming, and you're putting yourself and others at risk."

Maria: "I've just heard so many stories about people having bad reactions. I don't know."

Dr. Chen: "Those stories are mostly exaggerated or misattributed. The actual data shows serious side effects are extremely rare — much rarer than the risks of COVID itself. And by not getting vaccinated, you're contributing to community spread."

Maria: "I just don't feel comfortable yet. Maybe later."

Analysis: The confrontational approach activates psychological reactance — Maria's sense that her autonomy is being threatened. The practitioner's expertise-assertion and urgency framing position Maria as irresponsible, triggering defensiveness rather than reflection. The conversation ends with Maria disengaged and no closer to vaccination.

MI-Informed Approach

Dr. Chen: "Maria, I know we've talked about the vaccine before, and I respect that you're taking your time with this decision. Would you be comfortable telling me a little more about where you are with it?"

Maria: "I've just heard so many stories about people having bad reactions. My cousin had a really rough time after her second dose."

Dr. Chen: "I'm sorry to hear that about your cousin — that must have been scary to watch. So you've seen firsthand that the vaccine can cause some pretty significant side effects for some people. What else is going on in your thinking about it?"

Maria: "I'm just not sure I need it. I'm healthy, I work from home — my exposure risk is pretty low."

Dr. Chen: "That makes sense — if you're thinking about the risk-benefit balance for your specific situation, your low exposure risk is a real factor. What would make this decision easier for you? Is there anything that would help you feel more comfortable?"

Maria: "I guess I just want to understand the side effects better. If they're usually mild and short-term, that's one thing. If there's a real risk of something serious, that's different."

Dr. Chen: "That's a really reasonable distinction to draw — serious risks versus temporary discomfort are genuinely different things. I can go over the actual data on that with you — what we know and what we don't know — so you can make the most informed decision you can. Would that be helpful?"

Maria: "Yeah, I think so. I'd like to actually understand what the risks are rather than just hearing 'it's safe.'"

Analysis: The MI approach elicits Maria's specific concerns (her cousin's experience, her own perceived low risk), validates the emotional experience, asks what would help her, and ends with Maria herself expressing interest in more information — change talk. The practitioner has not given any additional information yet; they have created conditions under which information is more likely to be processed effectively.

Key MI Techniques Illustrated

Open-Ended Questions

"Would you be comfortable telling me more about where you are with it?" invites elaboration rather than a yes/no response. Open-ended questions gather more information and keep the patient talking — which is when change talk emerges.

Reflective Listening

"So you've seen firsthand that the vaccine can cause some pretty significant side effects for some people" reflects the content and emotional significance of what Maria said, demonstrating that the practitioner is listening rather than just waiting to talk.

Affirming Autonomy

"I respect that you're taking your time with this decision" validates Maria's right to decide rather than positioning her as an obstacle to a public health goal.

Developing Discrepancy Without Confrontation

The question "What would make this decision easier for you?" invites Maria to identify her own path to vaccination — drawing out her own values (wanting to make an informed decision) rather than importing the practitioner's values.

Eliciting Change Talk

Change talk is the patient's own expression of motivation for change — in this case, Maria's statement that she'd like to "actually understand the risks." The practitioner's job is to create conditions in which change talk emerges; once it does, the practitioner reflects it and amplifies it.

Practical Challenges in Applying MI to Vaccine Hesitancy

Time Constraints

Standard clinical visits are 15-20 minutes, of which the vaccine conversation may be a small component. Effective MI requires at least 10-15 minutes of focused conversation. Solutions: dedicated vaccine counseling appointments, nurse or pharmacist-delivered MI interventions, or brief MI for time-constrained settings.

Deep Conspiracy Beliefs

MI is most effective for ambivalence — patients who have mixed feelings about vaccination. For patients who hold strong, identity-central beliefs about vaccine safety conspiracies (e.g., belief that the vaccine contains tracking devices or is designed to alter DNA), MI techniques may be insufficient. These patients may require longer-term relationship-building and involvement of trusted community messengers.

Provider Training

MI is a skill that requires training and practice to deliver effectively. Practitioners who read about MI principles but have not practiced the techniques frequently revert to confrontational or advisory approaches under time pressure. Brief MI training programs (even 4-6 hours of instruction plus role-play) have been shown to improve practitioner skills.

Cultural Competence

Vaccine hesitancy in some communities is specifically rooted in historically founded distrust of medical institutions — including documented cases of exploitative research practices targeting communities of color. MI in these contexts must be combined with genuine acknowledgment of this history and structural efforts to rebuild trust, not used as a communication technique to overcome legitimate grievances.

Adapting MI Beyond Clinical Contexts

While MI was developed for clinical settings, its principles have been adapted for:

Community health workers: Trained community members from hesitant populations using MI to have peer conversations about vaccination. Research suggests peer-delivered MI is effective in some communities because it comes from trusted community members rather than medical authorities.

Telephone outreach: Studies of telephone-based MI interventions for childhood vaccine catch-up have shown effectiveness at increasing vaccination rates.

Digital adaptations: Chatbot-based and online MI adaptations are being tested; early results are mixed, as the empathy and genuine curiosity that make in-person MI effective are difficult to simulate.

Family conversations: The principles explored in Case Study 38-2 on QAnon conversations draw heavily on the same MI framework adapted for non-clinical family settings.

Discussion Questions

  1. MI explicitly respects patient autonomy — the right to make one's own health decisions. Is there a tension between respecting autonomy and the public health imperative to achieve sufficient vaccination rates for herd immunity? How should practitioners navigate this tension?

  2. The MI approach avoids direct argument and authoritative information-provision. Doesn't this risk leaving patients with false impressions? At what point in an MI conversation should the practitioner provide accurate information, and how should they frame it?

  3. MI was developed for individual clinical conversations. Vaccine hesitancy is a population-level phenomenon driven in part by large-scale misinformation campaigns. What are the limits of individual clinical communication in addressing a problem with systemic causes?

  4. Research on MI in vaccine contexts shows it is more effective than confrontational approaches. But how large are the effect sizes? Are they large enough to justify the additional time and training required? What would an evidence-based threshold for adopting MI as standard practice look like?

  5. Cultural competence in vaccine communication requires acknowledging historical institutional harms. Develop a specific approach for a practitioner working with a patient whose community has historical reasons to distrust medical institutions. What should the practitioner say and not say?

Key Takeaways

  • Motivational interviewing is an evidence-based clinical communication approach that outperforms confrontational and purely informational approaches for vaccine-hesitant patients.
  • MI works by eliciting the patient's own motivations, validating their autonomy, and creating conditions for "change talk" — the patient's own expression of reasons to consider vaccination.
  • Key MI techniques include open-ended questions, reflective listening, affirming autonomy, developing discrepancy between beliefs and values, and eliciting change talk without external argument.
  • MI is most effective for ambivalent patients; deep conspiracy beliefs may require additional approaches.
  • Clinical time constraints, provider training requirements, and cultural competence considerations are practical challenges in implementing MI for vaccine hesitancy.
  • MI principles have been adapted beyond clinical settings for community health workers, telephone outreach, and (with mixed results) digital channels.
  • MI is a necessary but insufficient response to vaccine hesitancy at the population level — it must be accompanied by structural trust-building and reduction of vaccine access barriers.