Vaccine communication training using the Brief Motivational Interviewing for Maternal Immunization intervention: A PRISM implementation evaluation.

Improving clinician-patient communication can increase uptake of recommended vaccinations during pregnancy. To evaluate adaptations to and pragmatism of the brief Motivational Interviewing for Maternal Immunizations (MI4MI) intervention and to use the Practical Robust Implementation and Sustainability Model (PRISM) to describe context and implementation outcomes among clinician and staff participants. We incorporated data from study team members, clinicians and staff participants, pregnant patients at participating clinics, and patient medical records. Quantitative and qualitative data were collected using surveys, chart reviews, study team notes, interviews, and focus groups. Adaptations were evaluated using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) and pragmatism was measured with PRagmatic Explanatory Continuum Indicator Summary (PRECIS-2). MI4MI was effective at improving participants' vaccine communication experiences. Adoption was limited by our recruitment approach. MI4MI implementation was shaped by contextual factors and associated adaptations related to the COVID pandemic and clinic and participant characteristics. Virtual asynchronous intervention delivery had mixed effects on adoption and implementation that varied across clinics and participants. Participants expressed interest in maintaining the MI4MI intervention moving forward; however, identification of sustainability infrastructure was limited. MI4MI was evaluated to be relatively pragmatic. Contextual factors strongly shaped implementation of MI4MI. Future iterations of MI4MI should include training delivery modes and incentives that accommodate a range of participants across job roles and organizational settings. Future studies including control clinics are needed to measure effectiveness for increasing vaccination and comparing virtual versus hybrid implementation strategies.

We studied a training program called Brief Motivational Interviewing for Maternal Immunizations (MI4MI). This program tried to teach doctors and other healthcare workers how to talk with pregnant people about vaccines. We looked at how this training program worked in different clinics. We talked with and gave surveys to the healthcare workers and patients at clinics who participated in this program. Healthcare workers who completed the MI4MI program had better experiences talking about vaccines after the training. This study happened during the early COVID pandemic, so training was done online. Healthcare workers and clinics had mixed responses to the online training approach. COVID made it hard for some people to participate. Many people who did the training said they would like to keep using the MI4MI training and skills in the future. More studies are needed to learn if the MI4MI training increases vaccination rates and to look at ways to improve online training.

Boot Camp Translation using Community-Engaged messaging for adolescent Vaccination: A Cluster-Randomized trial.

BACKGROUND: Routine vaccination coverage for adolescents living in the rural US is lower than adolescents living in urban areas. We sought to measure the effect of Boot Camp Translation (BCT), a community-based participatory intervention, on rural adolescent vaccination coverage. METHODS: A cluster randomized controlled trial was performed September 2018-November 2021 involving 16 rural Colorado counties. Intervention county community members engaged in BCT to develop interventions to improve adolescent vaccination locally. Adolescent vaccination coverage was measured using the Colorado Immunization Information System. RESULTS: For 11-12-year-olds, HPV initiation, HPV up-to-date, MenACWY, and Tdap vaccination coverage was lower post- versus pre-intervention in the control and intervention groups. For 11-12-year-olds in the intervention group, there was no significant difference post- versus pre-intervention in the odds of HPV vaccine initiation (adjusted ratio of odds ratios [aROR] = 0.93, 95 %: 0.85-1.02, p = 0.10) or up-to-date HPV vaccination (aROR: 1.10, 95 % CI: 0.98-1.23, p = 0.11) compared with the control group. Among 11-12-year-olds, the decrease in the proportion vaccinated with MenACWY and Tdap in the intervention group was significantly greater than the control group. Among 13-17-year-olds, there were significant increases in HPV initiation, HPV up-to-date, MenACWY, and Tdap vaccination coverage from pre- to post-intervention for both groups, with no significant differences between groups. CONCLUSION: 11-12-year-old vaccination coverage decreased slightly from pre- to post-intervention while 13-17-year-old vaccination coverage increased. We saw no effect from the BCT intervention. Our findings about the effectiveness of BCT for improving vaccine uptake may not be generalizable because the study coincided with the COVID-19 pandemic. CLINICAL TRIAL REGISTRY: This study was registered with ClinicalTrials.gov, NCT03955757.

Development of PIVOT with MI: A motivational Interviewing-Based vaccine communication training for pediatric clinicians.

Delay or refusal of childhood vaccines is common and may be increasing. Pediatricians are parents' most trusted source for vaccine information, yet many struggle with how to communicate with parents who resist recommended vaccines. Evidence-based communication strategies for vaccine conversations are lacking. In this manuscript, we describe the development and perceived usefulness of a curriculum to train clinicians on a specific vaccine communication strategy as part of the PIVOT with MI study, a cluster randomized trial testing the effectiveness of this communication strategy on increasing childhood vaccination uptake among 24 pediatric practices in Colorado and Washington. The communication strategy is based on the existing evidence-based communication strategies of a presumptive format for initiating vaccine conversations and use of motivational interviewing if hesitancy persists. Focus groups and semi-structured interviews with pediatric clinicians helped inform the development of the training curriculum, which consisted of an introductory video module followed by 3 training sessions. Between September 2019 and January 2021, 134 pediatric clinicians (92 pediatricians, 42 advanced practice providers) participated in the training as part of the PIVOT with MI study. Of these, 92 % viewed an introductory video module, 93 % attended or viewed a baseline synchronous training, 82 % attended or viewed a 1st refresher training, and 77 % attended or viewed a 2nd refresher training. A follow-up survey was administered August 2020 through March 2021; among respondents (n = 100), >95 % of participants reported that each component of the training program was very or somewhat useful. These data suggest that the PIVOT with MI training intervention is a useful vaccine communication resource with the potential for high engagement among pediatric clinicians.

Motivational interviewing for maternal Immunizations: Intervention development.

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 clinician-trainees. 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.

Parent Attitudes Towards Childhood Vaccines After the Onset of SARS-CoV-2 in the United States.

OBJECTIVE: To understand the influence of a novel infectious disease epidemic on parent general attitudes about childhood vaccines. METHODS: We conducted a natural experiment utilizing cross-sectional survey data from parents of infants in Washington and Colorado participating in a larger trial that began on September 27, 2019. At enrollment, parents completed the short version of the Parental Attitudes about Childhood Vaccines (PACV-SF), a validated survey scored from 0 to 4, with higher scores representing more negative attitudes. The exposure variable was onset of the SARS-CoV-2 pandemic in the United States, with the before-period defined as September 27, 2019 to February 28, 2020 and the after-period defined as April 1, 2020-December 10, 2020, with the after-period further separated into proximate (April 1, 2020-July 31, 2020) and distant periods (August 1, 2020-December 10, 2020). The outcome variable was parent negative attitudes about childhood vaccines, defined as a score of ≥2 on the PACV-SF. We estimated the probability of the outcome after (vs before) the exposure using log-binomial regression with generalized estimating equations adjusted for demographic confounding variables. RESULTS: Among 4562 parents, the risk of negative attitudes was lower immediately after (vs before) SARS-CoV-2 onset (adjusted risk ratio [aRR] = 0.58; 95% confidence interval [CI], 0.36, 0.94; P = .027), but by August-December 2020, the average rate of negative attitudes was 35% higher than during April-July 2020 (aRR: 1.35; 95% CI: 1.13, 1.61; P = .0009). CONCLUSIONS: A reduced risk of negative general vaccine attitudes observed immediately after SARS-CoV-2 onset was quickly attenuated.

Improving lifestyle obesity treatment during the COVID-19 pandemic and beyond: New challenges for weight management.

Objective: The COVID-19 pandemic has resulted in significant changes to daily life and many health-related behaviors. The objective of this study was to examine how the stay-at-home/safer-at-home mandates issued in Colorado (March 2020-May 2020) impacted lifestyle behaviors and mental health among individuals with overweight or obesity participating in two separate behavioral weight loss trials (n = 82). Methods: Questionnaires were used to collect qualitative and quantitative data on challenges to weight loss presented by the COVID-19 pandemic, including changes in dietary intake, physical activity, sedentary behavior, and mental health during the stay-at-home/safer-at-home mandates. Results: Using a convergent mixed method approach integrating qualitative and quantitative data, the greatest challenge experienced by participants was increased stress and anxiety, which led to more unhealthy behaviors. The majority perceived it to be harder to adhere to the prescribed diet (81%) and recommended physical activity (68%); however, self-reported exercise on weekdays increased significantly and 92% of participants lost weight or maintained weight within ±1% 5-6 weeks following the stay-at-home mandate. Conclusion: Study results suggest that obesity treatment programs should consider and attempt to address the burden of stress and anxiety stemming from the COVID-19 pandemic and other sources due to the negative effects they can have on weight management and associated behaviors.

"It's Like 1998 Again": Why Parents Still Refuse and Delay Vaccines.

We conducted a qualitative study from 2018 to 2019 to update the reasons why US parents' refuse or delay vaccines. Four focus groups and 4 semi-structured interviews involving 33 primary care pediatric providers were conducted in Washington and Colorado. A thematic analysis was conducted to identify themes related to reasons for parental refusal or delay. Five predominant themes were identified: (1) vaccine safety, (2) relative influence of information sources, decision-makers, and timing, (3) low perceived risk of contracting vaccine-preventable disease, (4) lack of trust, and (5) religious objection. Vaccine safety was the theme mentioned most frequently by providers (N = 45 times by 26 providers) and religious objection to vaccination was referred to the least (N = 6 times by 6 providers). Provider-reported reasons for parental refusal or delay of childhood vaccines in 2018 to 2019 remain similar to those reported in previous studies.

Rural Adolescent Immunization: Delivery Practices and Barriers to Uptake.

BACKGROUND: Rural adolescent vaccination rates lag behind urban. We sought to assess rural-urban differences in barriers to adolescent vaccination, perceived parental vaccine attitudes, and immunization delivery practices among public health nursing (PHN), pediatric (Peds), and family medicine (FM) clinicians. METHODS: Internet and mail survey of Colorado PHN, Peds, and FM clinicians from June-August 2019. Study population was recruited from local health plans and the American Medical Association Physician Masterfile. Rural and urban responses were compared using Cochran Armitage trend, Fisher's exact, and chi-square tests. RESULTS: Response rate was 38% (163/433; 91 rural, 72 urban). Rural respondents were less likely than urban to agree most patients have insurance that covers vaccination (86% vs 97%; P = .02). Rural respondents were less likely than urban to indicate most parents in their practice would agree with statements about vaccine benefits (P = .02) and trust in medical providers (P = .05). Rural respondents were more likely than urban to report adolescents were somewhat/very likely to receive vaccines at public health departments (65% vs 28%; P < .0001) and less likely to report adolescents were somewhat/very likely to receive vaccines at pharmacies (26% vs 45%; P = .02). Fewer providers strongly recommended HPV vaccine (81% for females, 80% for males 11 to 12 years) than other adolescent immunizations (Tdap: 97%, MenACWY at 11 to 12 years: 87%; influenza at 11 to 17 years: 87%; each P < .005, rural-urban responses did not differ). CONCLUSIONS: Rural barriers to adolescent vaccination include logistic issues and parental vaccine attitudes. Efforts to improve rural adolescent vaccination should include public health departments and address vaccine confidence and access barriers.

'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.

INTRODUCTION: A key contributor to underimmunisation is parental refusal or delay of vaccines due to vaccine concerns. Many clinicians lack confidence in communicating with vaccine-hesitant parents (VHP) and perceive that their discussions will do little to change parents' minds. Improving clinician communication with VHPs is critical to increasing childhood vaccine uptake. METHODS AND ANALYSIS: We describe the protocol for a cluster randomised controlled trial to test the impact of a novel, multifaceted clinician vaccine communication strategy on child immunisation status. The trial will be conducted in 24 primary care practices in two US states (Washington and Colorado). The strategy is called Presumptively Initiating Vaccines and Optimizing Talk with Motivational Interviewing (PIVOT with MI), and involves clinicians initiating the vaccine conversation with all parents of young children using the presumptive format, and among those parents who resist vaccines, pivoting to using MI. Our primary outcome is the immunisation status of children of VHPs at 19 months, 0 day of age expressed as the percentage of days underimmunised from birth to 19 months for 22 doses of eight vaccines recommended during this interval. Secondary outcomes include clinician experience communicating with VHPs, parent visit experience and clinician adherence to the PIVOT with MI communication strategy. ETHICS AND DISSEMINATION: This study is approved by the following institutional review boards: Colorado Multiple Institutional Review Board, Washington State Institutional Review Board and Swedish Health Services Institutional Review Board. Results will be disseminated through peer-reviewed manuscripts and conference presentations. TRIAL REGISTRATION NUMBER: NCT03885232.