MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 1 Motivational Interviewing as a Strategy to Reduce Vaccine Hesitancy in Rural Michigan: A DNP Evidence Based Practice Project Taylor M. Blank and Veronica GF Osborne Michigan State University College of Nursing April 28, 2023 MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 2 Table of Contents List of Tables ..............................................................................................................................4 List of Figures .............................................................................................................................5 Abstract ......................................................................................................................................6 Background & Significance.........................................................................................................8 Problem Statement .................................................................................................................... 12 Gap Analysis ......................................................................................................................... 13 Purpose of the Project............................................................................................................ 14 Evidence Based Practice Quality Improvement Model .............................................................. 14 The Health Belief Model ....................................................................................................... 14 Synthesis of the Evidence.......................................................................................................... 16 Search Strategies ................................................................................................................... 16 Selection Criteria................................................................................................................... 17 Factors Influencing Vaccine Hesitancy .................................................................................. 17 Instruments Used to Measure Vaccine Hesitancy................................................................... 18 Rural Population and Vaccine Hesitancy ............................................................................... 19 Use of Motivational Interviewing to Reduce Vaccine Hesitancy ............................................ 21 Provider Education ............................................................................................................ 21 Direct MI Application in Addressing Vaccine Hesitancy ................................................... 22 Goals, Objectives, and Expected Outcomes ............................................................................... 23 Methods .................................................................................................................................... 23 Population, Project Site, and Key Stakeholders...................................................................... 23 Ethical Considerations ........................................................................................................... 25 Setting Facilitators and Barriers............................................................................................. 26 The Intervention and Data Collection Procedure.................................................................... 26 PDSA Model ......................................................................................................................... 27 Plan ................................................................................................................................... 29 Do ..................................................................................................................................... 29 Study ................................................................................................................................. 30 Act .................................................................................................................................... 30 MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 3 Study Measures ..................................................................................................................... 31 Analysis .................................................................................................................................... 32 Sustainability Plan..................................................................................................................... 33 Implications for Nursing ........................................................................................................... 34 Conclusion ................................................................................................................................ 35 References ................................................................................................................................ 36 Table 1 ...................................................................................................................................... 44 Table 2 ...................................................................................................................................... 45 Table 3 ...................................................................................................................................... 46 Appendix A............................................................................................................................... 47 Appendix B ............................................................................................................................... 48 Appendix C ............................................................................................................................... 65 Appendix D............................................................................................................................... 66 Appendix E ............................................................................................................................... 67 Appendix F ............................................................................................................................... 68 Appendix G............................................................................................................................... 69 Appendix H............................................................................................................................... 71 MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 4 List of Tables Table 1: Characteristics of Participants Table 2: Knowledge about Motivational Interviewing Table 3: Comparison of Pre- and Post-MI Intervention Survey MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 5 List of Figures Figure 1: Fishbone Diagram Figure 2: Rural Michigan Maps Figure 3: SWOT Analysis Figure 4: Project Budget Figure 5: Pre/Post Intervention Survey MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 6 Abstract Background and Review of Literature: Vaccination hesitancy has become an important topic of discussion for health care providers, as well as for the general public. There are multiple reasons individuals experience vaccination hesitancy and chose not to become vaccinated. However, not receiving vaccinations leaves individuals at increased risk for serious vaccine-preventable illnesses. Individuals in rural areas are more likely to experience vaccine hesitancy. Health care providers have used different strategies to decrease vaccine hesitancy. An effective strategy to address behavior change, including vaccine hesitancy, is to use motivational interviewing in one- on-one discussions with patients. However, health care providers do not regularly use motivational interviewing (MI). Purpose: The purpose of this evidence-based practice (EBP) project is to provide an education session to the Michigan State University (MSU) Extension vaccine team members that are instrumental in the delivery of health care information to the rural population of Michigan, on why and how to use MI with clients, specifically focusing on addressing vaccine hesitancy. Methods: A two-person team of Doctor of Nursing Practice (DNP) students developed an educational information session on MI, in consultation with an MI expert. This session provides educational information for members of the MSU Extension vaccine team, focusing on strategically employing MI to address vaccine hesitancy. The educational session was administered over a synchronous zoom session to members of the MSU Extension vaccine team. Implementation Plan/Procedure: A survey was administered to participants pre-and post-the motivational interviewing session, to assess for changes in knowledge and confidence in utilizing motivational interviewing. This survey consisted of 3 participant characteristic questions, 4 MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 7 questions to gauge baseline understanding of participants knowledge of MI, and 9 pre- and post- survey questions that assessed knowledge related to MI. Results: There was an improvement of knowledge and confidence among participants regarding MI and its use. In addition, several participants were qualitatively surveyed after the educational session and overall they agreed that this intervention was beneficial, and they would like to continue to learn more about MI. Implications/Conclusion: This project highlights the continued need for MI education with healthcare providers and team members who regularly interact with the rural population regarding vaccine hesitancy. Keywords: Vaccine hesitancy, Vaccinations, Rural Michigan, Motivational Interviewing MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 8 Motivational Interviewing as a Strategy to Reduce Vaccine Hesitancy in Rural Michigan: A DNP Evidence Based Practice Project Vaccinations are a proven strategy for preventing diseases (Centers for Disease Control and Prevention [CDC], 2020). In fact, vaccinations have allowed for the smallpox eradication and near elimination of polio (CDC, 2020). Vaccines have even been described as one of the top ten health achievements in health care in the 20th century (The College of Physicians of Philadelphia, 2022a). However, many individuals choose to not become vaccinated. Strategies have been employed to tackle this health care concern; yet primary health care providers still struggle to address the importance of obtaining vaccinations with their patients. Specifically, the rural population in the United States has been shown to have increased rates of vaccine hesitancy and resistance to vaccines (Saelee et al., 2022). This paper describes an EBP project that seeks to improve knowledge of motivational interviewing (MI) for use in promoting vaccinations and the increase of vaccine uptake among individuals in rural Michigan. The project is centered on the development and delivery of an interactive educational session about using MI to address vaccine hesitancy, for members of the MSU Extension vaccine team. Background & Significance The World Health Organization (WHO) (2019) has named vaccination hesitancy as a top ten threats to global health in 2019. According to the WHO (2019), vaccine hesitancy is defined as “the reluctance or refusal to vaccinate despite the availability of vaccines” (para. 27). Vaccinations have been found to be one of the most cost-effective strategies in avoiding diseases and the lack of vaccine uptake has threatened to reverse the advancement made in tackling these preventable diseases (WHO, 2019). Vaccines assist to prevent 2-3 million deaths a year, MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 9 additionally “1.5 million deaths could be avoided if global coverage of vaccinations improved” (WHO, 2019, para. 27). Since the early 1800’s and the creation of the first vaccine, vaccine hesitancy has remained a prominent topic in health care and in society (The College of Physicians of Philadelphia, 2022a). The foundations of individuals' negative attitudes towards vaccines have varied including religious reasons, misinformation about vaccines, and political objections (The College of Physicians of Philadelphia, 2022a). Since the creation of vaccines, there have been continued shifts in the scientific and public arena regarding vaccines effectiveness and safety. Most notably in 1995, a group of researchers published a cohort study that described a relationship between the vaccine for Measles, Mumps, and Rubella (MMR) and bowel disease, these researchers believed that receiving the MMR vaccine led to increased and persistent infection in the intestinal tissues leading to increased rates of bowel disease among those who had received the vaccine. (The College of Physicians of Philadelphia, 2022b). Several years later one of the researchers who was a member of the initial team published a second study linking the MMR vaccine to autism, leading to an immediate drop in vaccination rates and mistrust in vaccines overall (The College of Physicians of Philadelphia, 2022b). However, no evidence has been found that vaccines are linked to increased rates of autism, and it was also determined that the study information had been falsified by the researchers (The College of Physicians of Philadelphia, 2022b). With the creation of new vaccines including the COVID-19 vaccination, there continues to be skepticism about vaccines and the scientific rational behind them. The history of vaccine hesitancy has shown that there are many reason individuals chose to not become vaccinated including for political, religious, or social reasons (The College of Physicians of Philadelphia, 2022a). Demographics also play a large role in whether individuals MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 10 chose to become vaccinated (Yasmin et al., 2021). A study done specifically for COVID-19 vaccine hesitancy found that in general, males were more willing to receive the COVID-19 vaccine, while breastfeeding and pregnant women as well as the general African American population were the least likely (Yasmin et al., 2021). This information should be alarming to health care providers, pharmaceutical companies, and society that there is a divide among those who are willing and not willing to be vaccinated. Given these facts, efforts need to focus on exploring why patients have the perspectives that they do, with vaccinations. It is demonstrated that non-vaccinated individuals experience increased hospitalization and greater adverse effects of COVID-19, which leads to potential threats to the financial stability and overall health of the country (Yasmin et al., 2021). A strategic approach is needed to restore trust in vaccines and medical professionals, especially targeting individuals in these groups (Yasmin et al, 2021). This study confirms that demographic factors significantly influence hesitancy of vaccination, which necessitates the implementation of education and access for all demographic populations. There is also a significant gap in COVID-19 vaccinations between rural populations and urban populations (Saelee et al., 2022). Specifically in April 2021, the COVID-19 vaccination rates of rural populations in the United States were 39% and urban populations was at 46%, while in January 2022 these two populations were at 59% and 75%, respectively (Saelee et al., 2022). These statistics stress the need for education and outreach to the rural communities about the importance and value of vaccines. Not only are COVID-19 vaccination numbers lower in rural populations, but other vaccinations are also falling behind as well. According to Brandt et al. (2021), the National Immunization Survey-Teen (NIS-Teen) data in 2019 showed HPV vaccinations were lower among rural youths compared to individuals in urban arenas, with rural adolescent rates at 47.3% which increased 6.6% from 2018, compared to 54.2% in the United MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 11 States which increased 3.1% from 2018. This study also discussed that rural residents face a unique set of barriers to receiving adequate health care; these include lower knowledge of vaccinations, health care provider shortages leading to fewer access points for health care services including telehealth services, and lower socioeconomic status (Brandt et al., 2021). In Michigan, immunization rates have remained stable among the adult population, despite the COVID-19 pandemic, but there is area for improvement (Michigan Department of Health and Human Services [MDHHS], 2022a). According to data from MDHHS (2022a), many counties are below 70% for routine adult vaccination rates. Four of the five counties in Michigan with the lowest vaccination rates reside in rural Michigan; Clare, Gladwin, Iron, Lake, and Oscoda counties are all below 60% vaccination rates for many routine vaccinations (MDHHS, 2022a). COVID-19 statistics are also low. Only 67.4% of people in Michigan have received at least one dose of the COVID-19 vaccine (MDHHS, 2022b). This means 32.5% are unvaccinated, of that 32.5%, about 70% reside in rural communities (MDHHS, 2022b). Studies have shown that rural areas are prone to poor health care outcomes which also includes lower childhood and adult vaccination rates. Based on the Kaiser Family Foundation (KFF) Vaccine Monitor of December 2020, rural communities are among the most vaccine hesitant, with only 31% being willing to get the COVID-19 vaccine, and 25% adamant against getting the vaccine when compared to urban areas with 42% willing to get the vaccine and only 15% adamantly opposed to getting vaccinated (Kirzinger, Muñana, & Brodie, 2021). In this same study it is discussed that a major factor that effects rural individuals choosing to become vaccinated against COVID-19 is the trust in their physician or other health care provider (Kirzinger, Muñana, & Brodie, 2021). Eight six percent of rural residents say that they trust the health care provider to deliver reliable information regarding the COVID-19 vaccine helping MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 12 them to make an educated decision (Kirzinger, Muñana, & Brodie, 2021). These barriers combined with limited literature focusing on rural populations, specifically regarding immunization rates, and the hesitancies of rural populations make it imperative to connect with rural populations utilizing effective methods to address vaccine hesitancy. Motivational interviewing (MI) is a behavior change strategy that is used by health care providers to assist patients in making a change to better their health. Health care providers tap into patients' motivations and engage them in the decision to make a behavior change as opposed to directly telling the patient what they should be doing to improve their health status (Rollnick, Miller, & Butler, 2008). There are three components that make MI successful. These include: fostering engagement in the patient relationship, cultivating a culture of partnership and empathy, and targeting the goal of the intervention, and understanding the patient/caregiver and adapting to their specific needs (Gagneur, 2020). Not only has MI been used successfully to improve health concerns such as decreasing alcohol abuse, gambling, smoking, drug use, poor dietary habits, and hypertension, there is also promising evidence that MI can improve vaccine uptake in hesitant individuals (Gagneur, 2020; Rollnick, Miller, & Butler, 2008). Problem Statement Vaccine hesitancy has remained a prominent topic in health care for many decades. With the COVID-19 pandemic this has become an even greater concern with part of the population choosing not to be vaccinated for various reasons (Green et al., 2021). Vaccine hesitancy has been shown to have negative effects on individuals and society (Green et al., 2021). Rural populations are disproportionately prone to be vaccine hesitant leading to increased illness in this population (Kirzinger, Muñana, & Brodie, 2021). Research on vaccine hesitancy has focused on causes, populations, and strategies for improvement. While there is a research specific to vaccine MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 13 hesitancy there is limited research focusing on the use of motivational interviewing in the rural population to improve vaccination rates. Gap Analysis The Ishikawa Model or “fishbone diagram” is used in this project to examine and organize the obstacles that lead to decreased vaccination rates in the rural population in Michigan (American Society for Quality [ASQ], 2022; Canva, n.d.). Determining the possible causes for decreased vaccination rates in this population was essential to directing the focus of this project and creation of the intervention. A fishbone diagram was constructed using four main categories that were determined from the literature, which could potentially be the cause of decreased vaccination rates (See Appendix A). These four categories are a) personal values, b) knowledge gaps, c) system level barriers, and d) health care provider considerations. Personal barriers that were identified were religious reasons for not vaccinating, lack or social support for vaccines, political reasons for not vaccinating, and mistrust in vaccinations overall (Fisher at al., 2020; Wang et al., 2021; Yasmin et al., 2021). Knowledge gaps play a large role in understanding vaccines, it was determined that individuals who lack knowledge of vaccines and limited access to credible sources leads to lower vaccination levels in the rural population (Wake, 2021). System level barriers that were identified are false information portrayed in the media, lack of access to care, and lack of transportations to receive vaccines (Gisondi et al., 2022; Wake, 2021). Finally, health care providers who are responsible for administering vaccines may feel discomfort with discussing vaccine uptake with individuals who are vaccine hesitant, they may feel hesitant to receive vaccines themselves (Ahmad, Akande, & Majid, 2022). Application of the fishbone diagram allowed for the examination and analysis of potential factors leading to decreased vaccination MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 14 rates in rural Michigan and aided with the development of the project intervention. Purpose of the Project The aim of this project is to focus on motivational interviewing as a strategy to improve knowledge and confidence in using MI among the MSU Extension Vaccine Team, which will hopefully contribute to increasing vaccine uptake, specifically in the rural population. This aim was accomplished by engaging the MSU Extension team in an interactive MI training experience. This session included a presentation on the purpose, goals, and methods of performing MI, as well as some role-play and practice using the skills taught for motivational interviewing. As the MSU Extension team members are already present in every county of Michigan, this training facilitates positive communication and information sharing within the rural communities. This training experience was accomplished in November 2022, and evaluation of this project was completed by May 2023. Evaluation was accomplished by analysis of the pre- and post-training surveys and demonstrating evidence of change in knowledge and confidence in using MI techniques through statistical analysis. With this improved knowledge, the hope is that the staff of MSU Extension will utilize MI to increase vaccination rates among the rural population of Michigan. Evidence Based Practice Quality Improvement Model The Health Belief Model The evidence-based practice model used to facilitate the intervention of this DNP project is the Health Belief Model. The Health Belief Model focuses on using evidence to anticipate health behaviors (LaMorte, 2019). Developed by the U.S. Public Health Service, this model was used to understand why people do not adopt healthy practices and focus on methods to overcome this lack of perceived “compliance” (LaMorte, 2019). The basis of this model suggests that MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 15 personal beliefs of the effectiveness of specific health behaviors will anticipate the likelihood of embracing these behaviors (LaMorte, 2019). Two major factors that affect individuals’ decisions are the perceived severity and susceptibility of contracting a particular disease or illness (Zampetakis, 2021). These two factors are instrumental in understanding why individuals may or may not choose to become vaccinated. With the current pandemic and rise of vaccine hesitancy among the population, the Health Belief Model has been used to predict the hesitancy of the population with regard to the COVID-19 vaccine. A study by Zampetakis (2021), analyzed the role the Health Belief Model plays in how people decided whether or not to become vaccinated to COVID-19. This study demonstrates that public health campaigns should be designed and implemented at different levels to address intention to vaccinate (Zampetakis, 2021). Examining vaccine hesitancy through the lens of the Health Belief Model allowed for a greater understanding of how to effectively and appropriately interact with individuals who are vaccine hesitant (Zampetakis, 2021). The Health Belief Model was used to develop this intervention based on evidence from the literature on rural populations, vaccine hesitancy, and overall health status in Michigan. When creating the proposed intervention, the DNP students utilized the main concepts of the Health Belief Model, perceived susceptibility, perceived severity, perceived benefits, and perceived barriers to influence the educational materials with a focus on how to apply these in conversations with the rural population utilizing MI (LaMorte, 2019). The MSU Extension team is present in all counties of Michigan and brings the resources and education available from MSU to the entire state. The MSU Extension team has established themselves as a trusted member of Michigan’s rural communities and provides resources for health education. It is evident from the literature that trusted members of the community are MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 16 pivotal in shifting mindsets of those who are vaccine hesitant (Alcendor, 2021; Hubach et al., 2022; Kirzinger, Muñana, & Brodie, 2021). By educating members of the MSU Extension team on the process of MI, MI can be used as a strategy with this population to address vaccination hesitancy in rural Michigan. Synthesis of the Evidence Search Strategies A literature search was conducted to examine the available literature on vaccination hesitancy among rural populations and the use of MI in with patients who are vaccine hesitant. To conduct this review, various searches were utilized in several databases including Cumulative Index for Nursing and Allied Health Literature (CINAHL), EBSCO research platform, PubMed, and Google Scholar. Furthermore, reference lists of several articles were also analyzed for additional sources. Vaccination hesitancy was defined as individuals’ rejection toward becoming vaccinated even if vaccines are available to them (WHO, 2019). Rural populations were defined as individuals who live outside of the urban area (Health Resources & Services Administration [HRSA], 2022). Motivational interviewing is defined as a behavior change technique used by health care providers to motivate positive change in the patient’s health (Rollnick, Miller, & Butler, 2008). Sources and articles published between 2014 and 2022 were considered for this literature review. The literature search was conducted between June 10, 2022, and July 1, 2022. An initial search was performed. Initial search teams included “vaccine” or “vaccination” AND “hesitancy” or “refusal”, a total of 5,296 articles were identified. After this search it was determined there needed to be a narrower focus, but this allowed the reviewers to visualize the vast amount of information that is available on vaccination hesitancy. Additional searches MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 17 included key search term such as “vaccination hesitancy” AND “impacts” or “effects” or “consequences”, which yielded 1274 articles, “vaccine hesitancy* or “vaccine refusal” AND “healthcare providers” or “healthcare professionals” or “clinicians” or “nurses” or “doctors” returned 1738 articles, “vaccine hesitancy” AND “motivational interview*” or “MI”, a total of 124 articles were identified. When the search terms “vaccine hesitancy” or “vaccine refusal” AND “rural population” or “rural community” were utilized, the search yielded 26 results. Selection Criteria Studies were selected based on their relevance to vaccination hesitancy or refusal for all vaccination types, including COVID-19. Studies were excluded if they were not published in English. The preliminary selection of studies was based on the title and abstract. The number of studies was further narrowed by confirming the concepts aligned with the original inclusion criteria and were published within the last five years except for one exception which was published in 2014. A total of 20 articles were utilized in the final literature synthesis and the following themes were identified: prominent factors influencing vaccines hesitancy, instruments used to assess vaccine hesitancy, examination of increased rates of vaccine hesitancy in the rural population, and motivational interviewing as a strategy to reduce vaccine hesitancy. A summary of the articles used for the literature synthesis can be found in the literature table in Appendix B. Factors Influencing Vaccine Hesitancy Understanding why individuals choose to not become vaccinated is essential to combating the problem of vaccine hesitancy. As noted, vaccine hesitancy has been a long- standing concern in the health care community and the public (The College of Physicians of Philadelphia, 2022a). Many of the reasons individuals have chosen to not be vaccinated have remained constant. Individuals have stated their discomfort towards receiving vaccinations stems MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 18 from medical mistrust, political views, religious beliefs, perceived barriers to receiving the vaccine, perceived effectiveness, and lack of access to vaccine due to geographic location, such as in rural populations (Fisher et al., 2020; Wang & Liu, 2021; Yasmin et al., 2021). There are also two specific populations that are regularly found to be more vaccine hesitant, these are women and individuals in the black population (Rane et al., 2022; Wang & Liu, 2021). The COVID-19 pandemic has put a narrow lens on vaccine hesitancy and there has been a substantial amount of research performed on how people receive their information about vaccines and if this plays a role in their decision to become vaccinated. Several studies confirmed that individuals were more likely to be vaccine hesitant if they received their information from social media (Wake, 2021; Wang & Liu, 2021). Health care providers who are equipped with the knowledge that these specific groups may be more prone to vaccine hesitancy are better able to address this at each health care encounter. Instruments Used to Measure Vaccine Hesitancy Many studies have assessed vaccination uptake in rural populations and vaccine hesitancy overall. Several survey instruments have been created to evaluate individuals rationale for not vaccinating. The results of these studies show that there may be a cultural aspect to hesitancy, that perceived safety, effectiveness, necessity, acceptance of vaccination schedule, positive opinions of the effectiveness, and perceived reliability and legitimacy of authorities to require vaccines may affect vaccine uptake (Akel et al., 2020; Anderson, 2014; Sarathchandra et al., 2018). Along with those opinions, the education of vaccine recipients, while increasing access to vaccines, and completing the routine audits of adult and pediatric practices would be an additional way to increase vaccine uptake. (Akel et al., 2020; Anderson, 2014; Sarathchandra et al., 2018). These models and surveys could be used to evaluate the hesitancy of rural populations MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 19 against getting vaccinations so more effective methods of communication could be developed for this population. These studies show that analyzing the aspects of hesitancy as well as using surveys to poll the population desired, display the types of information and the way to present them to this population (Akel et al., 2020; Anderson, 2014; Sarathchandra et al., 2018). From this information we can use our motivational interviewing project to address the specific concerns of the rural population regarding vaccine hesitancy, whether it be the COVID-19 vaccine, flu vaccines, or routine immunizations. Rural Population and Vaccine Hesitancy According to the WHO (2019), major reasons for vaccine hesitancy are “complacency, inconvenience of access to vaccines, and lack of confidence to vaccines”. This is echoed specifically in the rural population in a study that discusses reasons for lower vaccinations rate in this population include concerns about vaccine safety and the belief that vaccines are not necessary (Albers, Thaker, & Newcomer, 2022). Rural populations have continuously been shown to be among some of the most vaccine-hesitant groups, leading to increased risk for vaccine preventable diseases (Albers, Thaker, & Newcomer, 2022; Kirzinger, Muñana, & Brodie, 2021). Kirzinger, Muñana, & Brodie (2021) also discuss the statistics of rural populations to get the COVID-19 vaccine, approximately 35% of individuals surveyed “probably will not” or “definitely will not” get this vaccine. Studies have shown that the rural populations have unique barriers to health care; health care worker shortages, specifically pediatricians, fewer hospital beds, limited access to health care, and increased risk of death due to prevalence of chronic diseases (Albers, Thaker, & Newcomer, 2022; CDC, 2021; Kirzinger, Muñana, & Brodie, 2021). The CDC (2021) confirms in their Morbidity and Mortality Weekly Report in MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 20 May 2021, that COVID-19 vaccine hesitancy is substantial when comparing rural to urban populations. There is limited research that has been conducted in rural populations related to vaccine hesitancy, which presents a unique challenge that must be overcome. While research may be inadequate, there are key themes that have been identified when it comes to vaccine hesitancy in the rural population. Rural Americans have a lower health literacy and a greater distrust of the government, which are contributing factors leading to decreased vaccine uptake (Alcendor, 2021). Many vaccine interventions that have targeted the rural population have been focused on clinical initiation of vaccine discussions. This limits the reach of these interventions as rural Americans tend to have inadequate access to health care compared to their urban counterparts (Albers, Thaker, & Newcomer, 2022; CDC, 2021; Hubach et al., 2022). To increase vaccine uptake in rural communities', guidance must be facilitated by trusted community members including health care providers and other trusted members of the community such as faith leaders and rural community influencers (Alcendor, 2021; Hubach et al., 2022; Kirzinger, Muñana, & Brodie, 2021). These trusted community members need to provide the opportunity to achieve a higher level of health literacy to make informed decisions about vaccines and prevent infections by having open discussion regarding basic vaccine information and safety (Alcendor, 2021). This guidance should occur in locations in which these rural populations come together such as churches, grocery shops, feed, and supply stores, etc. (Alcendor, 2021). This research confirms that there are key factors that must be considered when engaging with the rural population regarding vaccine hesitancy such as location of interactions and the trust in the individuals who are providing the information. MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 21 Use of Motivational Interviewing to Reduce Vaccine Hesitancy Evidence based approaches are essential for providers to incorporate when it comes to reducing vaccine hesitancy (Breckenridge, Burns, & Nye, 2021). MI is a proven technique that has been shown to be effective at decreasing vaccine hesitancy (Breckenridge, Burns, & Nye, 2021; Gagneur A., 2020; Reno et al., 2018). Several studies have demonstrated its effectiveness with numerous types of vaccines including human papilloma virus (HPV), diphtheria, tetanus, pertussis (DTaP), MMR, and COVID-19 (Breckenridge, Burns, & Nye, 2021; Cole et al., 2022). Engaging patients and care givers in conversations regarding their reluctance towards vaccinations is a significant component of MI and allows for providers to target patients concerns and adapt the information provided to result in increased uptake of vaccines (Gagneur A., 2020). Application of the MI approach to combat vaccine hesitancy has been implemented with several methods including, provider education and direct use of MI by researchers (Cole et al., 2022; Gagneur et al., 2019; Reno et al., 2018). Provider Education Two studies examined the effects of provider education to improve techniques of MI to utilize during health care encounters with vaccine hesitant parents. (Cole et al., 2022; Reno et al., 2018). Cole at al. (2022), created a MI tool called MOTIVE, or MOtivational interviewing Tool to Improve Vaccine acceptancE, that guides health care providers through conversations with parents who are vaccine hesitant. This study provided education to health care providers in the use of MI and how to utilize the created tool effectively (Cole et al., 2022). The second study utilized a training program that was specific to HPV and empowered providers to utilize an approach that assumed parents were willing to vaccinate their child for HPV (Reno et al., 2018). Both studies involved the opportunity for health care providers to role-play MI techniques and MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 22 receive feedback to improve their methods (Cole et al., 2022; Reno et al., 2018). Both interventions ultimately demonstrated that providers feel more confident when using the technique of MI when it comes to discussing vaccine hesitancy and Cole et al. (2018) was able to determine a significant increase in vaccination uptake in the study populations (Reno et al., 2018). Direct MI Application in Addressing Vaccine Hesitancy A study conducted by Gagneur et al. (2019), implemented an intervention in the hospital setting, specifically in four university hospital maternity wards, for new mothers by teaching research assistants to employ MI to attempt to increase vaccination rates for newborns. This study focused on five main areas of vaccine hesitancy including, vaccine-preventable diseases consequences, vaccines effectiveness, the importance of the immunization schedule in infants, reluctance to vaccinate and side-effects, and vaccination facilities in each of the examined regions (Gagneur et al., 2019). Questionnaires were utilized before and after the intervention to assess effectiveness (Gagneur et al., 2019). While Gagneur et al. (2019) utilized a different approach to applying MI, this technique was also shown to be effective at decreasing vaccine hesitancy and enhancing the intention to vaccinate. Literature Synthesis Summary The current available literature documents numerous reasons individuals choose to not become vaccinated; these are compounded in the rural population as they have decreased trust in the systems that provide vaccines and they have more limited access to vaccines and vaccine information (Alcendor, 2021; Fisher et al., 2020). Several tools have been created in order to measure vaccine hesitancy, and these tools may be useful to utilize in the rural population. MI is a technique to help combat vaccine hesitancy in many populations but has mainly focused on MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 23 targeting parents of young children through newborn and HPV vaccinations (Gagneur A., 2020; Reno et al., 2018). Trusted members of the community are crucial when it comes to delivering information about vaccines as the rural population has shown more confidence in understanding the importance of vaccines through this delivery method (Alcendor, 2021). Through the implementation of this EBP project, the aim is to gain trust and improve the knowledge of this vulnerable community through proven techniques. It is essential that more research is conducted on the rural populations with established techniques, such as MI, to gain a better understanding of how to increase vaccine uptake and decrease fear of receiving vaccinations. Goals, Objectives, and Expected Outcomes To assess this EBP project and the administered intervention it is essential to define the intended goals and objectives. The primary outcome for this EBP project is to increase knowledge and confidence about motivational interviewing among MSU Extension team members. MSU Extension team member specifically includes those individuals who are a part of the Michigan Vaccine Project Team. This outcome was achieved by completing a one-time 3- hour presentation on MI with an emphasis on vaccine hesitancy in November 2022 to the members of the MSU Extension team via virtual format. This goal will be achieved if there is a statistically significant increase in results from a pre- and post- survey to examine for knowledge and confidence in using MI. Methods Population, Project Site, and Key Stakeholders The targeted population for this EBP project is the team members at MSU Extension vaccine team across Michigan. These individuals regularly have opportunities to connect with members of the rural Michigan community who comprise the members of the group this project MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 24 is ultimately aiming to effect by increasing their vaccination rates. The percentage of the population in Michigan that is considered rural is around 20% (United States Department of Agriculture [USDA], 2021). Rural populations can be defined as those populations outside urban areas (Citizen’s Research Council of Michigan, 2018). According to the 2010 decennial census, rural is defined as territories and settlements outside of towns and cities with fewer than 2,500 residents (Ratcliffe et al., 2016). Most of Michigan’s rural population lies above the 43rd parallel or “Bay City line” (Citizen’s Research Council of Michigan, 2018). Images of the rural population distribution for the state of Michigan can be shown in Appendix C (Citizen’s Research Council of Michigan, 2018). These images show that most of the area of the state of Michigan is rural, including most of the Upper Peninsula and the upper area of the Lower Peninsula (Citizen’s Research Council of Michigan, 2018). Major populated urban counties include Wayne, Washtenaw, Oakland, Kent, Ingham, Bay, Midland, Saginaw, Genesee, Muskegon, and Kalamazoo, while most of the other counties are considered rural (Citizen’s Research Council of Michigan, 2018). The community partner for this EBP project is MSU Extension. MSU Extension is an organization that brings all the resources and knowledge of MSU throughout the counties of the state of Michigan. The mission statement of MSU Extension is to “help people improve their lives through an educational process that applies knowledge to critical issues, needs and opportunities” (MSU, n.d.). This organization has a representation in every county in the state of Michigan including the Upper Peninsula and rural areas. This facilitates usage of MSU programs and services throughout the state and in every population. This provides a tremendous advantage for these counties to have resources at their disposal they otherwise would not have, more importantly, these programs and services are from a trusted source and major educator in the MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 25 state. These resources include health care, economic, and agricultural. MSU Extension team members connect with members of the Michigan population by many avenues including face-to- face interactions, television advertisements, printed flyers, radio advertisements, and telephone communication to name a few. MSU Extension focuses on “helping to grow the agricultural economy, sustainably using natural resources, or helping manage chronic illnesses to decrease health care costs and preparing the future leaders. MSU Extension is building better communities to keep Michigan strong and prosperous” (MSU, n.d.). With respect to our project, MSU Extension received a $7 million grant from the CDC and the MDHHS to explore vaccination rates and strategies to improve vaccination rates in rural Michigan among adult populations (MSU, 2021). Key stakeholders for the proposed intervention are the health care providers caring for members of the rural community in Michigan, the team at MSU Extension, and the rural population in Michigan. All individuals in the state of Michigan can potentially benefit from this intervention, increasing vaccination rates in any population will lead to a greater likelihood that a disease will not be transmitted to others. Ethical Considerations Michigan State University Internal Review Board (IRB) approval was obtained prior to initiating the DNP Project. This project was deemed not to be research. The official IRB Determination Form was submitted after the proposal was approved. Informed consent was obtained from all participants before initiation of the intervention. By obtaining informed consent, the risks and benefits of participating were explained and accepted by each participant. Participants of this project were informed their information would be kept anonymous and abide by all HIPPA, Michigan State University, and IRB policies. All information regarding the project MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 26 and its results was secured by password protected computers, no print information was utilized or provided for this intervention reducing potential data and information breaches. All interactions and interventions throughout the planning and implementation of this project took place virtually to minimize potential exposure to COVID-19. To gain better understanding of the objectives of the MSU Extension team, project team members worked closely with MSU Extension staff to ensure practicality and sustainability of the intervention. Setting Facilitators and Barriers For recognizing facilitators and barriers for this project a SWOT table analysis was utilized to identify strengths, weaknesses, opportunities, and threats to the community organization we are partnering with, in this case, MSU Extension. A SWOT analysis is used to help develop a broader awareness of an organization in order to explore solutions to a given problem and provides an organized format for determining where change may be possible (Renault, n.d.). See the SWOT table in Appendix D for further information of the SWOT analysis. The Intervention and Data Collection Procedure After examination of the literature and discussion with the project site it was determined the best direction to take was creating an intervention to educate the MSU Extension team. The initial intent of this project was to interact with members of the community by utilizing motivational interviewing techniques to invoke discussion about vaccine hesitancy and ultimately help rural community members come to the decision to become vaccinated. With the COVID-19 pandemic still affecting in-person communication with community members, it was ultimately decided the most safe and effective intervention would take place virtually and by educating members of the MSU Extension team about MI who have regular contact with this MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 27 rural population. The intervention is occurring in three phases, the first phase involved examining the available literature and gaining an understanding from the MSU Extension team about their needs in regard to reducing vaccine hesitancy. The second phase involved carrying out the proposed intervention with the MSU Extension vaccine team and collecting the data to assess the outcome of the intervention. Finally, the third phase is currently underway, and consists of data analysis and presentation of the EBP project findings. A full timeline of the project implementation can be found in Appendix E. An explanation of the project budget is located in Appendix F, with resources being donated in-kind for completion of the DNP Project. PDSA Model The Plan Do Study Act (PDSA) model was used to guide development and implementation of procedures in this project. PDSA is an evidence-based instrument utilized to guide individuals through the process of creating, implementing, and adjusting change interventions (Institute for Healthcare Improvement [IHI], 2022). The PDSA tool has been effectively applied in the health care setting for many types of change interventions. Each of the four steps of the PDSA model help to analyze the change intervention to allow for effective, thoughtful modification at each step of the process. The “plan” step involves gaining an understanding of what change needs to be achieved and how to gauge when this change has successfully occurred (IHI, 2022). During this step, it is crucial to determine what data needs to be collected and begin in development of the plan for the intervention (IHI, 2022). The “do” stage is when the actual intervention is carried out and data is collected, it is essential during this stage to monitor and track unexpected outcomes (IHI, 2022). During the “study” stage, data is analyzed and compared with the expected outcomes (IHI, 2022). Reflecting on lessons learned throughout the implementation process can help to assist with adjusting the intervention as MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 28 needed (IHI, 2022). Finally, the “act” step is when the intervention is either adapted, adopted, or abandoned based on the collected data (IHI, 2022). This step is when a plan for the future of the intervention is created, this may involve utilizing the PDSA tool multiple times throughout the process (IHI, 2022). The PDSA tool was applied to this EBP project as it allowed for an evidence-based guided approach to create the utilized intervention. The projected outcomes of this EBP project include increasing the number of MSU Extension team members that can apply MI when interacting with vaccine hesitant individuals in the rural community in Michigan. With the implementation of the PDSA cycle, the DNP students have been able to utilize the available literature to gain a better understanding of the problem and create a sustainable change intervention. During the “plan” stage the DNP students regularly met with the MSU Extension staff and faculty advisor for assistance in guiding the direction of the intervention. This step also included the creation of intervention material including the pre- and post- survey as well as the educational materials. The “do” phase consisted of the intervention implementation in which the DNP students provided the educational session about MI to the MSU Extension vaccine team. During this step, the pre- and post-survey were administered to the participants utilizing the Qualtrics system provided through MSU. The “study” step includes analyzing the data collected from the pre- and post- surveys after the intervention was administered. Finally, the “act” stage involves modification of the intervention and providing the MSU Extension staff with the resources needed to make the intervention sustainable. A detailed explanation of the PDSA tool for the applied intervention can be found below. MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 29 Plan To gain knowledge about the targeted population and understanding of its needs, two family nurse practitioner students met with the director of MSU Extension's Health and Nutrition Institute as well as several MSU Extension team members who are a part of the Michigan Vaccine Project Team. This allowed for better understanding of the needs of the organization and the vulnerable community they were trying to target. After this collaboration, it was determined the best potential option to impact the large rural population in Michigan was to implement a training program focused on the individuals who interact with this population regularly, the MSU Extension vaccine team. The DNP students implemented the MI educational session in the month of November to the MSU Extension staff. This was done through a secured virtual meeting as it allows for limited contact to decrease the potential COVID-19 exposure. The education that was provided focused on the main principles of MI, techniques to become more confident with using MI, exemplars showing effective and ineffective MI technique, and finally working through scenarios to interact with MSU Extension team members. Recruitment of individuals who took part in this intervention, was completed by the director of MSU Extension and a member MSU Extension Michigan vaccine team who was designated as the DNP students' point person. Do The DNP students facilitated the educational experience in the month of November. On the selected date of the session, the DNP students, and 15 members of the MSU Extension team met via a synchronous zoom session. Before beginning the educational activity, the DNP students administered the initial pre-survey to participants and consent was obtained. Several techniques were used throughout the synchronous zoom session, to educate the MSU Extension MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 30 staff about the technique of MI and how to apply it to individuals who are vaccine hesitant, including PowerPoint presentation, video examples, and role-play opportunities. After the conclusion of the educational session, the post-survey was administered to assess knowledge, confidence, and likelihood to apply MI skills. Additional information was collected from several participants utilizing a semi-structured interview approach in order to understand areas for potential improvement of the educational materials. All surveys were administered electronically, and information obtained was secured on a password protected laptop to ensure compliance and privacy of the collected information. Study The goal of this EBP project is to assess for change in knowledge and confidence of applying MI techniques to vaccine-hesitant individuals who live in rural Michigan at public event settings. The DNP students hope this will result in increased vaccination rates among this vulnerable population. After the completion of the educational session, the DNP students were then able to assess change from the completed pre- and post-surveys and calculate for statistical significance. This is outlined more in the analysis portion of the proposal. The DNP students also assessed possible changes that could be made to the applied intervention and looked for areas of improvement that can be made if this intervention were to be implemented in other settings. Act After the completion of the data analysis, changes will be made to the educational materials to make improvements for potential further use. After the intervention is complete, feedback was compiled from the individuals who attended the educational session to assist with the necessary changes to make an improved intervention. This was done through a brief post- intervention meeting with several individuals who attended the session. The brief interview MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 31 guide can be found in Appendix H. Information gathered from the data analysis will be provided to the director of MSU Extension and disseminated to the MSU Extension team. In collaboration with MSU Extension, it will be determined if the modified intervention can be applied and utilized for future staff of the MSU Extension Vaccine Team. Study Measures In order to measure the outcomes of this DNP project 3-part survey was used (Appendix G). The survey was created from incorporating information from the available literature including reviewing tools used to measure MI knowledge and confidence in various settings, discussion with the MSU Extension team members, and discussion with a statistician. In the first part of the survey (delivered only pre-MI intervention training), participant characteristic information (role, years with MSU extension, experience with MI) was collected. The second part of the survey had four yes/no/unsure questions related to knowledge about MI. The third part of the survey was adapted from a tool that was used to evaluate corrections officers in New Mexico after a MI training (Willits, Albright, Broidy, & Lyons, 2009). The tool has nine questions, and uses a 5-point Likert scale, that address knowledge and confidence, about vaccine hesitancy and MI. Both the second and third parts of the survey were delivered pre- and post-MI intervention. The pre- and post-survey was placed into the Qualtrics Survey Tool provided through MSU. At the conclusion of the intervention, qualitative data was collected from participants including the community project advisor, community project liaison, and several members of the MSU Extension team, utilizing a brief interview guide (Appendix H) to assess for potential improvements to the administered educational session and materials. The questions included asking what the participant thoughts of the educational session and what they believe could be MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 32 done to improve the intervention. The qualitative questions were delivered by two DNP students, with one student asking the interview questions, and one student taking field notes. Analysis Prior to the analysis of the data the DNP students met with a statistician to discuss the data analysis process. The pre- and post- surveys were paired within the Qualtrics system by utilizing a participant number which consisted of the individuals entering their first initial, last initial, and last four digits of their phone number. The pre- and post- test were then paired by utilizing the time stamps of when the questionnaires were taken. In the pre- and post-survey for the knowledge and confidence-based questions, the first six questions using nominal data were analyzed using a comparison of pre- and post-proportions. Assuming the assumptions of a normal distribution were met, a paired T-test was used to compare the pre- and post-survey data, on each of the individual remaining nine questions. SPSS, version 28.0.1.0, was used for data analysis. Finally, information from the brief interviews was reviewed, and answers were analyzed for similar content. Data Outcomes After the intervention took place, it was determined that there were 16 total participants who attended the educational session, and we had a response rate of 14 participants. One outlier participant completed only the pre-survey and one outlier participant completed only the post- survey, leading us to eliminate these results. Of the 14 participants, 57% (n = 8 of a total 14 participants) who took part in the educational session are known as Program Instructors, these are individuals who frequently interact with the rural population in various settings by attending and hosting public events (Table 1). The other 43% (n = 6 of a total 14 participants) of participants have varying roles MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 33 within the MSU Extension organization. The majority of the individuals who took part in the intervention also reported having less than 1 year of experience working at MSU Extension and also limited experience with MI, with the majority of individuals (57%, n = 8 of a total 14 participants) stating they had some or limited experience utilizing MI prior to the intervention. Previous knowledge and experience utilizing MI was also collected (Table 2). There were 79% (n = 11) of the participants reported having previous knowledge of MI and nine of the 14 participants recall having been provided education in the past about MI. Regarding the participants understanding of MI, the majority (86%, n = 12 of a total 14 participants) reported being unsure or did not know the four main processes of MI. The post-intervention results show that 100% of the participants reported an understanding of MI and 13 of the 14 participants felt confident that they gained further understanding of the four main processes of MI. Statistical significance was found in five of the nine pre- and post-survey questions (Table 3). Of note, knowledge of MI and confidence of utilizing MI in the field improved significantly. 64% of participants (n=9) reported improvement in understanding the basic ideas and principles of MI. While, 86% of participants (n=12) reported an improvement in feeling proficient and able to use MI in their practice after the intervention. Utilizing the brief question guide found in Appendix H, participants were asked their overall experience of the intervention and possible changes that could be made to improve the intervention. Overall, feedback was extremely positive from the participants, no recommendations were made for changes to the intervention. Sustainability Plan MI is a proven technique that can be utilized to tackle many health care areas such as vaccine hesitancy. Improving the knowledge and confidence of those who interact with vaccine MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 34 hesitant individuals, in utilizing techniques such as MI, is essential to continue to improve vaccination rates in those who seeking care less frequently from health care providers such as the rural population. Due to the positive results obtained from this intervention, a potential sustainability plan could be providing a similar education session on MI and requiring this as an annual training for all MSU Extension staff interacting with the rural population of the state of Michigan. Utilizing individuals such as DNP students or staff from MSU Extension team to carry out the educational intervention in the future could increase the likelihood of its sustainability and be a cost-effective option. Implications for Nursing Increasing knowledge and confidence of MI in individuals who frequently interact with vulnerable populations could lead to improved vaccination potential in Michigan. All individuals in every aspect of health care are responsible for continued learning and improving their knowledge, taking part in educational opportunities such as this intervention could fulfill a knowledge gap health care practitioners may have. Utilizing an established behavior change technique in a non-health care setting can help to reach populations that do not regularly see a health care provider. Additionally, the potential knowledge gained from this intervention could allow for advanced practice providers to approach patients differently who have had tailored conversations about their vaccine hesitancy beliefs and to build on the patient’s new knowledge. While much research has been conducted on vaccine hesitant individuals and techniques used to improve vaccination rates, little research has been done specifically on rural populations. This intervention will be specifically focused on improving knowledge about MI and confidence in using MI with individuals who regularly interact with members of the rural Michigan community hopefully leading to improved vaccination rates. Additional research could be done MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 35 at the completion of this project to see the actual implications of the intervention in terms of improving vaccination rates in the targeted population. Conclusion Vaccine hesitancy remains an important health concern among the health care community and the public (The College of Physicians of Philadelphia, 2022a). The rural population is disproportionately vaccine hesitant compared to their urban counterparts (Saelee et al., 2022). Several techniques have been effectively utilized to reduce the overall rates of vaccine hesitancy, including MI (Breckenridge, Burns, & Nye, 2021; Gagneur A., 2020; Reno et al., 2018). A key factor in individuals adjusting their beliefs about health care recommendations and procedures is receiving this information from a trusted source such as a reliable community member or health care provider (Kirzinger, Muñana, & Brodie, 2021). This EBP project was accomplished by two DNP students administering an interactive educational session to the MSU Extension vaccine team focusing on improving MI skills. This EBP project was intended to increase members of the MSU Extension Vaccine Teams’ knowledge and confidence of MI in regard to addressing vaccine hesitancy. The hope is in turn this would contribute to an improved vaccination rates of the population that they interact with most, members of rural Michigan. Data collected before and after the intervention demonstrated an increase in knowledge and confidence in the use of MI. to assess for change. There is a continued need for research on improving vaccine hesitancy specifically using MI. The hope is that this intervention will help to continue to build on the already available knowledge and enable future researchers to continue to expand to improve the health and welfare of the rural community. MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 36 References Ahmad, M., Akande, A., & Majid, U. (2022). Health care provider trust in vaccination: A systematic review and qualitative meta-synthesis. European Journal of Public Health, 32(2), 207–213, https://doi.org/10.1093/eurpub/ckab209 Akel, K. B., Masters, N. B., Shih, S. F., Lu, Y., & Wagner, A. L. (2021). Modification of a vaccine hesitancy scale for use in adult vaccinations in the United States and China. 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Health and Well-Being, MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 43 13(2), 469-484. https://doi.org/10.1111/aphw.12262 MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 44 Table 1 Table 1. Characteristics of Participants Role at MSU Extension # of Participants (n=14) Program Instructor 8 Supervising Educator 3 Director 2 Health Immunization Specialist 1 Years Experience < 1 year 10 1-5 years 1 5+ years 4 Experience/training with MI No experience 4 Some or limited experience 8 Extensive experience 2 MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 45 Table 2 Table 2. Knowledge About Motivational # of Participants Interviewing (n=14) 1. Do you know what motivational Pre- test Post- test interviewing is? Yes 11 14 No 1 0 Unsure 2 0 2. Have you utilized motivational interviewing before? Yes 8 8 No 1 1 Unsure 5 5 3. I have been provided education about motivational interviewing. Yes 9 14 No 5 0 Unsure 0 0 4. Do you know what the 4 main processes of motivational interviewing are? Yes 2 13 No 7 0 Unsure 5 1 MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 46 Table 3 Table 3. Comparison of Pre- and Post-MI Intervention Survey (n=14) Pre-test Post-test t p M (SD) M (SD) Questions 1. I understand the basic 3.29 (1.14) 4.57 (0.51) -3.80 <0.01 ideas and principles of motivational interviewing. 2. Motivational interviewing 4.14 (0.77) 4.57 (0.51) -3.12 <0.01 is applicable to my work. 3. I will use motivational 3.93 (0.73) 4.43 (0.85) -2.88 0.01 interviewing in my work. 4. I feel proficient and able 2.71 (0.99) 4.07 (1.00) -5.04 <0.01 to use motivational interviewing in my practice. 5. I believe that a client’s 4.57 (0.51) 4.71 (0.47) -1.00 0.34 own level of motivation for change is important. 6. If a client is not initially 2.86 (1.23) 2.64 (1.15) 0.51 0.62 motivated, I do not think that I will be able to increase his or her motivation. 7. I am a skillful and good 4.00 (0.78) 4.21 (0.89) -1.39 0.19 listener. 8. Some clients will never 3.36 (1.34) 3.43 (1.40) -0.43 0.67 change regardless of how I interact with them. 9. I think that the most 4.36 (0.75) 4.79 (0.43) -2.48 0.03 effective way to motivate clients or patients to change is by drawing on their own internal motivations. MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 47 Appendix A Gap Analysis Figure 1. Gap Analysis MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 48 Appendix B Literature Table Author/ Title of Design/Level Sam Purpose Findings How does Strengths/ Date Article/DOI of ple this relate to Weaknesse hyperlink Evidence/Pur your s/Implicati pose project? ons Ahmad, Health care Qualitative 22 To Findings When This study M., provider meta- stud explore revealed individuals provides Akande, trust in synthesis ies the that who are valuable A., & vaccination: (Level V) factors vaccine responsible insight for Majid, a systematic that hesitancy for understand U. review and influence amongst providing ing why (2022). qualitative vaccine nurses and vaccines to nurses and meta- hesitancy physicians patients do physicians synthesis amongst stemmed not believe may be https://doi.or nurses predomina in vaccines hesitant to g/10.1093/eu and ntly from or have vaccinate, rpub/ckab209 physicia two mistrust in it also ns factors: them, their gives distrust in patients are informatio health likely not n about authorities receiving how to and their information combat employers, or receiving this such as and them either, putting distrust in which is systems in vaccine perpetuating place to efficacy the cycle of report and safety. vaccine reactions hesitancy. and providing better education to this population regarding vaccine efficacy. Akel, Modification Cross- 245 To Findings This shows a This study K.B., of a vaccine sectional 2 evaluate revealed distinct was a Masters, hesitancy surveys parti vaccine that the difference simple N.B., scale for use (Level VI) cipa hesitancy participant between survey Shih, in adult nts between s in China vaccine administer S.F., vaccinations in the were much hesitancy in ed in China Lu, Y., in the Unit United less China and in March & United ed States hesitant to vaccine 2020, and Wagner, Stat receive the hesitancy in in United MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 49 A.L. States and es and COVID-19 the United States in (2021) China and China. vaccine, States which March and https://doi.or Chi whereas indicates June 2020. g/10.1080/21 na the there may be This 645515.2021. participant a cultural survey was 1884476 s in the aspect limited to United influencing only China States were vaccine and United almost 3x hesitancy. States and less likely was to get the administer vaccine. ed in the beginning of the pandemic when a vaccine had not yet been developed. The survey was administer ed through those that answered social media and advertisem ents looking for the participant s. Much more research in multiple countries is needed. Albers, Barriers to Systematic 17 To There are 5 This is Limitation- A. N., and Review stud evaluate key essential to small Thaker, facilitators (Level I) ies reasons reasons for gain a better sample J., & of early for decreased understand size due to Newco childhood decrease uptake in of the lack of mer, S. immunizatio d this studied available R. n in rural vaccine population: population research (2022) areas of the uptake in relationshi in this EBP United rural ps project States: A MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 50 systematic populatio with clinic review of the ns staff and literature providers, https://doi.or immunizati g/10.1016/j.p on tracking medr.2022.1 and 01804 reminder/ recall, parental vaccine hesitancy, accessing health services, and other immunizati on challenges in rural areas Alcendo Targeting Multiple 90 This Findings This article This study r, D.J. COVID Randomized cou compilati show that focuses on is very (2021) vaccine Controlled nties on of of the 90 the stark interesting hesitancy in Trials (Level surv studies counties, differences and covers rural I) eyed were 70 are between the entire communities down considered rural and state. in across rural. This urban There is no Tennessee: the 90 also shows communities evidence Implications counties that the with regards of level of for in level of to vaccine participatio extending Tennesse hesitancy hesitancy. n the COVID- e to is higher in This is throughout 19 pandemic assess the rural important to the in the South vaccine communiti our project counties https://doi.or hesitancy es than in because it but does g/10.3390/va in the the urban shows that confirm ccines911127 state as a communiti not just the 9 whole. es, Michigan suspicion representin rural that rural g a large communities communiti portion of , but out-of- es are more the state rural hesitant population. communities than urban are also communiti vaccine es to get hesitant. vaccinated with regards to MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 51 COVID- 19. Anderso Recommend Opinions of 1 To This study These This study n, E.L. ed solutions Authorities stud investiga shows us methods can is based on (2014) to the (Level VII) y te ways methods of be used the barriers to of communic along with opinions of immunizatio communi ating as motivational authorities ns in cating well as interviewing on specific children and with important to provide topics to adults patients subjects to accurate discuss https://pubme and discuss information with d.ncbi.nlm.ni families with to patients, patients h.gov/25211 about the patients by as well as regarding 867 importan health care providing immunizati ce of providers. information ons in vaccinati for health children ons with care and adults. regards providers on No actual to health. how to results are breach the given, just topic of recommen vaccinations dations. with their patients. Brandt, A narrative Narrative 30 To This study This This study H.M., review of Review stud investiga shows that significantly is effective Vanderp HPV (Level VI) ies te more affects our in showing ool, vaccination strategies studies project as that more R.C., intervention used to with we need to research Pilar, in rural U.S. increase regards to delve deeper needs to be M., communities HPV rural into done. Zubizarr https://doi.or vaccine communiti rationale for However, eta, M., g/10.1016/j.y uptake in es need to vaccine it does not & pmed.2020.1 rural be hesitancy in implicate Stradtm 06407 communi conducted. rural specific an, L.R. ties. communities practices to (2021) , not just be used or with regards evaluation to HPV. of the use of these practices. The study size is small and the barriers for rural communiti es are MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 52 evident from the lack of evidence in this study. Cataldi, Evidence- Opinion of 1 Summari This study This study This study J.R., based Authorities stud zes gives us states that is based Kerns, strategies to (Level VII) y current examples interventions current M.E., & increase evidence of effective for opinions of O’Leary vaccination -based communic physician pediatricia , S.T. uptake: a studies ation behaviors, ns and (2020) review to strategies improvemen more https://doi.or improve for t in public research g/10.1097/M immuniz providers health needs to be OP.0000000 ation to have processes, done to 000000843 rates. with policies, and assess patients patient effective and parents behaviors strategies to increase directly for vaccine impacts the communic uptake. prevalence ating with of vaccine vaccine- uptake. This hesitant study patients suggests the and implementat parents. ion of multiple studies will work in different settings to address the current barriers and optimize vaccine uptake in the pediatric population. Cole, J. Motivational Systematic 250 To The use of MI was Strength- W., M interviewing Review 4 determin MI shown to be A large H Chen, and vaccine (Level I) base e increased an effective and diverse A., acceptance line vaccinati vaccine technique at study McGuir in children: peri on rates increasing population e, K., The od, coverage significantl vaccine was Berman, MOTIVE 195 after an y in the uptake in the utilized. S., study. 4 educatio adolescent MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 53 Gardner https://doi.or inter nal population given Limitation- , J., & g/10.1016.j/v vent intervent study for population. There was Teegala, accine.2022. ion ion for recommen variable Y. 01.058 providers ded utilization (2022) utilizing vaccines. and uptake MI and a by created providers MI tool at the single site for this study. New staff were not provided education on the use of the MI tool. Fisher, Attitudes Cross- 100 To Overall, The Participant K. A., toward a sectional 0 assess 57.6% of information s' intent to Bloomst potential Survey parti intent to participant from this be one, S. SARS-CoV- (Level IV) cipa become s (n = 571) article vaccinated J., 2 vaccine: A nts vaccinate intended to allowed us was Walder, survey of d with a be to explored J., U.S. adults COVID- vaccinated, understand before a Crawfor https://doi.or 19 31.6% (n = intent for vaccine d, S., g/10.7326/M vaccine 313) were vaccination, was Fouayzi 20-3569 when is not sure, specifically available , H., & becomes and 10.8% for COVID- and when Mazor, available (n = 107) 19 the K. M. did not pandemic (2020). intend to was be affecting a vaccinated narrower swath of the United States. Questions about specific informatio n or factors that might increase vaccination acceptance were not included. The survey MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 54 response rate was 16.1%. Gabarda Using Best Randomized 22 This is a Reveals This article This study , A., & Practices to Controlled stud good that emphasizes is limited Butterw Address Trial (Level ies review motivation our project to Canada orth, Vaccine I) of al goals and and not to S.W. Hesitancy: multiple interviewin methodolog the rest of (2021) The Case for studies g has been y. This the world, the looking shown to confirms but the Motivational at using increase that population Interviewing motivati vaccine motivational and Approach onal uptake interviewing amount of https://doi.or interview when used has been a studies g/10.1177/15 ing with effectively proven assessed 24839921101 regards and method for was 6463 to appropriate changing significant vaccine ly. health as well as hesitancy behaviors in the types in the of patients Canada. population. surveyed. This does not focus on rural population s, but on the general population as a whole. Gagneur Promoting Randomized 1,22 To MI was This study Strengths- , A., vaccination Controlled 3 assess effective at provides a the study Battista, in maternity Trial (Level parti vaccinati decreasing different population M. C., wards ─ I) cipa on vaccination approach to was Boucher motivational nts intention hesitancy effective use diverse, the , F. D., interview and and of MI in tool used Tapiero, technique vaccinati increasing improving were B., reduces on vaccination vaccination validated Quach, hesitancy hesitancy intention in rates. and C., De and among the studied reliable Wals, enhances parents population. questionnai P., intention to who res Lemaitr vaccinate, received Limitation- e, T., results from an the initial Farrand a individua reason for s, A., multicentre l vaccine Boulian non- motivati refusal was ne, N., controlled onal not Sauvage pre- and interview collected MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 55 au, C., post- (MI) Ouakki, intervention based M., RCT-nested intervent Gosseli study, ion on n, V., Quebec, infant Petit, March 2014 immuniz G., to February ation Jacques, 2015. during M. C., https://doi.or post- & Dubé, g/10.2807/15 partum È. 60- stay (2019) 7917.ES.201 at a 9.24.36.1800 maternit 641 y ward Gagneur Motivational Opinion of 1 This Highlights This Not a , A. Interviewing Authorities artic article emphasizin confirms the study but a (2020) : A powerful (Level VII) le confirms g validity of relevant tool to that autonomy our project source of address motivati with purpose and informatio vaccine onal patients emphasizes n from best hesitancy interview while our aims. practices https://doi.or ing is a reducing This is used. No g/10.14745/c valid defensiven especially specific cdr.v46i04a0 tool for ess and relevant target 6 causing encouragin given the population healthcar g healthy current but good e behaviors COVID-19 informatio changes. in patients. pandemic n. and subsequent vaccine hesitancy. Green, The Impact Opinion of 1 This This This article This is an J., Petty, of the Anti- Authorities artic paper emphasizes summarizes informatio J., Vaccination (Level VII) le emphasiz that the methods nal article Whiting Movement ed the parents needed to on , L., and Vaccine importan own fear, educate educating Orr, F., Hesitancy ce of or past patients and parents Walker, on the talking experience their parents about the K., Health of to, only s, may about the importance Brown, the Child the contribute importance of vaccines A.M., The impact patient, to their of, the and Crisp, of the anti- but that hesitancy effectiveness informing E.P., vaccination family to get their of, and them of the Fowler, movement members children purpose of benefits C., & and vaccine may vaccinated requirement and Jones, hesitancy on inhibit and can of vaccines. decrease in the health of vaccinati perpetuate Does not risk since MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 56 L.K., the child — on, the directly they had (2021) Charles Sturt particula hesitancy. relate to been University rly with motivational vaccinated. Research regards interviewing Not a Output to but study, but (csu.edu.au) children. emphasizes informatio a hurdle we nal. must overcome with a subset of this population. Hubach, COVID-19 Cross- 391 To The rural This study Limitations R. D., vaccine sectional parti explore population highlights : small Shanno hesitancy study (Level cipa perceptio has several key reasons sample n, B., among rural III) nts ns prescribed why size in Morgan, Oklahomans regardin barriers individuals Oklahoma K. D., https://doi.or g and in the rural (may not Alexand g/10.22605/R COVID- benefits to community be er, C., RH7128 19 receiving choose to generalizab O'Neil, vaccinati the become or le) A. M., on COVID-19 not become Participatio Ernst, among vaccine. vaccinated. n was C., & unvaccin Including: voluntary Giano, ated rapid Z. (2022 residents vaccine Implication of rural developme s: new and Oklahom nt, lack of modified a. long-term interventio data, and ns vaccine responsive availability to rural , the communiti greatest es must be benefit was developed perceived to address decreased vaccine risk of hesitancy contracting the disease Olson, COVID-19 Systematic 75 To The This review This O., vaccine Review artic assess findings of gives review is Berry, hesitancy (Level I) les communi this steppingston older, C., & among rural cation systematic es for evaluating Kumar, Oklahomans strategies review addressing data N. https://doi.or to indicate vaccine between (2020) g/10.22605/R overcom early hesitancy, 2008 and RH7128 e building of which can 2019, and MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 57 parental trust with be tailored does not hesitance parents, to the rural include towards communic populations. current vaccinati ating with hesitancies on these caused by parents the specifically COVID-19 relating to pandemic their which will hesitancies directly , and relate to increased our project. vaccination Search size education and are the best amount of methods to data is reduce appropriate vaccine , just dated. hesitancy. Rane, Determinant Cohort Study 4,19 ~Measur Over time This study ~This M. S., s and trends (Level IV) 1 e trends there are provides a study was Kochhar of COVID- parti in many picture of done , S., 19 vaccine cipa vaccine reasons the online so Poehlei hesitancy nts hesitancy why difference the n, E., and vaccine in the individuals several population You, uptake in a United choose not months can does not W., national States to become make when encompass Roberts cohort of US for vaccinated, it comes to individuals on, M. Adults: A adults this does deciding to who do not M., longitudinal ~Identify shift and become have a Zimba, study subpopul change as vaccinated. smart R., https://doi.or ations new phone or Westmo g/10.1093/aje that informatio use the reland, /kwab293 might be n becomes internet. D. A., less available. ~Participan Romo, willing ts had to M. L., to be opt into the Kulkarn vaccinate study i, S. G., d ~Not all Chang, ~Examin participant M., e s Berry, sociode responded A., mograph to each Parcese ic and survey. pe, A. behavior M., al factors Maroko, as well A. R., as Grov, COVID- MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 58 C., related Nash, risk D., & perceptio Chasing ns that COVID correlate Cohort with Study vaccine Team hesitancy (2022) ~Assess the associati on between vaccine hesitancy and subseque nt vaccine uptake Reno, J. Improving Randomized 16 Intervent 88% of MI was Providers E., Provider Controlled prac ion providers shown to be were not O'Leary Communica Trial (RCT) tices applied who used an effective assessed or , S., tion about (Level I) (8 to MI when technique at observed Garrett, HPV inter examine engaging increasing for their K., Vaccines for vent if the with vaccine in proficiency Pyrzano Vaccine- ion, techniqu parents the given in using wski, J., Hesitant 8 e of who are population. MI outside Lockhar Parents cont motivati vaccine of t, S., Through the rol) onal hesitant the training Campag Use of interview toward the sessions na, E., Motivational ing HPV Additional Barnard Interviewing increase vaccine, research is , J., & https://doi.or vaccine found this needed as Dempse g/10.1080/10 acceptan helpful and there are y, A. F. 810730.2018. ce effective at very few (2018). 1442530 among increasing studies that parents vaccination focus on in rates as HPV children opposed to vaccine who are not uptake and recomme utilizing the use of nded to MI. MI. receive the HPV vaccine MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 59 Roy, Potential Systematic 47 To This study This study is This study D.N., factors Review artic identify shows that valuable to shows us Biswas, influencing (Level I) les the there are our project how much M., COVID-19 potential multiple as it shows work we Islam, vaccine reasonin factors worldwide must do to E., & acceptance g and influencing rationale for counter Azam, and rationale vaccine not some of M.S. hesitancy: A that hesitancy, receiving the the (2022) systematic influence including vaccine. misconcept review COVID- psychologi While some ions about https://doi.or 19 cal, of these vaccines. g/10.1371/jo vaccinati societal, reasons will The data is urnal.pone.02 on and and not be overwhelm 65496 refusal to reservation changeable ing as it do so, s about (I.e., cultural encompass and to vaccines in views), es 47 determin general. some articles e the reasons can covering statistics be the for influenced worldwide countries by issue of . increasing vaccine access to hesitancy. and education about vaccines. Saelee, Disparities Mortality and 64 Urban Significant This shows While R., Zell, in COVID- Morbidity juris populatio difference us the these E., 19 Report dicti ns are in disparities in statistics Murthy, Vaccination ons more vaccination COVID-19 are B.P., Coverage and vaccinate status vaccinations staggering, Castro- Between 5 d than between between and Roman, Urban and fede rural urban and urban and provided P., Fast, Rural ral populatio rural rural regions by the H., Counties – entit ns, and population in the United CDC, there Meng, United ies the gap s. States. are no L., States, between signifiers Shaw, December the on the L., 14, 2020 – percenta differences Gibbs- January 31. ges has between Scharf, 2022 only states. L., https://dx.doi grown More Chorba, .org/10.1558 over the statistical T., 5.mmwr.mm last 2 analysis Harris, 7109a2 years. must be L.Q., done for Murthy, Michigan MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 60 N. specifically (2022) . Sallam, COVID-19 Systematic 31 To Large This review This study M. Vaccine Review stud assess amount of shows the shows the (2021) Hesitancy (Level I) ies current variability effect of overall Worldwide: vaccinati exists lack of vaccine A Concise on worldwide vaccination acceptance Systematic acceptan regarding uptake in the Review of ce rates vaccine worldwide, world Vaccine in the acceptance vaccine which Acceptance world. which hesitancy provokes Rates could playing a future https://doi.or affect the major role studies for g/10.3390/va progressio could allow what is ccines902016 n of the for preventing 0 pandemic. significant certain Vaccine changes if areas from hesitancy hesitancy getting the seems to rationale is vaccine. play an evaluated. Unfortunat important ely, this role. study is subjective to bias and availability of people to be surveyed. Only 2 surveys were available in African nations. This demonstrat es a need for a more in-depth study to be performed not only assessing vaccine uptake but reasons for not getting vaccinated. MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 61 Sarathc A survey Tool based 1 No This is a This is not handra, instrument on the artic Explanat findings as possible tool a study D., for Opinion of le ion of a this is not a we may use with Navin, measuring Authorities tool that study, but to evaluate results to M.C., vaccine (Level VII) may be the overall the success compare, Largent, acceptance used to tool is of our but rather a M.A., & https://doi.or assess beneficial overall verified McCrig g/10.1016/j.y vaccine for our project aim tool to ht, A.M. pmed.2018.0 uptake. analysis. during the assess (2018) 1.006 This Analysis vaccine focuses on portion of uptake specific this project. within a aspects to population. evaluate why people are vaccine hesitant. Wake The Systematic 45 To The overall This No A. D. Willingness Review artic assess rate of systematic limitations (2021). to Receive (Level I) les the level participant review were COVID-19 of s’ allowed us discussed Vaccine and willingne willingness to gain and for this Its ss to to receive understandin systematic Associated receive the g of reasons review. Factors: COVID- COVID-19 for choice to The "Vaccinatio 19 vaccine not informatio n Refusal vaccine was ranged vaccinate, n provided Could and its from specific to can help us Prolong the associate 27.7% to COVID-19. to better War of This d factors. 91.3%. understand Pandemic" - There are the factors A many that Systematic factors that influence Review. play into vaccination https://doi.o this wide rates and rg/10.2147/ range. how we RMHP.S31 can 1074 continue to improve. Wang, Vaccination Systematic 38 To Gender, This Only 36 Q., against Review artic estimate educational systematic countries Yang, COVID-19: (Level I) les the level, review are taken L., Jin, A systematic COVID- influenza provides into H., & review and 19 vaccination information considerati Lin, L. meta- vaccine history, about on in the (2021). analysis of acceptan and trust in predictors review, acceptability ce rate the for vaccine leaving MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 62 and its and governmen uptake room for predictors. identify t were which error. https://doi.o predictor strong allows us to Representa rg/10.2147/ s predictors understand bility is RMHP.S31 associate of COVID- why some uncertain 1074 d with 19 individuals in utilized COVID- vaccination choose to studies, 19 willingness become leaving vaccine . vaccinated room for acceptan or not. sample ce bias. Wang, Multilevel Systematic 73 To The choice This study This study Y., & determinant Review stud determin to become allows us to only Liu, Y. s of COVID- (Level I) ies e reasons vaccinated understand focuses on (2021) 19 individua or not is why COVID- vaccination ls, multifactor individuals 19, but hesitancy in choose ial. Many may choose informatio the United not to of the to not n could States: A become reasons are become potentially rapid vaccinate long vaccinated be systematic d standing which is an generalized review specifica including, essential to other https://doi.or lly with race, piece of our vaccines. g/10.1016/j.p the geography, project. Only medr.2021.1 COVID- politics, PubMed 01673 19 and was used vaccine mistrust. for their etc. literature search. Yasmin, COVID-19 Systematic 65 To There are Information The pooled F., Vaccine Review artic determin many from this percentage Najeeb, Hesitancy in (Level I) les e factors factors that systematic s are H., the United that affect review subjected Moeed, States: A affect vaccine allows us to to A., Systematic vaccine hesitancy understand spectrum Naeem, Review hesitancy in the vaccine bias since U., https://doi.or in the United hesitancy in percentage Asghar, g/10.3389/fp United States: the current s for M. S., ubh.2021.770 States hesitancy climate of general Chughta 985 was mainly COVID-19 population i, N. U., driven by are pooled Yousaf, the lack of with Z., education terminally Seboka, and ill or B. T., understand marginaliz Ullah, ing of the ed groups. I., Lin, process of Percentage C. Y., & vaccine of COVID- MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 63 Pakpour developme 19 vaccine , A. H. nt and acceptance (2021) deep- is liable to seated random mistrust in error as the published healthcare studies system. were There are carried out several at different other phases of factors the such as coronaviru race, s peak. religion, Vaccine and acceptance pregnancy percentage status that s by states effect may be vaccination affected rates. due to demograph ic characterist ics differing across the region. Zolezzi, Using Opinions of 1 Synthesi Use of Using This is not M., motivational Authorities artic s of the integrated current a study, Paravatt interviewing (Level VII) le current theories to strategies to but rather il, B., techniques uses of prevent combat an El- to inform motivati vaccine COVID-19 authority Gaili, T. decision- onal hesitancy hesitancy, with a (2021) making for interview over the which has a positive COVID-19 ing with COVID-19 much larger opinion of vaccination respect vaccine. population the use of https://pubme to the involved, motivation d.ncbi.nlm.ni COVID- can help us al h.gov/34599 19 combat the interviewin 721 pandemi overall g with c and vaccine regards to resultant hesitant COVID- vaccine population. 19. It does hesitancy however give us a framework to use to enhance MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 64 our use of motivation al interviewin g to prevent vaccine hesitancy in the rural population. MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 65 Appendix C Rural Michigan Population Map Figure 2. Rural Map of Michigan MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 66 Appendix D SWOT Analysis Figure 3. SWOT Analysis MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 67 Appendix E GANTT Chart: Timeline of Project MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 68 Appendix F Project Budget Figure 4. Project Budget MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 69 Appendix G Motivational Interviewing Pre- and Post-Survey MSU Extension Vaccination Team MI Event This survey is being done to help us evaluate the change that occurs after education on motivational interviewing at MSU Extension. We are asking you to complete a survey before the initiation of the education program and again after the education program is complete. Our team would like to evaluate our motivational interviewing education and determine if we have improved motivational interview confidence and skills. Participation in this survey is voluntary and you may refuse to answer any question. You may withdraw or stop participating at any time without consequence. By completing the survey, you are indicating your voluntary agreement to participate. Contact person: Susan Weber Buchholz, PhD, RN, ANP-BC, FAANP, FAAN, Professor, Associate Dean for Research, Michigan State University, College of Nursing, O: (517) 432- 9159; buchho44@msu.edu Please complete the below information Role at MSU Extension: _________________ Years working at MSU Extension: __________________ Previous experience with motivational interviewing: ______________________________________________________________________________ ______________________________________________________________________________ Please answer Yes, No, or Unsure to the following four questions: Yes No Unsure 1. Do you know what motivational interviewing is? 2. Have you utilized motivational interviewing before? 3. I have been provided education about motivational interviewing. 4. Do you know what the 4 main processes of motivational interviewing are? MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 70 Please check one answer for the following nine questions, using this scale: 1 2 3 4 5 Strongly Disagree Undecided Confident Very Disagree Confident 1. I understand the basic ideas and principles of motivational interviewing. 2. Motivational interviewing is applicable to my work. 3. I will use motivational interviewing in my work. 4. I feel proficient and able to use motivational interviewing in my practice. 5. I believe that a client’s own level of motivation for change is important. 6. If a client is not initially motivated, I do not think that I will be able to increase his or her motivation. 7. I am a skillful and good listener. 8. Some clients will never change regardless of how I interact with them. 9. I think that the most effective way to motivate clients or patients to change is by drawing on their own internal motivations. MOTIVATIONAL INTERVIEWING AND VACCINE HESITANCY 71 Appendix H Brief Interview Guide 1. Overall, how did you feel about the education presented to you today about MI? 2. Do you feel there are any improvements that could be to this intervention?