Each year, a significant portion of U.S. health care resources is poured into evaluation and management of seasonal influenza. According to recent Centers for Disease Control and Prevention (CDC) data for the 2018-19 flu season, an estimated 38 million to 41 million people have been exposed to the flu and reported illness. Of these individuals, approximately 16.7 million to 19.4 million have sought medical care for their symptoms and about 500,000 to 600,000 have required hospitalization.1
Primary care physicians are at the frontline of the annual battle against influenza. Many patients arrive at their clinician’s office with erroneous information about the vaccine and have already decided to refuse their flu shot before they walk through the clinic doors. In response, practices and providers across the country have amplified their efforts to promote influenza vaccination by posting flu fact sheets and informational posters in waiting rooms and exam rooms, building flu immunization screening questions into clinic intake workflow, and implementing standing orders to administer an immunization if the patient assents. Despite these efforts, the CDC vaccine coverage estimates for the 2017-18 influenza season were only 37.1% for adults and 57.9% for children.2
Patients commonly give a brief answer when asked why they are declining flu immunization. Common objections include “the flu shot gave me the flu,” “I still got the flu after I got my flu shot last year,” and “I never get the flu.” So how do clinicians stand to make a change in this seemingly rising trend of vaccine refusal? We do that by anticipating our patients’ objections, remaining knowledgeable about true benefits and contraindications of influenza vaccines, and effectively communicating evidence-based knowledge through use of motivational interviewing.
Despite concerted efforts to educate patients with evidenced-based information and dispel any misperceptions, patients may persist in refusing vaccination unless they feel that you empathize and recognize their concerns. A physician’s or provider’s skill and comfort with motivational interviewing is a crucial means to bridge the divide between a patient’s concerns and the benefits of receiving the influenza vaccination. Motivational interviewing is not a new concept, but it is gaining popularity with physicians across the U.S. as a tool for health behavior change. Motivational interviewing is a nonimposing counseling technique that is patient-centered and goal-directed by nature.3 It focuses on sparking the patient’s inner conflict about an unhealthy belief to fuel a change in actions and behavior. In contrast to more commonly used strategies such as direct persuasion, broad topical education, and scare tactics, motivational interviewing relies on the patient’s readiness to change his or her behavior. It requires the physician to be collaborative, patient, tactful, and focused when guiding a patient to realize or achieve a certain goal. Therefore, in the era of the anti-vaccination movement, I believe building an effective patient-clinician therapeutic relationship regarding influenza vaccination is all in the approach.
Addressing your patient’s concerns in such a way that is non-accusatory, yet allows the door to be opened for further conversation is a great starting point. While there are several motivational interviewing techniques that can be utilized, I find the “Ask-Tell-Ask” method to be one of the most effective approaches based on my personality strengths.4 I recommend beginning with a statement of reflective listening and empathy, such as: “I’m sorry to hear that you got sick a week after your flu shot last year.” Then ask: “Would it be OK if I share some information about the flu shot that many of my other patients with similar concerns have found helpful?” Having obtained the patient’s consent to discuss the topic further, tell them evidence-based information to address their misconceptions and concerns while touching on other elements such as vaccination timing, efficacy, reduction of symptom severity, and role in at-risk populations. Conclude by asking: “What are your thoughts at this point about getting your flu shot today?”
Regardless of the patient’s ultimate decision, clinicians also should educate patients on proper hand hygiene, surface disinfection, and if applicable, the use of anti-viral drugs in the management of seasonal influenza. Additionally, CDC recommends that people experiencing flu-like symptoms remain home for at least 24 hours after fever cessation unless seeking medical care.1
In conclusion, seasonal influenza immunization denial is a continued problem facing physicians and health care providers across the country. While there are varied strategies to address this problem, motivational interviewing is an excellent approach that I believe clinicians should employ when they encounter objections and opposition from patients regarding this evidence-based preventive measure. Ultimately, establishing a therapeutic relationship with a patient, where the patient believes the physician or provider is attentive and empathetic to his or her concerns, will play an important role in the decision to accept or reject the immunization.
Stephen Line, DO, is a first-year family medicine resident, and Swati Avashia, MD, FAAP, FACP, is an associate professor of population health.
Both physicians are at the Dell Medical School at
The University of Texas at Austin.
1. 2018-19 U.S. Flu Season: Preliminary Burden Estimates. CDC Online. https://www.cdc.gov/flu/about/burden/preliminary-in-season-estimates.htm Accessed: Wednesday, April 24, 2019.
2. 2017-2018 Flu Season. Centers for Disease Control and Prevention. https://www.cdc.gov/flu/fluvaxview/1718season.htm. Accessed Wednesday. Feb. 20, 2019.
3. Searight, Russell, PhD, MPH. Counseling Patients in Primary Care: Evidence-Based Strategies. AAFP. Volume 98, Number 12. Dec. 15, 2018.
4. Colleen T. Fogarty, MD, MSC, FAAFP, and LaTresha Crues, LPN. How to Talk to Reluctant Patients About the Flu Shot. Fam Pract Manag. 2017 Sep-Oct;24(5):6-8.
Tex Med. 2019;115(7):4-5
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