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Engaging:

This step involves making a person feel safe talking to you. It’s important to ask someone’s permission to talk about COVID-19. You can ask them, “I want to talk to you about COVID-19 vaccines. Is that okay?”.

Focusing:

This step helps you learn why someone may not want to get the vaccine. You can ask someone questions like:

• “How do you feel about getting the vaccine?”
• “What are some reasons you don’t want to get the vaccine?”

Evoking:

In this step, you can help a person explore why a person might want to get the vaccine. You can also let them know you understand why they are still unsure. You can say:

• “You are worried about getting sick from the vaccine, but you also want to keep your parents safe because they are older and could get very sick from COVID.”
• “You heard that COVID isn’t a big deal, but you have seen the number of people dying from COVID on the news, which is scary.”

You can also help people explore reasons they may want to get the vaccine or some good things that could happen. You can ask:

• “What might be some good things about getting the vaccine?”
• “What are some things you would be excited to do if you got the vaccine?” 

You can also learn if a person is ready to get the vaccine. You can ask:

• “What information would help you make your decision to get the vaccine?”
• “How are you feeling about maybe getting the vaccine?”

Planning:

The planning stage is about helping a person take the next step. You should first ask their permission to provide information. You can ask:

• “Is it okay if I send you some information to help you make your decision?”
• “I have a list of drive-thru vaccine sites in our town that you would be able to visit. Would you like me to show you this list?”

You can help a person decide their next steps by asking

• “How are you feeling about getting the vaccine?”
• “What next steps would you like to take?”

If a person is ready to get the vaccine, you can offer to help them find or schedule an appointment. If a person is still unsure, it is important to offer to support them, even if you don’t agree with their decision. You can say

• “You are still figuring out what is best for you.”
• “It sounds like you need to talk to your family to help you make a decision.”
• “I will be here to talk if you have any questions later on.”
• “Please let me know if there’s anything else that I can help you find.”

Let’s take a quick look at what we’ve learned so far….

Closed-ended questions are answered with a “yes” or a “no.” The opposite are open-ended questions, which a person cannot answer with only “yes” or “no.”

A closed-ended question is, “Do you want to get your booster shot?”

An open-ended question is, “What do you need so you can get your booster shot?”

Open-ended questions help people think more deeply about how they feel and what choice they might want to make. We use open-ended questions when we want to get more information. Using phrases that start with “How”, “When”, or “Tell me about” are examples of how we can ask open-ended questions.

Affirmations are phrases you can use to help people see good things about themselves. Affirmations help people know why they can succeed. Affirmations are not giving someone a compliment.

You might compliment someone by saying, “I am proud of you.”

You would give someone an affirmation by saying, “You have worked hard to get here.”

Summaries also help people know you understand them but are usually longer than reflections. Summaries are when you take what someone has told you, pull out the most important parts, and say this information back to them. You can use summaries to help make sure you understand, change topics, or end a conversation.

Summaries, like reflections, help the person know you are truly listening to them. Summaries differ from reflections in that they synthesize key elements of what a person said or expressed and are rephrased back to them with the intent of helping them make sense of their thoughts and feelings.

Summaries should not retell every detail, but rather pick out key information to create a full story that will help the person move forward in their decision to make a change. Summaries should also have a natural flow and follow a logical train of thought. Important things to include in summaries are hints of change talk, situations where the person may feel ambivalent, or even educated guesses about what a person may be thinking or feeling. Summaries give the person an opportunity to clarify what they meant and help them see the bigger picture they have painted.

You can use summaries in many situations. It may be helpful to summarize to highlight understanding, point out ambivalence, reinforce change talk, switch to a new subject, or wrap up a conversation.

Below are some sentence starters which often help lead into a summary.

            “Let’s see if I understand what you are saying…”

            “Let’s take a step back and look at all of the pieces…”

            “From what you just told me, it sounds like…”

You can also give the person an opportunity to correct any misunderstandings by asking things like:

            “Did I get that right?”

            “What did I miss?”

            “What other information do you want to add?”

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Reflections are the most used skill within MI. Reflections are enacted by rephrasing what a person has told you they think and feel and then stating this information this back to them.  Using reflections helps a person feel heard, understood, validated, and builds trust.

There are many types of reflections you can use to support someone in making a behavior change. These are outlined in the chart below.

Type of Reflection	Definition	Example
Simple	Contains little to no information beyond what the person stated	“You have not yet gotten the vaccine yet.”
Complex	Adds more information to what was shared; can be a guess as to what the person may have meant	“You feel pressure to get vaccinated, but you are still unsure and afraid.”
Metaphor	A word or phrase comparing one object or action to another	“Seeing the rates of hospitalization really lit a fire under you to consider getting the shot.”
Reframing	Puts what a person just said into a different perspective	“You are trying to make the decision you feel most comfortable with.”
Continuing	Offering what the person might be inclined to say next	“You might feel more comfortable in public if you get the vaccine.”
Double-sided	Sharing both sides of the person’s argument, feelings, thoughts	“On one hand you are afraid to get the vaccine because of its side effects, but on the other hand you do believe it will keep you out of the hospital if you get COVID.”
Undershooting	Underestimates the intensity or emotion of what was expressed	“You’re just unsure about what to do.”
Amplified	Reflects back what was said at a greater intensity than was expressed	“This is causing major turmoil in your life.”

Try to use reflections to clarify what is said and to understand how to best help someone move forward. Effective reflections should come from genuine curiosity, and you must be willing to listen with an open mind. Avoid adding your thoughts; people may become defensive if they hear your opinions or judgments.

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Affirmations are a powerful tool in supporting self-efficacy – a person’s belief in their ability to do something. An affirmation is a statement that positively acknowledges a person’s values, strengths, and efforts.

Affirmations are often confused with praise or compliments. While praise or compliments convey that you are proud or think highly of what someone has done, affirmations reflect back to the person the positive traits and abilities to help them see what they are doing well.  

Let’s compare a few examples of affirmations versus praise.

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Open-ended questions help promote what is called “change talk”, which is a conversation that helps the person move towards making a healthier decision. Open-ended questions also help minimize leading questions, demonstrate your respect and interest in what they have to say, and support “ah-ha” moments. Open-ended questions are unable to be answered with a simple “yes” or “no” and require a more thoughtful response.

• Closed-ended questions often start with phrases like:
  • “Have you…?”
  • “Do you…?”
  • “Are you…?”
  • “Will you…?”

• Open-ended questions often start with phrases like:
  • “How…?”
  • “When…?”
  • “Tell me about..?”

You can also use questions beginning with “Why…?” but use with caution as “why” questions may come off as judgmental and put people in a defensive position.

Though we try to avoid closed-ended questions, they can have some use. Closed-ended questions can be used to gather basic information you might need but should be used sparingly while using MI as they often don’t help a person explore their beliefs and move towards change.

Let’s look at some examples of close-ended versus open-ended questions you might hear when talking to someone about getting the COVID-19 vaccine.

• Closed-ended questions:
  • “Are you ever going to get your vaccine?”
  • “Have you talking to your doctor about getting the vaccine?”
  • “Do you understand why you should get the vaccine?”

• Open-ended questions:
  • “How do you feel about getting the vaccine?”
  • “Tell me about your hesitations in getting the vaccine.”
  • “What information do you feel you need in order to make the decision?”

As you can see, open-ended questions people to elaborate on their thoughts, give more detail and provide you avenues for follow-up questions.

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