Introduction
Until January 8, 2023, more than 659 million confirmed cases of COVID-19 and more than 6.6 million deaths have been reported worldwide because of this virus [1]. To control the COVID-19 pandemic in the short term, interventions in the field of public health and personal health, such as social distancing, using masks, washing hands, and so on have been implemented. Simultaneously, the design and manufacture of vaccines have been on the agenda [2, 3, 4, 5]. So far, several vaccines have been introduced in DNA, messenger ribonucleic acid (mRNA), non-replicating, inactivated, live attenuated virus carriers, subunit vaccines, and immune-based vaccines [6, 7]. Similar to any vaccination, the COVID-19 vaccination has raised concerns from experts and executives regarding its side effects, such as redness, swelling, muscle pain, the amount of required dose, and the effectiveness and coverage of vaccination [8, 9, 10]. 
The lack of access to people from the target population of the desired vaccine or resistance and non-acceptance of vaccination are among the factors that determine the reduction of vaccination coverage [11, 12]. Vaccine hesitancy is defined as a delay in accepting or refusing vaccination despite the ability of vaccination services [13], which has different forms and intensities depending on the time, place, type of vaccine, and type of disease [14]. According to a report by the World Health Organization (WHO), vaccine hesitancy was one of the top ten public health threats in 2019 [15]. Social factors affecting health, health literacy, judgment about the ratio of risk and benefit, the level of trust in officials and healthcare workers, and personal or group beliefs, along with customs are factors related to the acceptance of vaccination by people [16, 17, 18, 19, 20]. The intention and motivation to inject the vaccine are key elements facilitating the vaccination process [21]. 
Motivational interviewing is a person-centered communication style to increase internal motivation by identifying and addressing individual uncertainties and doubts instead of relying on external sources, such as persuasion or coercion from others [22]. This approach is effective for ambivalent and hesitant clients and is used in the field of health and hygiene, including health behaviors and receiving healthcare [23]. Some people in society are hesitant about COVID-19 vaccination, despite the confirmation of the effectiveness and safety of the vaccine via numerous clinical trials and even despite the gradual increase in the proportion of the population who are vaccinated [24]. The difference in the effectiveness and adverse effects of some vaccines may cause mistrust of some vaccines, which subsequently affects the willingness to be vaccinated, especially when individuals are not given the right to choose the vaccine [25]. The concern of the community about the side effects and the possibility of having COVID-19 after the injection of the vaccine is considered one of the important reasons for resistance and hesitation to the injection of the vaccine [26]. To solve these challenges, designing and implementing strategies to increase the confidence and acceptance of vaccination among people is on the agenda of health systems to ensure the access and fair distribution of the COVID-19 vaccine [27].
Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI PACES) is a software program designed by the Joanna Briggs Global Institute to help healthcare professionals implement effective clinical audits appropriate to their local settings. It is beneficial to improve the quality and safety of healthcare and improve the outcomes for care recipients. This tool is an all-in-one solution, including project initiation, data collection, data analysis, change process facilitation, and evidence-in-practice application. JBI in completing the PACES approach recommends the getting research into practice (GRIP) framework to create interprofessional processes in teams to examine barriers to the use of evidence to support best practices and develop implementation strategies to overcome these barriers [28]. Our research team at Mazandaran University of Medical Sciences, following the field observation of the reduction of the vaccination coverage of COVID-19 in a village in the east of Mazandaran Province, Iran, investigated the causes and related obstacles using JBI PACES and GRIP approaches. This article is a report on how to use these tools and also investigates the role of motivational interviewing techniques in the acceptance of this vaccine in hesitant people. 
Materials and Methods
This quasi-experimental study was conducted in a village in the east of Mazandaran Province, Iran, in 2022 in the form of a project to implement the best evidence by an operational research team, including a reproductive health professor and a faculty member of Mazandaran University of Medical Sciences, a general practitioner in charge of the rural health center in the region, and a master’s student of counseling in midwifery and working in the health center of the region.
The project implementation tools were the JBI PACES and GRIP frameworks [28]. The evidence-based promotion process of the healthcare of the COVID-19 vaccination was conducted using the following 2 frameworks in 3 stages of activity [28, 29]:
Phase 1
Creating a team for the project and conducting a baseline audit
In the first stage, the basic vaccination index as well as the basic status of the clinical performance of healthcare workers in the field of COVID-19 vaccination were examined in terms of compliance or non-compliance with the following four JBI evidence-based audit criteria:
1- Is the instruction on how to get vaccinated against COVID-19 available? 
2- Does a system to remind the COVID-19 vaccination to exist in the covered population file?
3- Do healthcare workers receive training on the benefits, safety, injection time, and effectiveness of the COVID-19 vaccine?
4- Are verbal and written education based on the best evidence of the benefits, safety, injection time, and efficacy of the COVID-19 vaccine provided to the covered population?
In this process, the supervisor (working in the regional health center and a member of the present research team) asked the healthcare workers working in the health centers, who are the first line of the chain of injecting the COVID-19 vaccine, to explain their way of working in this field as well as to observe and evaluate their performance.
Phase 2
Designing and implementing strategies to investigate non-conformities found in the baseline audit 
In this phase, we asked healthcare workers to identify people resistant to receiving the COVID-19 vaccine and refer them to the health center. The implementation of the motivational interview technique was among the measures of this stage.
Phase 3
Conducting a follow-up audit after implementing the change strategy 
In the third stage, the change in the vaccination index was investigated according to the number of titrated vaccines related to people under motivational interview counseling.
Implementation of Motivational Interview Intervention
At first, during a meeting in the health center with the presence of the head of the center, the supervising healthcare provider, the first-line caregivers of vaccinations, along with people resistant to receiving the vaccine, the individual characteristics of these people, including the level of education and also their socio-economic status, were examined. Then, with targeted and focused person-centered planning, based on the need of each person, one to three motivational interview sessions according to the principles mentioned in the summary of the motivational interview protocol (Gary and Alistair, Leeds, January 2010) [30] to increasing internal motivation was held as follows: 
Creating an atmosphere of acquaintance between the interviewer and the client;
Asking open questions by the counselor at the beginning of the session to check the desire and resistance of the client and determine the stage of change;
The rain of thoughts about the long-term and short-term benefits and costs of vaccine injection, centered on the client’s opinion;
The rain of thoughts about the long-term and short-term benefits and costs of not injecting the vaccine, focusing on the client’s opinion;
Revealing inconsistencies and internal conflicts of the client;
Asking the client about the opinions of crucial people in his life (including their children, wife, father, and mother, as well as elders and crucial people in the society) regarding vaccination;
Clarification, identification, and confirmation of the client’s values; 
Confirming, reflecting, and summarizing the client’s statements; Increasing the awareness of clients regarding the history of vaccination, the effect of vaccination in controlling pandemic diseases, the types of COVID-19 vaccines, the benefits and natural side effects of the vaccine, and the number of COVID-19 vaccine recipients worldwide from the beginning until holding the motivational interview session; 
Ask open questions to the counselor at the end of the session to re-examine the desire and resistance of the client and determine the stage of change.
Results
The population covered by the rural health center under study included around 2000 people and 600 households. Five healthcare workers were in this center. The target population for the injection of the COVID-19 vaccine was more than 1500 people. The results of the baseline audit showed that the instruction related to the vaccination of COVID-19 were available to all of the health providers. The reminder system for the vaccine injection was only for less than half of the cases of the target population (600 out of 1500 people). About 60% of the target population for vaccination injection (900 people out of 1500 people) and all healthcare workers had received evidence-based training about the COVID-19 vaccine. Also, in terms of checking the vaccination coverage, 145 people resistant to vaccination (mostly the elderly with low socioeconomic status and low health literacy and knowledge) were identified, of which 110 people willingly participated in the motivational interview.
At the beginning of the motivational interview course, people had little desire to continue the course and also inject the vaccine; however, subsequently and upon understanding the centrality of their presence and role in the meeting, they continued with more desire and motivation and had stronger participation in such a way that they enjoyed the discussion and interview and at the end of the meeting, they confirmed the counselor’s statements. The results of the follow-up audit showed that the rate of compliance with the best evidence improved significantly (100%). 
The implementation of the motivational interviewing technique led to an 88% improvement in vaccination coverage in the group of 110 people resistant to vaccination; accordingly, 33 people (30%) at the end of the first session, 48 people (approximately 44%) at the end of the second session, and 16 people (approximately 14%) at the end of the third session agreed to inject the vaccine. On the other hand, in 13 people (approximately 12%), because of high internal resistance, the motivational interview had no effect and they resisted the vaccine injection.
Discussion
In this study, in the framework of the implementation project of the best evidence in the promotion of health care and JBI PACES and GRIP approaches, the effectiveness of motivational interviews on creating the willingness to inject the COVID-19 vaccine in a group of 110 resistant and hesitant people and the ratio of this vaccine was investigated. The findings indicated an 88% improvement in vaccination coverage in the targeted people. Consistent with this result, Bonnes et al. [31] demonstrated that doubting the COVID-19 vaccine is a behavioral phenomenon in some people who neither fully accept the vaccine nor completely reject it. This phenomenon is a big threat to health during the COVID-19 pandemic. Regarding the urgent need for new and effective approaches to the doubt of the COVID-19 vaccine, especially in healthcare environments, these researchers emphasized the importance of motivational interviewing as a collaborative relationship between the doctor (as a health service provider and consultant) and the patient and described a three-step process in this field. 
The first step is to implement a guiding model, encouraging the physician to conduct a motivational interview, including a discussion of vaccine skepticism in a collaborative, non-directive manner that is specified by considering neutrality, open-ended questions, the reflection of patient responses and opinions, and confirmation of underlying concerns of the patient and summarization (summary of the patient’s comments). This collaborative approach allows the doctor to communicate, emphasize the patient’s independence, and express their desire to understand the patient’s position instead of changing the patient’s opinion about the COVID-19 vaccine. This makes the patient feel comfortable and openly expresses their doubts. 
The second step is to discover the patient’s decision through more targeted and open-ended questions. In this step, other motivational interviewing tools are used, such as the calling-presenting-calling cycle. The patient is asked about their understanding and decision regarding the COVID-19 vaccine (calling), then, the doctor provides information about the vaccine in the form of short and targeted sentences with an emphasis on the patient’s personal choice (presenting), and subsequently, asks the patient about their opinion on the given information (calling). Balance in decision-making is another tool in which the doctor indirectly and by maintaining neutrality in a way that does not affect the direction of the patient’s decision, seeks the patient’s opinions about the benefits and harms of changing their behavior (decision to inject vaccine). 
The third step is the doctor’s informed and skillful response to the patient’s position in the form of highlighting the positive aspects of behavior change, asking about the patient’s new decision, and leading them to the final decision in such a way that the patient is involved in a shared decision-making process. In another study, Gebrezghi et al. [32] from the obstetrics and gynecology unit of the department of health and hospitals of Denver, USA, presented an educational video clip about how to conduct a motivational interview to counsel patients who are hesitant to take the COVID-19 vaccine for the guidance of obstetricians and gynecologists. According to these researchers, the opportunity to visit before surgery is an excellent time to review the patient’s concerns about the vaccine. This counseling tool is also useful to encourage such patients to perform the COVID-19 test and delay elective surgeries in people with positive tests.
One of the limitations of using the motivational interviewing technique to reduce resistance to COVID-19 vaccination in the present study was that some patients felt ambivalent about vaccination and were sensitive to the efforts of doctors and caregivers to convince them in any way. 
The findings of this study support the use of the psychological tool of motivational interviewing in improving the COVID-19 vaccination index. Since some of the members of this research team were healthcare providers in the area of conducting the study, showing the potential of healthcare providers in reducing the doubt about the COVID-19 vaccination practically is one of the strengths of this study. Other strengths of this study are the use of JBI PACES and the research audit along with the GRIP tool or the best evidence approach framework in promoting healthcare. The limitations exist in the use of motivational interviewing techniques in dealing with doubt and resistance to the vaccination of COVID-19 in the present study. Patients who feel ambivalent about vaccination may be sensitive to doctors’ attempts to persuade them in any way. People who are resistant to vaccination may not respond to the call of the service provider and may not refer to it.
Conclusion
The results of the present study showed that the implementation of the motivational interview technique is effective in improving the COVID-19 vaccination index, especially in people who are hesitant and resistant to this vaccine. Since the learning and application of this technique is also very easy and inexpensive, it is recommended that healthcare service providers receive training in this field and use it for people resistant to receiving these services. Perhaps most of the caregivers empirically use this technique but because it is not targeted and focused, it may eventually lead to confrontation and not create a suitable atmosphere, and lead to more conflict. Also, according to the method and findings of this study, strategic and operational planning to improve the provision and healthcare services in health and treatment centers in the framework of the implementation project of the best evidence and application of JBI PACES and GRiP approaches, as well as empowerment of healthcare providers are recommended in this field.

Ethical Considerations
Compliance with ethical guidelines
The project will be a quality improvement activity in healthcare centers, so no ethical approval is required. The basic measures were further met to ensure confidentiality, anonymity, the right to withdraw, and voluntary participation.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions
Conceptualization, supervision and methodology: Zeinab Hamzegrodshi; Data collection and best evidence implementation: Ferangis Habibi and Mohammad Ahmadi; Writing-original draft and writing-review and editing: All authors. 

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The health team of Gharib Mahaleh rural comprehensive health service center and the covered people who participated in the best evidence implementation plan are appreciated.

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