Training Students to Address Vaccine Hesitancy and/or Refusal

"Changing a patient's mind requires communication skills that can only be developed through practice and the possession of critical knowledge of how to persuade a hesitant individual."

Pharmacists are often the practitioners who educate patients and administer immunisations and, thus, can play a role in promoting this public health measure. As in the case of securing medication adherence, convincing patients of the importance of vaccinating themselves and their children requires good interpersonal communication skills and the use of individualised strategies that target the root of a patient's hesitancy. This paper describes a 2-week learning unit that focused on teaching pharmacy students the art of persuasion (rhetoric) as related to vaccine hesitancy. The objective of the study is to determine the impact of this learning unit on student knowledge, attitudes, perceptions, and the ability to address vaccine hesitancy and refusal.

Traditional pharmacy education regarding vaccines has been based on providing clinical information about vaccines and the proper administration technique. However, the impetus for the present study is that pharmacists need to be prepared to employ multiple strategies in the face of vaccine-hesitant patients.

• The first prong of this multifaceted approach would be for health care providers to master the art of rhetoric or persuasion so as to have meaningful and personal conversations with patients and parents. The foundation of this approach is building trust and a sense that the messenger is listening, truly attentive, and credible. The tenets of persuasion require that the individual cultivate an open and credible stance, develop an emotional connection to their audience, display a command over content, and offer logical argumentation. In the context of vaccine hesitancy, components of the art of persuasion include a genuine interest in the child/patient, acknowledgment of any concerns regarding vaccines, provision of accurate information on both risks and benefits of vaccines, and the overall social-emotional competence of the provider.
• The second prong would be to employ a clinical perspective on vaccine hesitancy. This strategy would include recognising and identifying the patient's concerns and then using strategies that would target those specific concerns. This technique involves avoiding information overload and focusing the conversation between the patient and provider.
• For vaccine-hesitant parents, the third prong would be to use social and emotional skills to arouse emotions to relay the importance and immediacy of vaccinating young children. Highlighting personal stories of tragedies related to this illness may have an emotional impact on parents not possible through statistical data or regulatory strategies.

At the University of the Pacific, in the United States (US), students complete the American Pharmacist Association (APhA) Immunization Training Certification Program. In 2016, during the third semester of the programme, a 2-week vaccine hesitancy learning unit was added to the required Practicum II course as a formative component. The vaccine hesitancy unit consisted of 2 standardised patient (SP) simulations scheduled 1 week apart, with a self-study module in between simulations. Twenty actors were hired and trained for 4 hours to serve as SPs for the simulation. Each scenario began with an SP who approached the student pharmacist and expressed a vague concern about getting themselves or their child vaccinated. Four common vaccine myths as identified by the World Health Organization (WHO) were selected for this exercise: vaccines overwhelming a child's immune system, vaccines causing the illness they are supposed to prevent, vaccines containing harmful additives such as thimerosal, and vaccines causing side effects. During each one-on-one simulated interaction, the SP brought up 2 of the selected vaccine myths. The scenario was deliberately vague, as students were expected to evaluate the patient by asking questions, providing counseling, mediating any conflict, and maintaining the patient-provider relationship despite possible disagreements.

To further prepare students, the researchers developed an hour-long online module and two 6-minute-long YouTube videos. The module provided information on strategies for countering vaccine myths, impact of common vaccine-preventable diseases, the art of persuasion, and common vaccine side effects. The YouTube videos provided instruction on how to recognise the patient's exact concerns, how to quickly counter any vaccine hesitancy, how to use disease facts to develop an emotional tie to the patient, and how to employ a multimodal approach, like the one outlined above, that does not rely on any one strategy.

The second simulated interaction was conducted the following week. The scenario and script setup was similar to the first but focused on 2 different vaccine concerns. This simulation gave students the opportunity to use and practice the new techniques introduced in the online module and videos. Following each simulation, SPs provided formative feedback with the help of a grading rubric developed by faculty. The grading rubric was divided into 3 components: the art of the rhetoric, communication skills, and social-emotional competence.

There were 203 students who participated in both phases of the learning unit, 180 of whom completed both the pre- and post-attitudes surveys. Nine items showed significant improvement. The largest changes were seen in Q1 (knowledge about the use of thimerosal as a preservative), Q9 (speaking about how too many vaccines do not overwhelm a child's immune system), and Q5 (knowledge about vaccinations not overwhelming a child's immune system). Overall, 94% of students were satisfied with this unit on vaccine myths and concerns.

With regard to the 16 rubric assessment questions as graded by the SP, the greatest gain (pre-training mean = 1.7, post-training mean = 2.7, p<.001) was seen in students' ability to acknowledge risks. Other items with larger gains all dealt with creating a positive environment for patient-consultant interactions (e.g., soliciting questions, expressing empathy, validating concerns). The smallest gain was in providing the patient with information to dispel the myth; however, even here, the gain was significantly positive (p<.05). Of note, conflict escalation occurred in 15.7% of SP encounters pre-intervention and only 5% of encounters post-intervention. Total mean scores improved from 35.3/48 for the initial activity to 42.9/48 post-intervention. In addition, students were more likely to change an SP's mind, post-intervention (1.87 vs 2.42, p<.001).

In short: "By assessing student abilities in dealing with vaccine hesitancy before and after completing an active learning exercise, this study was able to show significant increases across all areas of confidence, knowledge, and student skill. The simulated exercise, when paired with standard didactic teaching materials, provided a conceptual model of how to teach critical communication skills to improve students' ability to address vaccine hesitancy."

The researchers suggest that programmes looking to incorporate such an exercise to their curricula should consider the significant resource costs of SPs and the time needed to schedule and execute simulated patient interactions.  In addition, significant effort needs to be put into improving the realism of each simulation, so that students take it seriously and learn from any feedback.

In conclusion, while this study showed significant short-term gains, further study needs to be done to confirm long-term gains in knowledge and skills. In addition, further research on student performance on advanced pharmacy practice experiences (APPEs) and post-graduation in practice would provide data to support this strategy. Finally, including students from other healthcare professions would make this an interprofessional education experience.