“Being Persistent without Being Pushy”: Student Reflections on Vaccine Hesitancy
Our goal as pediatric educators is to graduate physicians who have witnessed effective approaches and have grasped the nuances of communication strategies between vaccine-hesitant families and health care providers. We identified vaccine hesitancy as a recurring topic in 19 of 304 medical student reflective narratives addressing an issue in professionalism or systems-based practice. We conducted content analysis on the narratives in order to gain a better understanding of student perceptions of visits in which they observed a provider discussing vaccine hesitancy with a parent. We identified four major themes: perceived effectiveness of provider-family communication, student reaction to the encounter, physician approach to vaccine hesitancy, and gaps in students’ own knowledge. Most students described communication positively, despite only 4 of 19 observing eventual vaccine acceptance. Information regarding vaccines, vaccine delivery, and approaches to vaccine hesitancy needs to be introduced and enhanced in the educational curriculum of providers at all levels, including medical students, resident physicians, and attending physicians, in order to ensure that providers possess the comprehension and communication skills to ethically optimize vaccine uptake among patients.
Ethical Focus, Ethics Education, Hidden Curriculum, Qualitative Content Analysis, Qualitative Methods, Vaccine Hesitancy, Vaccine Refusal
According to the Centers for Disease Control and Prevention (CDC), immunizations are among the safest and most successful public health interventions (CDC, 1999). These interventions have been so effective that many vaccine-preventable diseases are now unfamiliar to both providers and patients. Parental and provider vaccine hesitancy, defined as an active desire to defer or omit [End Page 59] any of the vaccines routinely recommended by the U.S. Department of Health and Human Service’s Advisory Committee on Immunization Practices (ACIP), has become an increasingly common and nearly inevitable challenge, particularly in pediatric practice (Opel et al., 2011). Flanagan-Klygis, Sharp, and Frader (2005) reported that as many as 85 % of pediatricians encountered parents who had refused at least one vaccine for their child in the past year.
Parental vaccine decision-making is often influenced by the provider-patient relationship, provider recommendation, and provider response to patient and parental concerns (Sadaf, Richards, Glanz, Salmon, & Omer, 2013; Healy & Pickering, 2011; Leask et al., 2012; Rand et al., 2010; Diekema, 2005; Freed, Clark, Butchart, Singer, & Davis, 2010). Optimizing this provider-parent interaction requires that the provider have both the confidence and the necessary communication skills to promote vaccine uptake to patients and parents. Gaps in provider confidence in vaccines have been described across training levels, from medical students to attending physicians (Lehmann, Ruiter, Wicker, Chapman, & Kok, 2015; Suryadevara, Handel, Bonville, Cibula, & Domachowske, 2015; Suryadevara et al., 2016). This combination—of vaccine concerns among health care personnel and the lack of formal vaccine communication training in medical education—may produce health care providers who lack the expertise to address vaccine hesitancy successfully. Given the widespread availability of anti-vaccine misinformation, all health care providers are likely to encounter vaccine hesitancy, whether in their practice or in the context of public health concerns. Medical students are expected to have a solid understanding of immunity and immunization practices as part of their core curriculum in pediatrics, and this material is integral to teaching general pediatrics.
The pediatric clerkship in the third year of medical school provides the opportunity for didactic vaccine teaching, clinical observations of provider-parent vaccine discussions, and role modeling of important communication skills. Recent literature suggests that simple education has little or no influence on parental decisions regarding vaccines (Jarrett, Wilson, O’Leary, Eckersberger, & Larson, 2015). Reasons for vaccine hesitancy are varied and often multiple, including concerns about safety or efficacy, costs, and concurrent illness (Larson, Jarrett, Eckersberger, Smith, & Paterson, 2014; Salmon, Dudley, Glanz, & Omer, 2015). Methods for approaching vaccine hesitancy are also varied, with limited evidence supporting one approach over another (Jarrett et al., 2015).
A required component of the pediatric clerkship at our institution is the completion of a reflective narrative of up to 1,000 words addressing an issue in professionalism or systems-based practice observed during the clerkship. The use of student reflective narratives has been promoted as a mechanism for enhancing deeper learning, potentially integral to the growth and formation of professional identity (Karnieli-Miller, Taylor, Cottingham, et al., 2010). Such narratives can be used as both a teaching tool and an innovative method for evaluating the quality of medical education. These reflective pieces may reveal themes regarding knowledge, skills, behaviors, and attitudes observed during actual clinical encounters, often referred to collectively as the “hidden curriculum.” After noting that the issue of vaccine hesitancy frequently appeared in student narratives, we sought to examine those describing vaccine hesitant encounters in order to understand student perceptions of these visits, to consider how the topic of vaccine hesitancy is approached in medical education, and to examine the hidden curriculum with regard to the observed provider communication skills.
The required 5-week pediatric clerkship at our institution is divided evenly between clinical experiences in the inpatient units of the affiliated children’s hospital and in an outpatient setting. Third-year medical students (8–17 per block) are assigned to various community and academic sites for their outpatient experience and to a hospitalist team for their inpatient experience. Professionalism and systems-based practice objectives are [End Page 60] incorporated into the institutional educational program objectives and the objectives of the pediatric clerkship. Students participate in a longitudinal curriculum, spanning all 4 years of medical school, and are expected to have a working knowledge of the four principles of biomedical ethics: autonomy, justice, beneficence, and non-maleficence. They are also expected to have a basic knowledge and understanding of the communication skills required for developing rapport and empathy, providing patient education, and building partnerships with patients and families.
Since May 2012, our institution has required students to submit a reflective narrative (up to 1,000 words) addressing an issue in professionalism or systems-based practice observed during the clerkship. Instructions were derived and adapted from previously published literature (Karnieli-Miller, Vu, Holtman, Clyman, & Inui, 2010) and are open-ended with regard to topic. Narratives are submitted during the fourth week of the clerkship; although ungraded, they are required in order to pass the professionalism component. All narratives are reviewed by the clerkship director and the department chair. During the final week of each clerkship, students meet with the department chair, the clerkship director, a faculty member from the Center for Bioethics and Humanities, and the pediatric hospital chaplain. Three to five narratives are selected and de-identified to provide the basis for a discussion of professionalism and systems-based practice. In the course of these discussions, the authors (A. S. B., T. R. W., and A. C. B.) noted that vaccine hesitancy was a recurring topic, appearing in at least one narrative submitted during almost every clerkship block.
Three hundred four narratives were submitted between May 2012 and May 2015, de-identified, and uploaded into QSR International’s NVivo Version 10.0. (2014). All narratives were read by the authors, who identified those that were vaccine related. In addition, all submissions were searched for the following relevant word stems in order to identify any missed narratives: vaccin*, immune*, and shot. Of the 22 narratives initially identified by the query, 19 addressed situations involving vaccine hesitancy or vaccine refusal. The three excluded narratives included stories about accidental repeat vaccines and children admitted with diseases that were vaccine preventable. All students received grades for the clerkship prior to inclusion of their narratives in the study, which was declared exempt from review by our Institutional Review Board.
We performed a content analysis of each vaccine narrative (Crabtree & Miller, 1999). After a first-pass review of the narratives, two authors independently coded each vaccine narrative within the NVivo environment, reaching consensus and saturation regarding the themes present. Initial discrepancies were resolved through independent review by a third author, followed by discussion in order to reach consensus. Three authors (A. C. B., A. S. B., and T. R. W.) then reviewed the coding results iteratively for further development of subthemes (subcodes) and relationships between themes (codes). The online mind-mapping tool MindMeister (2015) was used to further explore relationships between themes.
Of the 19 narratives, 15 described a specific encounter with a single family and physician involved (Table 1). Four students referred to witnessing multiple instances of vaccine hesitancy without discussing a specific patient or family. Most encounters occurred in the outpatient setting and involved an attending physician preceptor. When specific vaccines were identified as the source of hesitancy, those most frequently mentioned were the human papillomavirus (HPV) vaccine (10/19) and the influenza vaccine (8/19). Four major themes were identified: (1) students’ perceived effectiveness of provider-family communication (Figure 1), (2) students’ self-described reaction to the encounter (Figure 2), (3) student perceptions of the physician’s approach to the encounter (Figure 3), and (4) gaps in students’ own knowledge (Figure 4). The first three major themes were present in all narratives (19/19); the fourth was present in seven narratives. [End Page 61]
Perceived effectiveness of provider-parent communication
It is hard to find the right balance of being persistent without being too pushy and I felt like she did a great job with that and in the end, she was able to convince the mother and daughter.
Although only four narratives reported eventual vaccine acceptance during the encounter, 17 students (89 %) felt that provider-parent communication was effective, indicating that students perceived the effectiveness of the communication to be independent of the acceptance of the vaccine. Students reported positive observations of [End Page 62] the communication skills of their preceptors when faced with vaccine hesitancy, regardless of whether vaccine acceptance was achieved (Figure 1). In one narrative in which the vaccine was eventually accepted, the student commented:
The mother quickly became less reluctant to give the vaccine and admitted to not hearing the full story in regards to the vaccine. The doctor I was working with really emphasized the importance of patient education in promoting health care. He also exemplified the significance of excellent communication skills and creating a respectful therapeutic alliance which benefited everyone involved.
However, another student described an encounter as a “great success” even without resulting in vaccine acceptance:
Although the doctor was not able to provide an argument sufficiently convincing to influence the child’s mother about having her immunized, it seemed that her words were at the very least thought-provoking to the mom. In my opinion, this was a great success as I believe every action begins with even a single thought!
Some students used such phrases as “good communication skills” and “effective communication” to describe their preceptor’s approach, even in the absence of vaccine acceptance, suggesting a broad understanding of the goals of the encounter. For example, one student noted that
the attending, without giving a formal lecture on how to approach patients and their families, was showing us how to positively engage with people while speaking in layman’s terms as an example of good communication skills.
In regards to the care of the patient, it is impossible to say with absolute certainty whether this [End Page 63] approach was the most effective one. More than likely these children didn’t receive their vaccine shots . . . I think my preceptor effectively communicated to the parents the evidence we have in support of childhood vaccines, thereby empowering the parents to make this decision on their own. Her willingness to accept their decision and the respectful way in which she handled the situation were both effective at maintaining a trusting relationship with the family.
The establishment of a “trusting relationship” and the possibility of continued dialogue and future acceptance of vaccines may have underpinned this broad understanding. Three students explicitly stated that they believed the parents were open to ongoing conversations about vaccination with their primary care providers.
The mother was very receptive to his advice and concluded that she would “think about it.” What impressed me the most about this encounter was how much the pediatrician made the patient’s mother a part of the decision-making process. Rather than questioning her intelligence and making her feel inferior, he wanted her to still have some control in the management of her son’s healthcare, while providing her with the most accurate information to guide her decision making, emphasizing the idea that the patient-doctor relationship is a team and not one of subordination.
However, my preceptor did not just immediately accept this mother’s decision to not vaccinate her child; she first asked to know the reasoning behind this mother’s choice. Asking calmly and compassionately about her thought process helped us learn more about how the mother was likely to react to decision in the future and whether or not there was even a possibility for us to convince her to change her mind about her daughter receiving the flu vaccine.
Students’ self-described reactions to vaccine hesitancy encounters
Students’ descriptions of their personal reactions to the encounter broadly included personal affective responses and self-reported “lessons learned” (Figure 2). These lessons included the application of ethical principles to a real encounter (11/19), a sense of how to approach similar encounters in the future (12/19), and an understanding of professionalism (14/19).
I realized how easy it is to bypass or neglect controversial conversations regarding patient care, particularly in pediatrics, where you are not even having the conversation directly with the patient many times.
In terms of professionalism, particularly interesting were narratives that focused on the discrepancy between one’s professional demeanor and private emotional reaction. Seven students specifically emphasized the ability of the preceptor to remain calm in the face of frustration as an important aspect of the encounter. Two students described feelings of guilt at their own anger toward the parent refusing the vaccine, in contrast with the calm, patient demeanor of their preceptors, and were consequently ashamed at their self-perceived lack of professionalism. Following the preceptor’s private disclosure of a personal emotional response, students wrote about their own relief:
I felt a little troubled because of the calm composure of the resident which was in stark contrast to my boiling anger . . . I found it relieving that he too was very upset but only maintained calm composure for the sake of maintaining professional demeanor.
I never would have guessed that the doctor was upset with the mother when we were in the room. She only seemed concerned and understanding as she tried to redirect the mother’s thinking on vaccines. It was a little bit relieving to know that the mother was making her upset while we were in the room because I felt that way myself.
Four students admitted to feeling angry or frustrated themselves, while two students described a sense of failure after the encounter:
After leaving the room it felt as though we had failed the patient because he was unable to get the protection offered by the two vaccinations.
By leaving the child unvaccinated, it leaves not only the child vulnerable to infections but also the public who will come into contact with this child . . . I felt that we failed to be professional.
Only one student mentioned the temptation to “roll my eyes” as a “knee-jerk reaction to vaccine skeptics” but then described learning from the preceptor’s [End Page 64] patient and thoughtful response; no students expressed contempt or disrespect for the parents involved. Five students discussed the dual concepts of learning “what not to do” and the belief that they would “do better,” though, as discussed below, their specific intentions sometimes indicated gaps in their knowledge of vaccines and vaccine hesitancy.
Where I would differ in approach is that I think I would leave the room before asking the patient’s family for a decision on this topic. There is so much media and controversy surrounding the issue that while I support vaccination and would encourage it, I would want to know that my patient and his/her parents feel completely comfortable in the decision.
Student perceptions of provider approaches to vaccine hesitancy
They demonstrated that medical expertise without commensurate empathy and communication skills would be of little value.
Students described witnessing a variety of approaches to vaccine hesitancy, both in terms of the provider’s demeanor and the approach to vaccine hesitancy itself, with all but two narratives describing provider attempts to persuade the family to vaccinate the child (Figure 3). A third narrative negatively contrasted the observed behaviors of other physicians with the student’s current preceptor:
In other instances, I saw physicians simply hand the parent the refusal form without education, questioning or any communication about the issue at hand.
Most narratives described providers as attempting to explain the importance and safety of vaccination, using evidence-based data to refute vaccine misperceptions. Nine students noted that providers asked the parents about their reasons for vaccine refusals and vaccine concerns, an approach that, though not shown to convince vaccine-hesitant parents, is a standard response to any refusal of treatment by a patient. The narrator quoted above had this to say:
I was very impressed by this physician because as my time with him continued, I realized he [End Page 65] always made sure to ask why a parent wanted to refuse vaccinations, explained the benefits of vaccination, and made sure all parents signed a refusal form.
Only three students perceived that the provider directly initiated discussion with a strong recommendation for vaccination, the approach to vaccine hesitancy with the most support in the literature (Opel et al., 2013).
In my 2.5 weeks working with [the preceptor], not a single family refused vaccination. . . . I think part of what made him so effective was his approach. He did not wait to “feel” for a reaction when he advised vaccination but instead, he immediately explained the vaccine and the research.
One student described an encounter in which she believed the physician intentionally provided misinformation (exaggerating the risks of tetanus) in order to convince a mother to accept a vaccine.
Sometimes, however, this determination [to provide the highest standard of care] gets the better of them and their altruistic intentions infringe upon the rights of the parents of the patients they treat. Through techniques that scare parents into vaccinating their children, pediatricians can force these parents to do something they are not comfortable with.
This student, though clearly uncomfortable with her preceptor’s approach, did go on to question whether parents should have the right to place their child at increased risk for a potentially lethal disease:
Finally, although the doctors may seem deceptive, is it really fair for the parents to make such a dangerous decision for their children who have no say in this process?
Another narrative described a physician who recommended that the vaccine-hesitant parent find a different provider, particularly someone who specializes in holistic or alternative medicine. The student went on to reflect that [End Page 66]
[The provider] instead reminded me that . . . what we may consider to be the standard of care or evidence based medicine is not necessarily appropriate for every patient.
Gaps in student knowledge
Students also provided observations that reflected their lack of knowledge regarding specific vaccines and vaccine-preventable diseases, vaccine delivery, causes of vaccine hesitancy, and effective strategies for addressing it (Figure 4). For example, one student stated that physicians should provide written vaccine education materials to patients, apparently unaware that Vaccine Information Sheets (VISs) already are produced by the CDC and are required by federal law to be given prior to any vaccine administration (CDC, 2016).
I think if pediatricians are so worried about vaccination they should have education packets available for parents. These packets could have basic information about vaccines along with links to more information about vaccination for parents who are interested. This is something that could save doctors time educating patients in person and allow them to discuss any other specific concerns the parents have.
Possible biases and assumptions in approaching vaccine-hesitant parents were also described, some of which may have been reinforced by the preceptors themselves.
the time spent arguing with a patient that will not result in any satisfactory interaction or changed decision could be used to serve other patients . . .
I would also ask some of my female colleagues with children to talk to [the mother]. That way I think she can better relate to her as mothers.
Of note, one student explained that while he/she had learned about the HPV vaccine earlier in medical school,
one thing we are not taught is how to counsel a patient and their family on why they should receive the vaccine. [End Page 67]
To the best of our knowledge, this is the first study of student perceptions of pediatric provider encounters with vaccine-hesitant parents. Students described the calm, professional provider interaction in contrast with their personal emotional reaction to the visit. They also described witnessing a variety of provider approaches to the vaccine hesitancy encounter. The majority of students believed that provider-parent communication was effective, even though the discussion often did not result in a change in parental vaccine decision-making.
Using original reflective essays to gather student perceptions about their experiences is a valuable method for gaining a better understanding of the inner thoughts and development of physicians in training (Karnieli-Miller, Taylor, Cottingham, et al., 2010; Karnieli-Miller, Vu, Holtman, et al., 2010; Kind, Everett, & Ottolini, 2009; Balmer, Master, Richards, & Giardino, 2009). In order to avoid expanding the rift between what students are taught in the formal curriculum and what they see in practice, preceptors or other clerkship faculty should take a moment to directly but sensitively discuss the vaccine refusal. This has been referred to as “space” in the curriculum for reflection and dialogue (Kumagai & Naidu, 2015). As educators, our goal is to provide role models for excellent communication skills and to teach students evidence-based approaches to the array of challenges encountered in engaging vaccine-hesitant parents. These narratives point to the need for further education regarding vaccine knowledge, delivery, and hesitancy, and demonstrate that students may leave such an encounter with continued misapprehensions about best approaches to the latter. Such unacknowledged confusion may result in these students, after they graduate, continuing to use methods known to be ineffective (Opel et al., 2013; Henrikson et al., 2015; Nyhan, Reifler, Richey, & Freed, 2014; Nyhan & Reifler, 2015).
Along these lines, the provider approach to vaccine hesitancy encounters that was most commonly described was the use of evidence-based scientific data to explain the importance and safety of vaccinations. Few students described provider initiation of vaccine discussion with a strong vaccine recommendation and none mentioned the “presumptive” versus “participatory” communication style (Opel et al., 2013). While it seems intuitive that correcting vaccine myths would reduce vaccine misperceptions, this method has in practice been shown to reduce intent to vaccinate among respondents with high levels of vaccine concerns (Nyhan et al., 2014; Nyhan & Reifler, 2015).
Provider initiation of vaccine discussion—delivering a strong presumptive vaccine recommendation rather than a participatory recommendation or query, and maintaining this recommendation in the face of initial resistance—has been associated with increased vaccine uptake, even among initially hesitant parents (Opel et al., 2013). Similarly, motivational interviewing, defined as a patient-centered counseling style for eliciting behavior changes by helping the patient “to explore and resolve ambivalence,” has been proposed as a communication strategy for discussing vaccines with hesitant families (Leask et al., 2012; Miller, 1983). This contrast, between approaches to vaccine hesitancy observed by the students and evidence-based strategies demonstrated to be effective, highlights opportunities for improved education across all levels of practice, from medical students to pediatric residents to attending physicians.
Narratives revealed intriguing biases that may influence students’ approach to these encounters, such as the claim that a vaccine-hesitant mother would be more apt to vaccinate her child if the recommendation came from a provider who was also a mother. Provider concerns regarding the drivers of parental vaccine decision-making are also known to affect the strength of provider vaccine recommendations (Healy, Montesinos, & Middleman, 2014). Providers who believe that parents of 11- to 12-year-olds are going to refuse HPV vaccine are less likely to strongly recommend the vaccine to adolescents in this age group; however, it has been shown that providers overestimate parental vaccine hesitancy, particularly for HPV and influenza vaccines (Healy et al., 2014; Daley et al., 2010; McRee, Gilkey, & Dempsey, 2014; Perkins et al., 2014). [End Page 68] Educating students to set aside their own perceptions of parental concerns and to address the real drivers of each parent’s decision to vaccinate his or her child is a skill needed to optimize vaccine uptake throughout their careers. It is notable that this skill was neither recognized nor described in the narratives within our sample.
Since previous data also indicate that medical students lack knowledge regarding their own vaccination needs (e.g., HPV and influenza), it is possible that vaccine information, recommendations, and scientific research may not be well taught prior to the pediatric clerkship at our U.S. medical school (Suryadevara et al., 2016). Providing this information earlier in the student’s career may avoid later misconceptions.
Conclusions from qualitative data can be difficult to generalize to other settings, particularly when the sample size is small. Our study provides data from a singular setting: one clerkship in a single medical school over three years. Furthermore, the original intent of the assignment was not to obtain data for this type of analysis. However, we believe that our findings can guide other educators as they develop curricula addressing vaccine hesitancy and provider-parent communication, as well as researchers who seek a better understanding of what students learn from their observation of challenging clinical encounters. While the specific details of the hidden curriculum may vary from institution to institution, the greater themes are likely to be relevant throughout Western medical school culture.
As pediatric educators, our goal is to graduate physicians who have witnessed effective approaches and have grasped the nuances of communication strategies between the health care provider and all patients, including vaccine-hesitant parents. Based on the findings from this qualitative study, vaccine importance and approaches to vaccine hesitancy need to be introduced into or enhanced in the educational curriculum for providers at all levels, including medical students, resident physicians, and attending physicians, in order to ensure that they have the vaccine confidence and communication skills needed to optimize vaccine uptake among their patients.
Center for Bioethics and Humanities, SUNY Upstate Medical University
Conflicts of Interest. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no conflicts of interest to declare.
The authors wish to thank Drs. Jana Shaw, Rebecca Garden, and Cynthia Morrow for their willingness to discuss this topic during the preparation of this manuscript. Drs. Gregory Eastwood, Karen Teelin, and Anne Sveen, and Reverend Jane Dasher were integral to the student clerkship discussions. The authors also wish to thank the College of Medicine students for their candid and well-written contributions of reflective narrative assignments.