Simulated Encounters With Vaccine-Hesitant Parents: Arts-Based Video Scenario and a Writing Exercise

"...understanding the perspectives of the people for whom immunization services are intended is essential in forming a meaningful dialogue with them..."

As poor doctor-patient communication is considered one of the factors contributing to the rejection of vaccines, the Strategic Advisory Group of Experts (SAGE) Working Group for Vaccine Hesitancy calls for appropriate training for medical and health care students concerning encounters with vaccine-hesitant individuals. However, during pre-clinical training, the vaccine-hesitant parents are typically represented through impersonal text-based cases, lists of their concerns, and sometimes a virtual patient. However, in reality, vaccine-hesitant parents have many health beliefs and arguments that are accompanied with intense emotions. To that end, this study is an experimental pilot test in stimulating medical students' understanding of, and ability to respond to, vaccine-hesitant parents' beliefs and questions. An arts-based video scenario and a writing exercise are used to demonstrate a rich narrative case by realistically portraying the complexity of patient presentation and interaction, stimulating the students' holistic awareness of vaccine hesitancy.

In the intervention described in this article, the purpose is to demonstrate the complexity of a situation that may appear unrealistically simple as a written case. The video case connects to the views of medical humanities and narrative medicine, building on aspects of Bakhtin's dialogic theory and challenging the monologic and linear qualities in narratives currently produced in medical practice and education. As part of the video-making process, one of the authors interviewed 9 vaccine-critical parents in the Netherlands and Finland in 2015 and 2016. The parents were mothers and fathers of all levels of hesitancy - from delay or selection to total refusal. Each parent was invited to pose a question about immunisation to a medical student and donate home video footage of their children for the film. "The purpose was not only to create a video that simulates clinical encounters but also to appreciate the parents as whole persons and learn about their particular health beliefs as a necessary foundation to encounter them meaningfully in the future. Furthermore, the video's purpose was not to arm the students with convincing counterarguments against the parents' beliefs. The video intentionally digs deeper into such beliefs by visualizing and deconstructing them, considering that only by gaining understanding of these and tolerance for the emotions that they raise, can the students begin to think of constructive communication strategies."

The film is trilingual (English, Dutch, Finnish), allowing the parents to speak in their native language, and is subtitled in English. It has 3 main parts: the parents' everyday lives; health care encounters, based on the parents' actual experiences; and parents' beliefs explored through diagrammatic visualisations and an artist-scientist dialogue with senior scientist Johan Holst from the Norwegian Institute of Public Health. As outlined in the article, the video supports learning about vaccine hesitancy in the following ways:

• Stimulating students to take the case seriously by the presence of authentic vaccine-hesitant parents;
• Introducing a variety of health beliefs and arguments supporting vaccine hesitancy;
• Demonstrating (reasons for) failed vaccine-hesitancy encounters in health care;
• Presenting a non-linear and ethically complex case that cannot be solved with only strict medical information; and
• Role-modeling a vaccine professional who is reflexive and does not show frustration.

For the intervention, 1 third-year medical student problem-based learning (PBL) tutor group (female = 3, male = 6), tutored by one of this paper's authors, was recruited for this experimental pilot study. The video described above, Conversations with Vaccine-Critical Parents, was viewed in 2 parts (9 and 7 minutes), during 2 different PBL sessions. The structured group discussions (45 and 30 minutes) were conducted accordingly during 2 separate PBL sessions on August 22 and 26, 2016. The tutorial discussions were structured with open-ended questions. These included identifying reasons for vaccine hesitancy the video included (and excluded), as well as the types of information and health care relationships the parents were currently lacking. In addition, the discussion invited the students to share their personal attitudes towards vaccine hesitancy. The discussions were audio-recorded and transcribed verbatim.

The writing exercise, whose central aim was to activate the student to explore aspects of their existing attitudes and communication and to reflect how these may affect their encounters with vaccine-hesitant parents, was to be completed at home between the 2 in-person sessions. In this exercise, the students were invited to answer 7 of the parents' questions presented in the video, playing the role of a physician. The questions include: (i) Why does my baby need tetanus and hepatitis B vaccines? (ii) What is so serious about a mumps? (iii) Why does my baby get so many vaccines at one time? In real life, you never get 5 diseases at the same time. (iv) Doesn't my child have the right to go through children's infectious diseases? These support mental and physical development. (v) Do I have to fight a war against my own body to save others? (vi) I want to live as natural life as possible. How does "natural" relate to vaccination? (vii) Is the purpose of life, according to medicine, to live as long as possible? The students had 3 days to complete the exercise, and they were free to search the literature if they felt answering the questions required doing so. As part of the intervention evaluation, the study compares these individual answers with the themes that emerged in the group discussions.

The results of the group discussions, which involved making sense of vaccine hesitancy with peers, are shared. Very briefly, it was found that the group discussion seems to function as a "hospital breakroom", in which the physicians can momentarily drop the professional role and share their thoughts and experiences as a "whole person". Aside from their emotional reactions towards the non-compliant parents, the group discussions revealed that some students have doubts about the necessity of certain vaccines, about how the governmental decides which vaccines are made, and about the role of the pharmaceutical industry. Thus, such students share concerns with the vaccine-hesitant parents and may not be able to gain the parents' trust due to their own ambivalence about certain aspects of vaccines.

Most students respond differently to vaccine hesitancy in the classroom than in their written homework. The writing exercise, which was a simulated encounter with a vaccine-hesitant parent, unveiled 3 main modes of communication in the students' answers: (i) addressing the parent and child as persons: talking in second person, acknowledging the parents' rhetoric, asking counter questions, and involving self-disclosure; (ii) delivering impersonal medical information in a passive voice; and (iii) answering with sarcasm and disrespecting the parent. According to the criteria used in this study, which is the engagement in a humane "I-You" health care dialogue and the acknowledgement of parents' concerns, 3 out of the 9 students failed. They either ignored the patient as a whole person or their own professional role, or both.

After completing the study sessions, the students were invited to share their experiences on this pilot. Several noted that the involvement of the actual vaccine-hesitant parents in the video case made the situation more authentic and made them realise they are likely to encounter similar parents in the future. When asked how they had experienced the writing exercise, a few students spoke about specifically having imagined being a physician and restraining from expressing frustration or from using professional jargon. This had caused them think how to formulate their answers, even though they know that "naturalness", for instance, is an important issue for the parents.

As the study surprisingly identifies some gaps in students' confidence in vaccines, the authors will include these findings in the discussion about the prevention curriculum development. In addition, they plan to conduct a more in-depth study with larger sample size and control groups.

In conclusion: "There are no easy answers to the challenge that vaccine hesitancy presents to the medical education at all levels. It is important to provide the students with opportunities to encounter opinions that they might experience as intellectually dissatisfying and harmful to the patient and the society. The students should have diverse possibilities to practice dialogue in such instances knowing that the results might more often than not be disappointing. This study aims to offer one alternative for that purpose."