Training Students to Address Vaccine Hesitancy and/or Refusal

Deepti Vyas, PharmD; Suzanne M. Galal, PharmD; Edward L. Rogan, PharmD; Eric G. Boyce, PharmD


Am J Pharm Educ. 2019;82(8):6338 

In This Article

Abstract and Introduction


Objective: To determine the impact of a vaccine hesitancy learning unit on student knowledge, attitudes, and ability to address vaccine hesitancy and/or refusal.

Methods: The learning unit consisted of two standardized patient simulation encounters performed one week apart. A 13-item attitudes survey was administered prior to the simulations to determine student confidence and knowledge regarding vaccine hesitancy. Students then participated in an encounter with a simulated patient who assessed the students' abilities using a 16-item grading rubric related to the art of the rhetoric, communication skills, and social, emotional competence. Post-simulation, students received feedback, completed a self-reflection exercise, and received formal coursework on addressing vaccine hesitancy. The following week, students participated in a second simulated patient encounter and thereafter completed the same attitudes and satisfaction surveys.

Results: There were 203 students who went through the learning unit, with 180 (88.6% response rate) completing all the survey tools. The results showed significant improvements in all 16 items of the assessment rubric. On the pre/post attitudes questions, 9 out of 13 items showed significant improvement. Gains were largest for knowledge on the use of thimerosal as a preservative, speaking about how vaccines will not overwhelm a child's immune system, and knowledge about vaccinations not overwhelming a child's immune system. Overall, 94% of students were satisfied with the learning unit.

Conclusion: This learning unit was effective in improving student confidence and ability to address vaccine hesitancy.


The number of cases of vaccine-preventable diseases in the United States is on the rise. In 2014, there were 644 reported cases of measles, which was three times higher than reports in 2013. In 2010, the state of California reported more than 9000 cases of pertussis, a historic rise in numbers, and the highest since 1947.[1–3] These cases occurred mainly in infants who were not yet vaccinated and therefore relied on herd immunity for protection. Vaccination rates appear to be about 90% for most preventable childhood diseases, but these statistics may mask a subset of communities that may not routinely vaccinate their children or who may have similarly held beliefs regarding the dangers of vaccinations.[1] This subset of communities represent the likely gaps in herd immunity and a source for disease outbreaks. A review of recent outbreaks of vaccine-preventable diseases suggests that US vaccination rates may still be inadequate with large regional variation.[1,4] Another recent study estimated that 2009 immunization rates of children in California ranged from 64% to 92% for measles, mumps, and rubella 1 (MMR1) and from 25% to 58% for MMR2 in typical schools, and from 49% to 90% for MMR1 and from 16% to 63% for MMR2 in schools with high personal belief exemptions for vaccinations – with all these ranges being lower than the herd immunity threshold range of 88% to 95% for MMR.[5] Among adults, the rates of vaccinations are even more alarming with tetanus-diphtheria-acelluar pertussis (Tdap) and pneumococcal (high-risk populations) vaccination rates around 20% of populations that should be immunized.[6] These and other reports provide evidence of a growing number of patients who refuse to get themselves and their children vaccinated due to a belief that vaccines can cause harm.

Study of vaccine refusal among parents and patients reveals a deep-rooted mistrust of medicine and fear that vaccines may cause more harm than good. This subset of the population is either anti-vaccine or vaccine-hesitant.[7–12] The vaccine-hesitant group may under-vaccinate their children or may request delays in the vaccine schedule. Even in cases where they get vaccinations on time, they may have serious doubts about the safety and efficacy of vaccines.[1]

Various factors appear to influence parental vaccine hesitancy, including parent-specific factors (knowledge of vaccines, past experiences, socioeconomic status, education level, and demographics), vaccine-related factors (perceived vaccine efficacy, vaccine safety, and disease susceptibility), and external factors (policies, requirements, norms, media, and patient-provider relationships).[13] Public concerns range from anxiety about vaccines causing autism, vaccines overloading a child's immune system, harmful ingredients in vaccines such as thimerosal and aluminum, to a general mistrust of the health care system. This public misperception needs to be addressed quickly and strategically by public health officials, professional organizations, and individual health care providers.[1] Two recent systematic reviews revealed that while the evidence is low to moderate on the effectiveness of individual strategies to address parental vaccination hesitancy or refusal, an approach employing multiple strategies may be effective.[14,15]

Available strategies include targeting under-vaccinated populations, enhancing awareness and education, improving access, mandating vaccinations or enforcing sanctions for those not vaccinated, and engaging religious and other community leaders in promoting vaccination.[14] On a personal level, educating parents on the impact of childhood diseases may also present a viable strategy for addressing vaccine hesitancy.[16] The Centers for Disease Control and Prevention (CDC) outlined a series of facts designed to counter most common vaccine myths and address likely causes of vaccine hesitancy. This may be a useful tool for providers who need talking points when counseling a parent on vaccine use. However, simply countering vaccine myths may not be effective.[1] It is imperative for vaccine promoters to use a multifaceted strategy for promoting vaccine use.

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. As Aristotle stated, an effective strategy in persuading another individual is to employ the art of rhetoric.[17] The foundation of which is building trust and a sense that the messenger is listening, truly attentive, and credible. The tenets of persuasion require that the individual have an open and credible stance, an emotional connection to their audience, display a command over their content and offer logical argumentation. In the context of vaccine hesitancy, components of the art of persuasion should 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 recognizing and identifying the patient's concerns and then using strategies that would target those specific concerns. This technique could avoid information overload and focus the conversation between the patient and provider.[18] For vaccine-hesitant parents, the third and last 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, unparalleled to any statistical data or regulatory strategies.

Pharmacists play an important role in educating patients, dispensing, and administering immunizations and are central to promoting this public health measure. It is important to educate pharmacists to recognize and respond to vaccine hesitancy. Like medication adherence, convincing patients of the importance of vaccinating themselves and their children requires good communication skills and the use of individualized strategies that target the root of that patient's hesitancy. However, even with optimal communication strategies, some patients/parents may remain unconvinced. Pharmacists must focus on maintaining the patient-provider relationship despite disagreement. The inclusion of these vital humanistic communication strategies along with the clinical aspects of immunizations is imperative for the pharmacy curriculum. The 2016 ACPE Standards support this by stating that the graduating pharmacist should be a patient advocate, understand and respect a patient's health beliefs, and promote population-based health.[19]

Traditional pharmacy education regarding vaccines has been based on providing clinical information about vaccines and the proper administration technique. The authors are not aware of any published research in pharmacy education that describes the development and assessment of student ability to understand and apply strategies to address vaccine hesitancy and refusal. The only reference found was an abstract in the nursing education literature.[20] This paper describes a two-week learning unit that focused on teaching pharmacy students the art of persuasion (rhetoric) as related to vaccine hesitancy. The objective of this study is to determine the impact of this learning unit on student knowledge, attitudes, perceptions, and the ability to address vaccine hesitancy and refusal.