{"id":72024,"date":"2023-03-20T08:37:07","date_gmt":"2023-03-20T00:37:07","guid":{"rendered":"https:\/\/medicine.nus.edu.sg\/taps\/?post_type=issues&#038;p=72024"},"modified":"2023-07-04T09:09:11","modified_gmt":"2023-07-04T01:09:11","slug":"qualitative-analysis-of-reflective-writing-examines-medical-student-learning-about-vaccine-hesitancy","status":"publish","type":"issues","link":"https:\/\/medicine.nus.edu.sg\/taps\/issues\/qualitative-analysis-of-reflective-writing-examines-medical-student-learning-about-vaccine-hesitancy\/","title":{"rendered":"Qualitative analysis of reflective writing examines medical student learning about vaccine hesitancy"},"content":{"rendered":"<p>Submitted: 1 August 2022<br \/>\r\nAccepted: 1 November 2022<br \/>\r\nPublished online: 4 April, TAPS 2023, 8(2), 36-46<br \/>\r\n<a href=\"https:\/\/doi.org\/10.29060\/TAPS.2023-8-2\/OA2855\">https:\/\/doi.org\/10.29060\/TAPS.2023-8-2\/OA2855<\/a><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Marina C. Jenkins<sup>1<\/sup>, Caroline R. Paul<sup>2<\/sup>, Shobhina Chheda<sup>1<\/sup> &amp; Janice L. Hanson<sup>3<\/sup><\/span><sup><span lang=\"EN-GB\"><\/span><\/sup><\/p>\r\n<p style=\"text-align: justify;\"><i><sup><span lang=\"EN-GB\">1<\/span><\/sup><\/i><i><span lang=\"EN-GB\">School of Medicine and Public Health<\/span><\/i><i><span lang=\"EN-GB\">, University of Wisconsin-Madison, United States; <sup>2<\/sup>Langone Health, Grossman School of Medicine, New York University, United States; <sup>3<\/sup>School of Medicine, Washington University in St. Louis, United States<\/span><\/i><\/p>\r\n<p style=\"text-align: center;\"><b><span lang=\"EN-GB\">Abstract <\/span><\/b><\/p>\r\n<p style=\"text-align: justify;\"><b><span lang=\"EN-GB\">Introduction:<\/span><\/b><span lang=\"EN-GB\"> Increases in vaccine hesitancy continue to threaten the landscape of public health. Literature provides recommendations for vaccine communication and highlights the importance of patient trust, yet few studies have examined medical student perspectives on vaccine hesitancy in clinical settings. Therefore, we aimed to explore medical student experiences encountering vaccine hesitancy, mistrust, and personal biases, with the goal of informing medical student education. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><b><span lang=\"EN-GB\">Methods:<\/span><\/b><span lang=\"EN-GB\"> A health disparities course including simulated clinical scenarios required students to complete a written reflection. We sorted reflections written in 2014-2016 to identify common topics and used inductive thematic analysis to identify themes relevant to vaccine hesitancy by group consensus. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><b><span lang=\"EN-GB\">Results:<\/span><\/b><span lang=\"EN-GB\"> Our sample included 84 de-identified essays sorted into three non-exclusive topics: vaccine hesitancy (n=42), mistrust (n=34), and personal bias (n=39). We identified four themes within medical students\u2019 reflections: 1) Building a Relationship, including emphasis on patient-centred approaches; 2) Preparedness and Need to Prepare for Future Encounters, including highlighting gaps in medical education; 3) Reactions to Encountering Hesitant Patients, including frustration; 4) Insights for Providing Information and Developing a Plan with Hesitant Patients, including approaches to presenting knowledge.\u00a0 <\/span><\/p>\r\n<p style=\"text-align: justify;\"><b><span lang=\"EN-GB\">Conclusion:<\/span><\/b><span lang=\"EN-GB\"> Reflections in the context of simulated encounters and discussion are useful in students identifying their preparedness for vaccine discussion with patients. Student reflections can assist educators in identifying missing educational frameworks for particular scenarios such as vaccine hesitancy. Without a structured framework regarding addressing vaccine hesitancy, students draw upon other skills that may contradict recommended practices.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><b><span lang=\"EN-GB\">Keywords<\/span><\/b><b><span lang=\"EN-GB\">:<\/span><\/b><span lang=\"EN-GB\">\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span><i><span lang=\"EN-GB\">Medical Education, Vaccine Hesitancy, Reflective Writing, Bias, Mistrust<\/span><\/i><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">Practice Highlights<\/span><\/strong><\/p>\r\n<ul>\r\n\t<li style=\"text-align: justify;\"><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">Reflective writing <\/span><span lang=\"EN-GB\">can be a useful tool in medical education toward addressing vaccine hesitancy.<\/span><span lang=\"EN-GB\"><\/span><\/li>\r\n\t<li style=\"text-align: justify;\"><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">Medical student reflective writing can be used to demonstrate curricular gaps.<\/span><\/li>\r\n\t<li style=\"text-align: justify;\"><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">Medical students expressed feeling unprepared to care for vaccine hesitant patients.<\/span><\/li>\r\n\t<li style=\"text-align: justify;\"><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">Without a framework for vaccine communication, students may draw on other inappropriate skills.<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: center;\"><span lang=\"EN-GB\"><\/span><strong><span lang=\"EN-GB\">I. INTRODUCTION<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Increases in vaccine hesitancy and refusal threaten public health (He et al., 2022; Hough-Telford et al., 2016; Kempe et al., 2020; Santibanez et al., 2020), especially with the COVID-19 pandemic introducing a need for quick and widespread uptake of a new vaccine (Hamel et al., 2022; Ognyanova et al., 2022). Patients, especially parents, are increasingly seeking alternative forms of health information, such as online sources that can include misinformation (Broniatowski et al., 2018; Hara &amp; Sanfilippo, 2016; Jenkins &amp; Moreno, 2020; Meleo-Erwin et al., 2017). Patient trust in their clinician and the health care system delivering the vaccine strongly influence vaccination decisions (Goldenberg, 2016; Kennedy et al., 2011; Larson, 2016). Trust remains the most important barrier to acceptance and uptake of the COVID-19 vaccine, with mistrust of government, medicine, and science presenting major barriers to vaccine uptake (Ognyanova et al., 2022). Vaccine hesitant patients may bring preconceptions and concerns from their own research to in-clinic vaccine communication. Thus, it is important for clinicians to be well-prepared to work with vaccine-hesitant patients and parents.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Existing recommendations for clinicians encountering vaccine hesitancy emphasise centring patient views and voice instead of a medical, academic perspective (Holt et al., 2016; Koski et al., 2019). Approaches including motivational interviewing, presumptive language around vaccine recommendations, and persistent vaccine reminders without pressuring or dismissing patients have been shown to be effective in addressing vaccine hesitancy in medical practice (Dempsey et al., 2018; Gagneur et al., 2018; Hofstetter et al., 2017), while correcting misinformation and offering evidence to patients have been found to be counterproductive (Holt et al., 2016; Koski et al., 2019). These pre-COVID recommendations remain the same for addressing COVID-19 vaccine hesitancy, and lack of physician preparedness for encountering these patients is still an important issue (Centres for Disease Control and Prevention, 2021). Physicians may have misconceptions about patients\u2019 reasons for vaccine hesitancy, often assuming lack of understanding or information on the safety, effectiveness, and necessity of vaccines (Hough-Telford et al., 2016), rather than recognising the more central roles of trust and validation of concerns. If physicians do not learn approaches for centring patient voices in vaccine communication, these pre-conceived biases may present a barrier to vaccine uptake and patient-physician trust. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">While valuable recommendations for addressing vaccine hesitancy in the clinical setting exist, current efforts center around informing practicing clinicians on these approaches and providing more educational resources to patients (Centres for Disease Control and Prevention, 2021). These may not represent a sufficient, long-term solution. Furthermore, resources available for healthcare workers may be inaccessible or overwhelming for physicians independently seeking tools (Karras et al., 2019). Incorporating vaccine hesitancy-centred curriculum into medical education may be the optimal, long-term solution to the lack of physician preparedness for these encounters, especially in the face of future pandemics and introduction of new vaccines. With curriculum renewal efforts incorporating early clinical experiences, students could encounter patients for whom vaccines are recommended, including vaccine hesitant patients, early in medical school. It would provide a better educational experience for students and a better health care experience for patients if students receive education to prepare them for these conversations. However, few studies have examined medical student perspectives on vaccine hesitancy in the clinical setting. Existing studies have found mixed findings around medical students\u2019 reflections on their preparedness for encountering vaccine hesitant patients and highlight the need for expansion of related curriculum in medical education (Brown et al., 2017; Kern\u00e9is et al., 2017). While COVID vaccine hesitancy literature lacks exploration of medical student perspectives and preparedness, recent studies have highlighted an additional barrier of vaccine hesitancy among medical students in some settings (Lucia et al., 2021). These findings provide additional motivation for including vaccine hesitancy-specific curriculum in medical education. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Understanding medical students\u2019 reactions to vaccine hesitancy is critical in preparing students to address vaccine hesitancy while maintaining patient trust. In the present study, which used a scholarship-of-teaching approach, we aimed to expand on existing research on medical student preparedness for encountering vaccine hesitancy to examine written reflections on mistrust and personal bias in clinical encounters more broadly and use a larger sample of student narratives. We analysed students\u2019 structured reflections regarding assigned reading, simulated patient encounters, peer discussions, and faculty-facilitated discussions to evaluate medical students\u2019 learning during a health disparities curriculum. Structured reflection on simulated encounters has been shown to be a useful tool for understanding student perspectives (Koski et al., 2018); this approach can inform development of medical curriculum for addressing vaccine hesitancy and may be a useful teaching tool as well for students to practice, discuss, and reflect on their own biases in an educational setting. Therefore, the purpose of this study was to explore medical student reflections on encountering vaccine hesitancy, patient mistrust, and personal biases, with the goal of informing medical student education.<\/span><\/p>\r\n<p style=\"text-align: center;\"><span lang=\"EN-GB\"><\/span><strong><span lang=\"EN-GB\">II. METHODS<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">In this qualitative study, we analysed written reflections from a third-year medical student Skills to Impact Health Disparities course, to evaluate their learning about interacting with vaccine-hesitant patients and parents. This study was determined to be exempt by the relevant institutional review boards, including a waiver of informed consent.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">From 2006-2018, a medical school at a U.S., Midwestern university required a one-day core session with the goal of developing learner skills to impact health disparities. Small groups of approximately six students went through five to six standardized patient scenarios, each designed to generate discussion and reflection about clinician bias that can unintentionally influence patient care. During the learning activity, each student spent 3-5 minutes interacting with a standardized patient who presented a challenge designed to provoke a level of discomfort in the learners to allow for discussion and reflection. One of these six scenarios included a parent with a history of vaccine refusal for their child expressing concerns about a recommended vaccine. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Following each case, students engaged in a 15-minute, non-facilitated discussion based on a list of focused questions. After all cases, students joined another group of six students for a 75-minute faculty-facilitated debrief. In addition, students were required to complete a brief critical reflection based on a theme of the core day activity using the LeAP framework (Aronson et al., 2012). This framework is modelled on a clinical framework, the SOAP note (Chief complaint, Subjective, Objective, Assessment, and Plan). Students were asked to consider a specific experience that led to concern or questions; describe the experience as fully as possible; reconsider the experience by getting other perspectives; synthesize learning; and make a plan to address future similar challenges. Students could choose to reflect on simulated or real clinical experiences. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Written reflective essays were available for analysis from years 2014-2016, providing qualitative data about students&#8217; observations and experiences with health disparities and health equity. All available essays (n=292) from 2014, 2015, and 2016 that were submitted as a course requirement for the Skills to Impact Health Disparities Core Day required course were de-identified and organized by year. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">To ascertain the topics that the students addressed, three investigators (two involved in this study and one from another study using the larger set of all essays) read all essays. Each investigator then designated each essay to a topic from a jointly-developed list of non-exclusive topics derived from the data. After individually assigning topics for a sample of essays, the investigators met to compare their sorting and reconcile any differences before they went on to sort through another set of essays. This process continued until all essays were assigned to one or more topics. Most topic labels matched topics of the simulated scenarios that the students encountered in the course, while others related to broader issues highlighted across scenarios. With the goal of selecting reflections relevant to the issue of vaccine hesitancy, all reflections designated under the topics of vaccine hesitancy, mistrust, and personal bias were gathered for qualitative data analysis. Literature review and initial reading of essays suggested essays on encountering mistrust and bias relate to students\u2019 experiences when encountering vaccine hesitant patients, despite not all essays relating directly to vaccine hesitancy. Each essay was assigned an identifier with cohort year and an essay number. Individual essays were excluded based on group consensus on lack of relevance to vaccine hesitancy. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Inductive thematic analysis was used to identify codes and themes in the reflection data using a semantic, realist approach to identify explicit reactions from students grounded in clinical experiences to identify themes that could be directly applied to clinical practice (Braun &amp; Clarke, 2006). Four investigators, including two involved in topic assignment (CRP, SC) and two additional investigators (MCJ, JLH), read and discussed six essays to develop a preliminary codebook, applied these codes to the same six essays, then met to discuss and revise the codebook. Subsequently, investigators coded the remaining essays in pairs using the revised codebook through four rounds of coding, making further iterative changes to the codebook and reconciling differences within pairs. The full team then met to discuss the coding, revise code descriptions, refine the grouping of the codes, and agree on descriptions of the groups. Any changes made to the codebook during the analysis process were retrospectively updated in all previous coding, so that all coding data reflected the final version of the codebook. Data were organized with qualitative analysis software (HyperResearch version 4.5.4). After all data were coded, investigators discussed and reached consensus on the themes.<\/span><\/p>\r\n<p style=\"text-align: center;\"><span lang=\"EN-GB\"><\/span><strong><span lang=\"EN-GB\">III. RESULTS<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">A total of 90 reflections were collected from the Skills to Impact Health Disparities course across three cohorts of third-year medical students from 2014-2016 at one U.S., Midwestern university. Based on investigator consensus on lack of content relevance, six reflections were excluded from our study sample. Our final study sample included 84 de-identified reflections across three, non-exclusive topics: 42 categorized as relating to vaccine hesitancy, 34 as mistrust, and 39 as personal bias. We identified four major themes in medical students\u2019 reflections on encountering vaccine hesitancy, mistrust and personal bias: 1) Building a Relationship, 2) Preparedness and Need to Prepare for Future Encounters, 3) Reactions to Encountering Hesitant Patients, and 4) Insights for Providing Information and Developing a Plan with Hesitant Patients. Representative quotes for each theme can be found in Table 1. Supplemental Table 1 lists each theme with the codes that informed the theme.<\/span><\/p>\r\n<p><i><span lang=\"EN-GB\">A. Building a Relationship<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">In our first theme, medical students recognized the importance of Building a Relationship with hesitant parents or patients as the foundation for discussions about vaccines or other care about which patients expressed hesitance. They focused on approaches such as building rapport, centring the parent\/patient\u2019s views during the discussion, acknowledging their efforts to gather information about their health decisions, expressing empathy, and avoiding direct confrontation of the patient\u2019s viewpoint during the discussion. Many of these observations occurred during the core day experience. For example, one student wrote: <\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-GB\">\u201cI learned the importance of letting the patient try to teach the doctor what they know rather than the doctor jumping in and lecturing to the patient. In the future I will try to talk less and let the patient explain more about why they oppose vaccinations to better gauge what they understand about the literature before I try to explain why vaccinations are important and the facts about vaccinations.\u201d <\/span><\/p>\r\n<p align=\"right\" style=\"text-align: right;\"><span lang=\"EN-GB\">[Year3_61]<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">The students saw the importance of finding points of commonality between their perspectives and those of the patient and moving the conversation toward establishing goals that they could work together with the patient to accomplish. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">One student described, \u201cI learned that a big part of approaching this difficult conversation is establishing the correct approach: common goal, shared decision making.\u201d <\/span><\/p>\r\n<p align=\"right\" style=\"text-align: right;\"><span lang=\"EN-GB\">[Year3_65]<\/span><\/p>\r\n<p><i><span lang=\"EN-GB\">B. Preparedness and Need to Prepare for Future Encounters<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Another major theme identified in medical student reflections on encountering hesitant patients was Preparedness and Need to Prepare for Future Encounters. This theme included discussion of whether the student expressed feeling ready for the encounter or whether they thought it was successful, as well as specific plans for preparing for similar encounters in the future. One way that students discussed their own feelings of preparedness was by recognizing their own biases upon reflection of the encounter. For example, one student wrote:<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">\u201cI realized my own prejudices influenced my care of my patients more than I would have liked. \u2026 It was an eye opener that I am not as impartial as I would like to be and that it takes a lot more self-reflection and awareness to be the best care provider I can be.<\/span><\/p>\r\n<p align=\"right\" style=\"text-align: right;\"><span lang=\"EN-GB\">[Year3_16]<\/span><span lang=\"EN-GB\">\u00a0<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">When discussing a need to prepare for future encounters, many students referenced plans to independently seek additional resources, especially those referenced by patients in encounters. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Other students mentioned plans to practice patient interactions related to the reflection encounter; including, \u201cFor me, practicing acknowledging a patient\u2019s views and concerns without endorsing or validating false information is paramount.\u201d <\/span><\/p>\r\n<p align=\"right\" style=\"text-align: right;\"><span lang=\"EN-GB\">[Year1_07]<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Some students also referenced plans to request feedback or advice from more senior clinicians. Additionally, several students identified gaps in their medical school curriculum that contributed to their lack of preparedness or that needed to be filled to support future preparedness. Students specifically referred to needing more resources, support, and training for encountering hesitant patients. They sometimes called for system-wide changes to address this gap in knowledge. <\/span><\/p>\r\n<p><i><span lang=\"EN-GB\">C. Reactions to Encountering Hesitant Patients<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">One of the themes identified in the students\u2019 self-reflection was related to their own and others\u2019 Reactions to Encountering Hesitant Patients. While some students expressed frustration with patients\/parents who expressed hesitance about vaccines, they acknowledged that they can be passionate about the topic of vaccines in their patient care, but ultimately, patients and parents make their own decisions. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">One student shared, \u201cI have always found it quite distressing when an otherwise healthy child goes unvaccinated, given the enormous amount of evidence in favour of vaccination efficacy and its effect on public health.\u201d <\/span><\/p>\r\n<p align=\"right\" style=\"text-align: right;\"><span lang=\"EN-GB\">[Year2_86] <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Another student shared, \u201cI knew I could not force the patient, and I knew that she ultimately was in control of what she would do.\u201d <\/span><\/p>\r\n<p align=\"right\" style=\"text-align: right;\"><span lang=\"EN-GB\">[Year3_78]<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">In some reflections patient and parents were labelled, for example, as \u201canti-vaxxers.\u201d Some reflections described parents\u2019 and patients\u2019 bias towards the physician or clear messaging of a desire for a different doctor.\u00a0 In encountering standardized patients in our scenarios or in reflecting on patients seen in clinical settings, students acknowledged that these conversations were difficult, and they were able to self-assess their level of comfort with conversations. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">This was well-summarized in one reflection: \u201cIt was remarkable to me how such a strong reaction from this patient\u2019s mother elicited an equally strong reaction in me.\u201d<\/span><\/p>\r\n<p align=\"right\" style=\"text-align: right;\"><span lang=\"EN-GB\">[Year2_34] <\/span><\/p>\r\n<p><span lang=\"EN-GB\">\u00a0<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">At times students recognized a point where these difficult conversations could reach a dead end. One student stated, \u201cNo matter how hard I would try, nothing seemed to work.\u201d <\/span><\/p>\r\n<p align=\"right\" style=\"text-align: right;\"><span lang=\"EN-GB\">[Year2_03] <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Especially in this context, students reflected ambivalence towards the patient\u2019s decision. For example: <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">\u201cI personally feel that providers allowing for healthy children on their patient panels to remain unvaccinated indirectly reinforces non-vaccination as being acceptable by the medical establishment. That said, I also see and appreciate that turning a child away from one\u2019s practice because their parents refuse to vaccinate them not only does not solve the problem at hand, but it also leaves a child at a very critical developmental age with no health care at all until an alternative provider can be found. Ultimately, I found attempting to reconcile these seemingly incompatible sides of the issue of dealing with anti-vaccination quite confusing and uncomfortable.\u201d <\/span><\/p>\r\n<p align=\"right\" style=\"text-align: right;\"><span lang=\"EN-GB\">[Year2_86]<\/span><\/p>\r\n<p><i><span lang=\"EN-GB\">D. Insights for Providing Information and Developing a Plan with Hesitant Patients<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">A fourth theme centred on students\u2019 insights regarding how to provide information appropriately to patients and how to create a plan with patients who were hesitant regarding the medical recommendations given to them. Medical students suggested a variety of ways to provide information to patients who were hesitant. They noted the importance of contributing relevant facts and evidence, stressing that such information and knowledge in general needed to be presented in an understandable manner. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">As one student described, \u201cFinding the appropriate words to use in such conversations with a patient is essential.\u201d <\/span><\/p>\r\n<p align=\"right\" style=\"text-align: right;\"><span lang=\"EN-GB\">[Year1_44] <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Students often wrote that they needed to provide reputable information to inform the patient\u2019s decision-making. Some suggested strategies for how to present information to patients, including the sharing of stories and the use of scary information to convey the level of seriousness of the medical recommendation and advice. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">One student referenced storytelling in the literature, \u201c\u2026the use of storytelling, the same method used by the anti-vaccination movement, [can be] a way to counteract the barrage of misinformation regarding vaccines.\u201d <\/span><\/p>\r\n<p align=\"right\" style=\"text-align: right;\"><span lang=\"EN-GB\">[Year1_90]<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Sharing these insights about how to present information, students also moved towards how to develop a plan with their patients with some deliberate suggestions. Some students felt they needed to be persistent in their recommendations for vaccines. Some students explained how intentional discussions on the risks and benefits of their recommendations can help in their negotiation about a care plan with their patients. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">One student noted, \u201cThis draws along the line of patient autonomy, and as long as we are clear about the risks and benefits with the patient, then ultimately, it&#8217;s up to the patient to make the decision about which medications she will take.\u201d<\/span><\/p>\r\n<p style=\"text-align: right;\"><span lang=\"EN-GB\">[Year1_52]<\/span><\/p>\r\n<div align=\"center\">\r\n<table border=\"0\" cellspacing=\"0\" cellpadding=\"0\" style=\"width: 98.3392%;\">\r\n<tbody>\r\n<tr>\r\n<td width=\"954\" colspan=\"2\" valign=\"top\" style=\"width: 102.615%;\">\r\n<p><b><span lang=\"EN-US\">Medical Students\u2019 Experiences with Vaccine Hesitancy, Mistrust, and Bias<\/span><\/b><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"396\" valign=\"top\" style=\"width: 41.5272%;\">\r\n<p><b><span lang=\"EN-US\">Themes <\/span><\/b><\/p>\r\n<\/td>\r\n<td width=\"558\" valign=\"top\" style=\"width: 61.0879%;\">\r\n<p><b><span lang=\"EN-US\">Exemplar Quotes<\/span><\/b><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"396\" valign=\"top\" style=\"width: 41.5272%;\">\r\n<p><b><span lang=\"EN-US\">Building a relationship<\/span><\/b><\/p>\r\n<\/td>\r\n<td width=\"558\" valign=\"top\" style=\"width: 61.0879%;\">\r\n<p><span lang=\"EN-US\">\u201c<i>I felt it was most important that I listen to his story as much as I possibly could, before I spoke. So I let him talk. I said, \u2018tell me your concerns.\u2019\u201d [Year3_18]<\/i><\/span><\/p>\r\n<p><i><span lang=\"EN-US\">\u201cMy feelings during this situation were somewhat of frustration but more of just desire for the patient to feel as though I was there to care for her child above all else and to come alongside her rather than combat with her.\u201d [Year3_03]<\/span><\/i><\/p>\r\n<p><i><span lang=\"EN-US\">\u201cOne suggestion that my classmate said was to start out the conversation by validating how they are feeling more and that you understand that they are a good parent rather than jumping into facts about vaccinations which caused the patient to become defensive.\u201d [Year3_61]<\/span><\/i><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"396\" valign=\"top\" style=\"width: 41.5272%;\">\r\n<p><b><span lang=\"EN-US\">Preparedness and need to prepare for future encounters<\/span><\/b><\/p>\r\n<p><span lang=\"EN-US\">\u00a0<\/span><\/p>\r\n<\/td>\r\n<td width=\"558\" valign=\"top\" style=\"width: 61.0879%;\">\r\n<p><i><span lang=\"EN-US\">\u201cI need more tools for dealing with these situations in the future.\u201d [Year1_04]<\/span><\/i><\/p>\r\n<p><i><span lang=\"EN-US\">\u201cMy plan is to educate myself more on the materials available for parents regarding immunizations.\u201d [Year3_03]<\/span><\/i><\/p>\r\n<p><i><span lang=\"EN-US\">\u201cUltimately it would be nice to see EMRs advance to the point where they can track a patient&#8217;s problem, not just on a list, but through stages of management and onto completion, with a provider responsible for follow-up.\u201d\u00a0 [Year2_33]<\/span><\/i><\/p>\r\n<p><i><span lang=\"EN-US\">\u201cI will seek feedback from my attendings and residents so that I can improve my motivational interviewing skills.\u201d [Year3_81]<\/span><\/i><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"396\" valign=\"top\" style=\"width: 41.5272%;\">\r\n<p><b><span lang=\"EN-US\">Reactions to encounter-ing hesitant patients<\/span><\/b><\/p>\r\n<\/td>\r\n<td width=\"558\" valign=\"top\" style=\"width: 61.0879%;\">\r\n<p><i><span lang=\"EN-US\">\u201c<\/span><\/i><i><span lang=\"EN-GB\">Ultimately this is a decision of the parent and I can only offer my professional advice\u2026I learned that this topic did elicit some emotion which I was surprised about.\u201d<\/span><\/i><span lang=\"EN-GB\"> <i>[Year3_79]<\/i><\/span><\/p>\r\n<p><i><span lang=\"EN-US\">\u201cI learned that I need to work on my bluntness (what I consider to be honesty), as well as increasing affirmation of patients\u2019 fears, since telling someone they are wrong (in any facet of life) typically doesn\u2019t work out that well.\u201d [Year2_34]<\/span><\/i><\/p>\r\n<p><i><span lang=\"EN-US\">\u201cI felt uncomfortable and offended at times during the conversation. The patient clearly was not interested in negotiating vaccination, and when I tried to discuss the validity of some of the studies and articles she had read, she became very defensive.\u201d [Year2_82]<\/span><\/i><\/p>\r\n<p><i><span lang=\"EN-US\">\u201cI dealt with a mother who had embraced the anti-vaccination movement. This is an issue that I have thought about a lot but despite my reflections, it is an issue that I do not know how to address well. This filled me with fear because I honestly didn\u2019t know what the best approach was.\u201d [Year1_90]<\/span><\/i><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"396\" valign=\"top\" style=\"width: 41.5272%;\">\r\n<p><b><span lang=\"EN-US\">Insights for providing information and creating a plan with hesitant patients<\/span><\/b><\/p>\r\n<p><span lang=\"EN-US\">\u00a0<\/span><\/p>\r\n<\/td>\r\n<td width=\"558\" valign=\"top\" style=\"width: 61.0879%;\">\r\n<p><i><span lang=\"EN-US\">\u201cFrom the debriefing session I learned that a promising approach for the anti-vaccine population is to continue to offer the vaccines at each well-child check-up without intensive counsel on the risks\/benefits of vaccines.\u201d [Year1_13]\u00a0\u00a0\u00a0\u00a0 <\/span><\/i><\/p>\r\n<p><i><span lang=\"EN-US\">\u201cI also learned about using pictures to get a visceral response from the parent which hopefully would change their mind about not getting a vaccine.\u201d [Year3_69]<\/span><\/i><\/p>\r\n<p><i><span lang=\"EN-US\">\u201cWhen I encounter this scenario in the future, as I&#8217;m sure I will, I will begin by teasing out whether the patient is interested in more information, in which case I can have resources and studies available, or if they have already made up their mind and at that point I need to negotiate the visit to ensure that they continue to see me for whatever care they are willing to receive, even if that doesn&#8217;t include all the preventive measures I would like.\u201d [Year2_82]<\/span><\/i><\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<p align=\"center\"><span lang=\"EN-GB\">Table 1. Medical students\u2019 experiences with vaccine hesitancy, mistrust, and bias\u2014Themes and exemplar quotes<\/span><\/p>\r\n<p style=\"text-align: center;\"><span lang=\"EN-GB\"><\/span><strong><span lang=\"EN-GB\">IV. DISCUSSION<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">In this qualitative study of a curricular activity designed to build medical students\u2019 skills for interacting with patients toward reducing health disparities, we explored medical student reflections on real and simulated patient care encounters related to vaccine hesitancy, mistrust and personal bias, with the overall goal of informing medical student education. This allowed for evaluation of the utility of this curriculum framework, as well as highlighting gaps in medical curriculum around addressing vaccine hesitancy. Our analysis supports that medical student reflections across the areas of vaccine hesitancy, mistrust and personal bias share thematic structure and implications for informing medical curriculum regarding encounters with patients who resist medical advice, as well as recommendations for teaching approaches to communication with patients and parents who express hesitancy about vaccines.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">This study highlights the benefits of reflections on simulated clinical encounters in the context of a Skills to Impact Health Disparities course. Reflections in the context of simulated encounters and discussion were successful in encouraging students assess their preparedness for vaccine discussions with patients. Review of written reflections, like those analysed in this study, can assist educators in identifying missing educational frameworks for particular patient care scenarios such as vaccine hesitancy. While efforts are growing to incorporate vaccine hesitancy information into medical curricula, especially now, in response to the COVID-19 pandemic (Kelekar et al., 2022; Onello et al., 2020; Real et al., 2017; Schnaith et al., 2018), there is little focus on recommending or evaluating these efforts on a large scale in the U.S. However, recent efforts to establish innovative curriculum of this kind have shown it to be feasible and effective for improving medical student preparedness in addressing vaccine hesitancy (Kelekar et al., 2022; Onello et al., 2020; Real et al., 2017; Schnaith et al., 2018). The curriculum structure assessed in this study may offer a strong approach to teach students valuable lessons related to vaccine hesitancy and evaluate existing progress in this area.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Findings from this study also highlight gaps in existing medical curriculum for preparing students to encounter hesitant patients. We found that without a structured and deliberate learning framework for addressing vaccine hesitancy, students will draw upon other skills that may not be appropriate and may be counterproductive. Students in this study often expressed feeling unprepared, aligning with prior studies (Brown et al., 2017; Kern\u00e9is et al., 2017). However, we found that using a structured framework for reflection encouraged planning future preparation for similar encounters. This included calling for system-wide changes to curriculum and availability of resources. Additionally, discussion with peers and reflection were cited as helping students to feel more prepared for future encounters with hesitant patients.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">While discussion with peers as a learning strategy was widely recognized as helpful, outcomes of these discussions varied greatly and were directly related to the student\u2019s overall reflection and plan for future preparation. This sometimes led to misguided solutions, highlighting the need for aligning education and training around similar encounters with evidence-informed recommendations. Many students referenced using an approach of centring patient views, either during the clinical encounter or after peer discussion and reflection, which aligns with recommendations (Centres for Disease Control and Prevention, 2021; Holt et al., 2016; Jarrett et al., 2015; Koski et al., 2019). However, many others referenced using only facts to correct knowledge, which is advised against in the vaccine hesitancy literature (Holt et al., 2016; Koski et al., 2019). In the context of these reflections, there would not be a space for students who came to misguided conclusions about approaching vaccine hesitancy to have this knowledge corrected based on recommended practices. Additional support and curriculum around vaccine hesitancy should be implemented alongside this framework of practice, peer discussion and reflection. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Previous research has shown that written reflections provide an effective tool for students to acknowledge their biases and the potential impact on patient care, as was seen in this study (Ross &amp; Lypson, 2014). Physician biases related to perceptions of patient education, lifestyle, and identity have been documented and found to impact patient care and rapport (Forhan &amp; Salas, 2013; Franz et al., 2021; Verbrugge &amp; Steiner, 1981; Walls et al., 2015). There are concerns of physicians\u2019 dismissal of patients expressing vaccine hesitancy from their care and physicians\u2019 beliefs that patient hesitancy is due to lack of reliable information (Hough-Telford et al., 2016). Physician frustration may contribute to lack of willingness to bridge communication with hesitant patients; this has been seen even at the student-level, in this study and in previous research (Koski et al., 2018). Preparing students for these types of encounters by promoting reflection on frustrations and biases is important for addressing vaccine hesitancy. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Limitations of this study include that data were collected from a single institution. However, detailed, written reflections allowed for in-depth thematic analysis that may transfer to medical students more broadly. Additionally, reflections were from a course required for all medical students at the institution from cohorts over three years. Students\u2019 reflections were written in 2014-2016, prior to the COVID-19 pandemic. However, vaccine hesitancy is an even more relevant topic now and reasons for vaccine hesitancy as well as strategies for addressing it are largely unchanged (Centres for Disease Control and Prevention, 2021). Indeed, vaccine hesitancy to the COVID-19 vaccine highlights the need for deliberate curricular efforts. Another limitation is that our sample only includes students who chose to discuss vaccine hesitancy, mistrust and bias in their reflections. However, this allowed us to analyse a fairly large sample of student reflections for a qualitative study, aiding in robust thematic saturation and providing insights that are relevant beyond vaccine hesitancy cases.<\/span><\/p>\r\n<p style=\"text-align: center;\"><span lang=\"EN-GB\"><\/span><strong><span lang=\"EN-GB\">V. CONCLUSION<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">There are several meaningful implications of this study for medical education. Our findings illustrate benefits of learner reflection to build insights about communicating and building relationships to address vaccine hesitancy in medical education. Students found encounters with vaccine hesitant patients challenging, in part due to lack of preparedness, highlighting a gap in curriculum. Findings demonstrate varied familiarity with existing recommendations for addressing vaccine hesitancy, emphasizing the need to incorporate specific training into medical curriculum regarding specific skills gaps such as with communication. By focusing on mistrust and personal bias beyond vaccine hesitancy-specific cases, medical curriculum can better prepare students to approach these underlying issues with vaccine hesitant patients and patients expressing hesitancy to other medical recommendations in their future clinical practice. Finally, comprehensive efforts to improve vaccine hesitancy preparedness amongst learners are needed in our current climate of medical mistrust, given the prominence of vaccine hesitancy not just in paediatrics but also throughout clinical care in the context of the current COVID-19 pandemic. To improve vaccine confidence and decrease mistrust in the physician-patient relationship, medical educators must address medical student preparedness for encounters with vaccine-hesitant patients and parents through intentional learning strategies incorporated into medical school curriculum. We recommend that medical schools explore incorporating simulated patient encounters or role-play scenarios with structured reflection and discussion activities in response to encounters with hesitant patients, alongside didactic curriculum on evidence-based vaccine communication strategies, as research continues to evaluate best practices for preparing medical students to encounter vaccine hesitancy.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">Notes on Contributors<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Marina C. Jenkins BA was involved in the conceptual development of this qualitative analysis; analysis of reflective writings for development of themes; writing of introduction, results, methods and discussion and editing all sections and final approval of the manuscript.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Caroline R. Paul MD was involved in the original curriculum, the original sorting process of student reflective writing; the conceptual development of this qualitative analysis; analysis of reflective writings for development of themes; writing of results section and editing of all sections and final approval of the manuscript.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Shobhina Chheda MD MPH was involved in the original curriculum, the original sorting process of student reflective writing; analysis of reflective writings for development of themes; writing of results section and editing of all sections and final approval of the manuscript.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Janice L. Hanson PhD EdS MH was lead in the conceptual development of this qualitative analysis and organization of qualitative data; analysis of reflective writing; writing of results; writing of methods; and primary mentor to first author on writing of introduction and discussion; editing of all sections and final approval.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">Ethical Approval<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">This study received exemption status from the Institutional Review Boards from the University of Wisconsin-Madison and the Washington University in St. Louis.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">Data Availability<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">We do not have IRB permission to share our data in a data repository. The data are essays written by medical students during a required university course. While the essays are de-identified, it could be possible for someone who wrote an essay or participated in discussion groups with those who wrote the essays to identify an individual who wrote an essay.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">Acknowledgement<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">We would like to acknowledge Andrea Maser, MS for her assistance in de-identifying student reflections and organization of student reflections from various student cohorts.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">We would like to acknowledge Roberta Rusch, MPH for assistance in the original sorting of student reflections.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">Funding<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">There is no funding source for this study.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">Declaration of Interest<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">The authors have no conflicts of interest to disclose.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">References<\/span><\/strong><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Aronson, L., Kruidering, M., Niehaus, B., &amp; O&#8217;Sullivan, P. (2012). UCSF LEaP (Learning from your experiences as a professional): guidelines for critical reflection. <i>MedEdPORTA<\/i>L, <i>8<\/i>, 9073. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.15766\/mep_2374-8265.9073\">https:\/\/doi.org\/10.15766\/mep_2374-8265.9073<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Braun, V., &amp; Clarke, V. (2006). Using thematic analysis in psychology. <i>Qualitative Research in Psychology<\/i>, <i>3<\/i>(2), 77-101.<\/span><span lang=\"EN-US\"> <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1191\/1478088706qp063oa\">https:\/\/doi.org\/10.1191\/1478088706qp063oa<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Broniatowski, D. A., Jamison, A. M., Qi, S. H., AlKulaib, L., Chen, T., Benton, A., Quinn, S. C., &amp; Dredze, M. (2018). 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United States Department of Health and Human Services. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/www.cdc.gov\/vaccines\/covid-19\/downloads\/vaccination-strategies.pdf\">https:\/\/www.cdc.gov\/vaccines\/covid-19\/downloads\/vaccination-strategies.pdf<\/a><\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Dempsey, A. F., Pyrznawoski, J., Lockhart, S., Barnard, J., Campagna, E. J., Garrett, K., Fisher, A., Dickinson, L. M., &amp; O\u2019Leary, S. T. (2018). Effect of a health care professional communication training intervention on adolescent human papillomavirus vaccination: A cluster randomized clinical trial. <i>JAMA Pediatrics<\/i>,<i> 172<\/i>(5), e180016. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1001\/jamapediatrics.2018.0016\">https:\/\/doi.org\/10.1001\/jamapediatrics.2018.0016<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Forhan, M., &amp; Salas, X. R. (2013). Inequities in healthcare: A review of bias and discrimination in obesity treatment. <i>Canadian Journal of Diabetes<\/i>, <i>37<\/i>(3), 205-209. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1016\/j.jcjd.2013.03.362\">https:\/\/doi.org\/10.1016\/j.jcjd.2013.03.362<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Franz, B., Dhanani, L. Y., &amp; Miller, W. C. (2021). Rural-urban differences in physician bias toward patients with opioid use disorder. <i>Psychiatric services<\/i>, <i>72<\/i>(8), 874-879. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1176\/appi.ps.202000529\">https:\/\/doi.org\/10.1176\/appi.ps.202000529<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Gagneur, A., Gosselin, V., &amp; Dub\u00e9, \u00c8. (2018). 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Parental perspectives on immunizations: Impact of the COVID-19 pandemic on childhood vaccine hesitancy. <i>Journal of Community Health<\/i>,<i> 47<\/i>(1), 39-52. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1007\/s10900-021-01017-9\">https:\/\/doi.org\/10.1007\/s10900-021-01017-9<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Hofstetter, A. M., Robinson, J. D., Lepere, K., Cunningham, M., Etsekson, N., &amp; Opel, D. J. (2017). 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The importance of the patient voice in vaccination and vaccine safety\u2014Are we listening? <i>Clinical Microbiology and Infection<\/i>,<i> 22<\/i>, S146-S153. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1016\/j.cmi.2016.09.027\">https:\/\/doi.org\/10.1016\/j.cmi.2016.09.027<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Hough-Telford, C., Kimberlin, D. W., Aban, I., Hitchcock, W. P., Almquist, J., Kratz, R., &amp; O&#8217;Connor, K. G. (2016). Vaccine delays, refusals, and patient dismissals: A survey of pediatricians. <i>Pediatrics<\/i>,<i> 138<\/i>(3), 9, Article e20162127.<\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1542\/peds.2016-2127\">https:\/\/doi.org\/10.1542\/peds.2016-2127<\/a><\/span><span lang=\"EN-US\"> <\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Jarrett, C., Wilson, R., O\u2019Leary, M., Eckersberger, E., &amp; Larson, H. J. (2015). Strategies for addressing vaccine hesitancy\u2013A systematic review. <i>Vaccine<\/i>,<i> 33<\/i>(34), 4180-4190. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1016\/j.vaccine.2015.04.040\">https:\/\/doi.org\/10.1016\/j.vaccine.2015.04.040<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Jenkins, M. C., &amp; Moreno, M. A. (2020). Vaccination discussion among parents on social media: A content analysis of comments on parenting blogs. <i>Journal of Health Communication<\/i>,<i> 25<\/i>(3), 232-242. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1080\/10810730.2020.1737761\">https:\/\/doi.org\/10.1080\/10810730.2020.1737761<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Karras, J., Dub\u00e9, E., Danchin, M., Kaufman, J., &amp; Seale, H. (2019). A scoping review examining the availability of dialogue-based resources to support healthcare providers engagement with vaccine hesitant individuals. <i>Vaccine<\/i>,<i> 37<\/i>(44), 6594-6600. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1016\/j.vaccine.2019.09.039\">https:\/\/doi.org\/10.1016\/j.vaccine.2019.09.039<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Kelekar, A., Rubino, I., Kavanagh, M., Lewis-Bedz, R., LeClerc, G., Pedell, L., &amp; Afonso, N. (2022). Vaccine hesitancy counseling\u2014an educational intervention to teach a critical skill to preclinical medical students. <i>Medical Science Educator<\/i>,<i> 32<\/i>(1), 141-147. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1007\/s40670-021-01495-5\">https:\/\/doi.org\/10.1007\/s40670-021-01495-5<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Kempe, A., Saville, A. W., Albertin, C., Zimet, G., Breck, A., Helmkamp, L., Vangala, S., Dickinson, L. M., Rand, C., &amp; Humiston, S. (2020). Parental hesitancy about routine childhood and influenza vaccinations: A national survey. <i>Pediatrics<\/i>,<i> 146<\/i>(1). <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1542\/peds.2019-3852\">https:\/\/doi.org\/10.1542\/peds.2019-3852<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Kennedy, A., LaVail, K., Nowak, G., Basket, M., &amp; Landry, S. (2011). Confidence about vaccines in the United States: Understanding parents\u2019 perceptions. <i>Health Affairs<\/i>,<i> 30<\/i>(6), 1151-1159.\u00a0 <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1377\/hltaff.2011.0396\">https:\/\/doi.org\/10.1377\/hltaff.2011.0396<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Kern\u00e9is, S., Jacquet, C., Bannay, A., May, T., Launay, O., Verger, P., Pulcini, C., Abgueguen, P., Ansart, S., Bani-Sadr, F., Bannay, A., Bernard, L., Botelho-Nevers, E., Boutoille, D., Cassir, N., Cazanave, C., Demonchy, E., Epaulard, O., Etienne, M., &amp; Wyplosz, B. (2017). Vaccine education of medical students: A nationwide cross-sectional survey. <i>American Journal of Preventive Medicine<\/i>,<i> 53<\/i>(3), e97-e104. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1016\/j.amepre.2017.01.014\">https:\/\/doi.org\/10.1016\/j.amepre.2017.01.014<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Koski, K., Lehto, J. T., &amp; Hakkarainen, K. (2018). Simulated encounters with vaccine-hesitant parents: Arts-based video scenario and a writing exercise. <i>Journal of Medical Education and Curricular Development<\/i>,<i> 5<\/i>, 2382120518790257. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1177\/2382120518790257\">https:\/\/doi.org\/10.1177\/2382120518790257<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Koski, K., Lehto, J. T., &amp; Hakkarainen, K. (2019). Physician self-disclosure and vaccine-critical parents\u05f3 trust: Preparing medical students for parents\u05f3 difficult questions. <i>Health Professions Education<\/i>,<i> 5<\/i>(3), 253-258. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1016\/j.hpe.2018.09.005\">https:\/\/doi.org\/10.1016\/j.hpe.2018.09.005<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Larson, H. J. (2016). Vaccine trust and the limits of information. <i>Science<\/i>,<i> 353<\/i>(6305), 1207-1208. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1126\/science.aah6190\">https:\/\/doi.org\/10.1126\/science.aah6190<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Lucia, V. C., Kelekar, A., &amp; Afonso, N. M. (2021). COVID-19 vaccine hesitancy among medical students. <i>Journal of Public Health<\/i>,<i> 43<\/i>(3), 445-449. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1093\/pubmed\/fdaa230\">https:\/\/doi.org\/10.1093\/pubmed\/fdaa230<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Meleo-Erwin, Z., Basch, C., MacLean, S. A., Scheibner, C., &amp; Cadorett, V. (2017). &#8220;To each his own&#8221;: Discussions of vaccine decision-making in top parenting blogs. <i>Human Vaccines &amp; Immunotherapeutics<\/i>,<i> 13<\/i>(8), 1895-1901. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1080\/21645515.2017.1321182\">https:\/\/doi.org\/10.1080\/21645515.2017.1321182<\/a><\/span><span lang=\"EN-US\"> <\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Ognyanova, K., Lazer, D., Baum, M., Perlis, R. H., Druckman, J., Santillana, M., Qu, H., Trujillo, K. L., Safarpour, A., Uslu, A., Quintana, A., Green, J., Pippert, C. H., &amp; Shere, A. (2022). The COVID States Project# 82: COVID-19 vaccine misinformation trends, awareness of expert consensus, and trust in social institutions. Open Science Framework. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.31219\/osf.io\/9ua2x\">https:\/\/doi.org\/10.31219\/osf.io\/9ua2x<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Onello, E., Friedrichsen, S., Krafts, K., Simmons, G., Jr., &amp; Diebel, K. (2020). First year allopathic medical student attitudes about vaccination and vaccine hesitancy. <i>Vaccine<\/i>,<i> 38<\/i>(4), 808-814. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1016\/j.vaccine.2019.10.094\">https:\/\/doi.org\/10.1016\/j.vaccine.2019.10.094<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Real, F. J., DeBlasio, D., Beck, A. F., Ollberding, N. J., Davis, D., Cruse, B., Samaan, Z., McLinden, D., &amp; Klein, M. D. (2017). A virtual reality curriculum for pediatric residents decreases rates of influenza vaccine refusal. <i>Academic Pediatrics<\/i>,<i> 17<\/i>(4), 431-435. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1016\/j.acap.2017.01.01\">https:\/\/doi.org\/10.1016\/j.acap.2017.01.01<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Ross, P. T., &amp; Lypson, M. L. (2014). Using artistic-narrative to stimulate reflection on physician bias. <i>Teaching and Learning in Medicine<\/i>, <i>26<\/i>(4), 344-349. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1080\/10401334.2014.945032\">https:\/\/doi.org\/10.1080\/10401334.2014.945032<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Santibanez, T. A., Nguyen, K. H., Greby, S. M., Fisher, A., Scanlon, P., Bhatt, A., Srivastav, A., &amp; Singleton, J. A. (2020). Parental vaccine hesitancy and childhood influenza vaccination. <i>Pediatrics<\/i>,<i> 146<\/i>(6), Article e2020007609. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1542\/peds.2020-007609\">https:\/\/doi.org\/10.1542\/peds.2020-007609<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Schnaith, A. M., Evans, E. M., Vogt, C., Tinsay, A. M., Schmidt, T. E., Tessier, K. M., &amp; Erickson, B. K. (2018). An innovative medical school curriculum to address human papillomavirus vaccine hesitancy. <i>Vaccine<\/i>,<i> 36<\/i>(26), 3830-3835. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1016\/j.vaccine.2018.05.014\">https:\/\/doi.org\/10.1016\/j.vaccine.2018.05.014<\/a><\/span><span lang=\"EN-US\"> <\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Verbrugge, L. M., &amp; Steiner, R. P. (1981). Physician treatment of men and women patients: Sex bias or appropriate care? <i>Medical Care<\/i>, <i>19<\/i>(6), 609-632. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1097\/00005650-198106000-00005\">https:\/\/doi.org\/10.1097\/00005650-198106000-00005<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Walls, M. L., Gonzalez, J., Gladney, T., &amp; Onello, E. (2015). Unconscious biases: Racial microaggressions in American Indian health care. <i>The Journal of the American Board of Family Medicine<\/i>,<i> 28<\/i>(2), 231-239. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.3122\/jabfm.2015.02.140194\">https:\/\/doi.org\/10.3122\/jabfm.2015.02.140194<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\">*<span lang=\"EN-GB\">Marina C. Jenkins<\/span><br \/>\r\n<span lang=\"EN-GB\">Department of Paediatrics<\/span><br \/>\r\n<span lang=\"EN-GB\">University of Wisconsin-Madison<\/span><br \/>\r\n<span lang=\"EN-GB\">2870 University Ave., Suite 200<\/span><br \/>\r\n<span lang=\"EN-GB\">Madison, WI 53703<\/span><br \/>\r\n<span lang=\"EN-GB\">Email address: mcjenkins@wisc.edu<\/span><br \/>\r\n<br \/>\r\n<\/p>\r\n<\/div>","protected":false},"featured_media":0,"parent":0,"menu_order":4,"template":"","issues_category":[12],"archive_category":[],"issue_type":[25],"volume_category":[61876],"class_list":["post-72024","issues","type-issues","status-publish","hentry","issues_category-original-articles","issue_type-past-issue","volume_category-volume-8-number-2-april-2023"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Qualitative analysis of reflective writing examines medical student learning about vaccine hesitancy - The Asia Pacific Scholar<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/medicine.nus.edu.sg\/taps\/issues\/qualitative-analysis-of-reflective-writing-examines-medical-student-learning-about-vaccine-hesitancy\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Qualitative analysis of reflective writing examines medical student learning about vaccine hesitancy - The Asia Pacific Scholar\" \/>\n<meta property=\"og:description\" content=\"Submitted: 1 August 2022 Accepted: 1 November 2022 Published online: 4 April, TAPS 2023, 8(2), 36-46 https:\/\/doi.org\/10.29060\/TAPS.2023-8-2\/OA2855 Marina C. Jenkins1, Caroline R. Paul2, Shobhina Chheda1 &amp; Janice L. 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