With almost one quarter of Americans unwilling to get immunized with available COVID-19 vaccines,¹ vaccine hesitancy remains a substantial obstacle to controlling the coronavirus pandemic. This essay describes our experience with a “Theater for Vaccine Hesitancy” (TVH) training program that uses improvisational theater techniques to help healthcare workers have collaborative conversations with unvaccinated patients about the benefits of COVID-19 vaccination.

The program had 2 precedents. One of us (J.P.C.) had previously trained in the methods of “Forum Theatre,” one of the components of “Theatre of the Oppressed” -- a style of improvisational theatre developed in the 1970s by social theorist Augusto Boal to catalyze critical dialogue, explore alternative solutions to challenging social situations, and advance social justice -- to teach medical students appropriate, authentic, and respectful responses to patient expressions of bias in clinical encounters.^2,3 In 2021 the Centers for Disease Control and our university funded a 16-month Finger Lakes Rural Immunization Initiative (FLRII) that supported efforts of medical center faculty, health project coordinators, and graduate students to address low vaccination rates in rural areas. With underuse of COVID-19 vaccines a substantial public health problem, we adapted the theatre methods we had used in medical education to try to help regional health care staff navigate potentially challenging conversations about vaccination with vaccine hesitant patients.

Each training session is framed as a 60-minute workshop comprising a didactic component (“The Science of Motivation”), an improvisational theatre component (“Difficult Conversations”), and an interactive improvisational follow-up component (“Changing the Conversation”) (eFigure in the Supplement). The session begins with a review of the importance of autonomy, competence, and relatedness -- key tenets of Self Determination Theory (SDT) and motivational science^4,5 -- and how they relate to vaccine hesitancy, including imagining what it might be like to hear and believe conspiracy theories and then have a trusted clinician tell you they are not true. Using SDT techniques, including maintaining unconditional positive regard⁶ towards the individual and making a clear recommendation supporting vaccination, the session reviews how to guide patients through that cognitive dissonance in a way that prioritizes their autonomy and competence.⁷

In the improvisational theatre component (“Difficult Conversations”), team members acting as health care workers and patients read scripted conversations reflecting the give-and-take of vaccine recommendation and hesitancy. The scripts are based on interviews previously conducted with health care providers and staff at affiliated community-based organizations (CBOs) as part of the FLRII to identify real world social and behavioral drivers of patient reluctance; a variety of scripted cases address pregnancy, childhood vaccination, younger healthy adults, concerns about speed of vaccine development, and other reasons to fit the audience. An impartial facilitator introduces the actors and instructs attendees (the “theatre audience”) to watch and notice parts of the dialogue that don’t lead to increased vaccination acceptance. After an initial run-through, in which vaccine hesitancy is not effectively addressed, audience participants are asked to share feedback, including about specific parts of the dialogue that might have prevented increased vaccine acceptance. The scene is then re-enacted with audience members urged to yell “stop” if they would change the dialogue of healthcare worker to improve the scenario outcome. The performance is paused, the facilitator asks the person why they stopped the performance, and the person is asked to step into the role of the health care worker to use their suggested approach to change the outcome of the conversation, becoming a “spect-actor” (spectator/actor, in accordance with the Forum Theatre tradition). The format compels spect-actors and audience to realize it is easier to suggest what should be done than to do it effectively in an actual situation, although the health project coordinator playing the role of the vaccine hesitant patient is trained to express less vaccine hesitancy when the spect-actor does a good job using the tenets of SDT in the conversation.

In the postperformance interactive improvisational follow-up component (“Changing the Conversation”), the session facilitator asks the spect-actors “Did you accomplish what you set out to do?,” and asks the team member playing the patient role how they felt during the encounter. If the spect-actor playing the clinician was successful, generally the team member patient will respond they found it challenging to find continued reasons to decline vaccination; examples of responses to vaccine skepticism judged to be especially effective by attendees are provided in Table 1. Finally, the facilitator asks the audience members what they think the spect-actors accomplished, trying to avoid disapproval of the spect-actors and their performance. Critics of the performance are asked to explain what they would do differently and are invited to assume the role of clinician and act out the patient encounter incorporating their suggestions. These scenarios are re-enacted multiple times, permitting a number of individuals to practice having these difficult conversations.

The program was launched within our local healthcare systems for clinical personnel and then expanded and offered to health care workers, first responders, and staff in CBOs in surrounding rural counties, recruited via peer or personal emails and word of mouth (eTable 1 in the Supplement). Between November 2021 and April 2022 we conducted 6 sessions with 78 attendees (median attendance 12.5, interquartile range 2.8, 24), comprising 5 online and 1 hybrid online/in-person sessions; 1 was incorporated into routine Family Medicine resident didactic sessions and an additional 10 sessions are planned until funding ends in September 2022.

In survey measures sent to 46 participants to date (e Appendix in the Supplement), 79% (33 of 42 respondents) endorsed feeling more confident when discussing vaccines with their patients following engagement with the intervention, 45% (19 of 42 respondents) judged that patients they had spoken to were more likely to get vaccinated based on their change in conversational approach, and 29% (12 of 41 respondents) believed vaccine-hesitant patients they’d spoken to became vaccinated because of the conversation (eTable 2 in the Supplement). In addition, front-line individuals have experienced burnout, moral injury, and an experience of isolation from persistence of the pandemic and the responsibility for caring for seriously ill vaccine-hesitant individuals, ^8,9 and informal feedback suggests the workshops create a sense of camraderie among participants, which may in itself be an intervention.

As the next phases of the global pandemic arrive and new ones may be on the horizon, addressing vaccine hesitancy will be a continued challenge. This combination of improvisational theatre techniques from the social-justice movement grounded in evidenced-based motivational theory may help bring a glimmer of hope to change vaccine hesitant conversations, lighten the burden on health care providers, and improve the public’s health.