General practitioners’ attitudes and behaviors toward HPV vaccination: A French national survey

Highlights

• We assessed French GPs’ attitudes and behaviors about HPV vaccination.

• HPV vaccine hesitancy is fairly prevalent among GPs.

• Perception of the vaccine risk-benefit balance is the strongest determinant of this behavior.

Abstract

Objective

General practitioners (GPs) play a crucial role in human papillomavirus (HPV) vaccine acceptance in France. We sought to study: (1) GPs’ perceptions of its risks and efficacy and their recommendation behavior; (2) the relative importance of factors associated with the frequency of their recommendations.

Methods

Cross-sectional observational study in 2014 nested in a national panel of 1712 randomly selected GPs in private practice in France (response rate: 92.4%). We used model averaging to analyze the associations of self-reported frequency of GPs’ HPV vaccine recommendations with their perception of its risk-benefit balance and their opinions about the utility of vaccines in general.

Results

Overall, 72% of participants reported frequently recommending HPV vaccination; 60% considered that not enough is known about its risks. The model averaging showed that the factors most associated with infrequent recommendation of this vaccine by GPs were: unfavorable perceptions of its risk-benefit balance (OR = 0.13; 95%CI = 0.09–0.21; partial R² = 0.10), a decision not to vaccinate one's own daughter(s) with this vaccine (OR = 0.13; 95%CI = 0.07–0.24; partial R² = 0.05), and doubts about vaccine utility in general (OR = 0.78; 95%CI = 0.71–0.86; partial R² = 0.03).

Conclusion

Although nearly three-quarters of French GPs frequently recommended the HPV vaccine, our findings indicate that a substantial percentage of them are hesitant about it. Doubts about its risks and efficacy strongly influence their recommendation behavior. More research is warranted to help design and evaluate tailored tools and multicomponent intervention strategies to address physician's hesitancy about this vaccine.

Introduction

Europe authorized the sale of the first vaccine against human papillomavirus (HPV) in 2006. In 2013, the French High Council for Public Health recommended either the quadrivalent (Gardasil^®) or bivalent vaccine (Cervarix^®), for girls only, specifically those aged 11–14 years, with catch-up to age 19. In France, the national health insurance fund reimburses patients (who are the purchasers of vaccines in France) 65% of its price (100% for those with very low incomes); privately purchased insurance covers most of the remaining 35%; 5% of the population has no private or public complementary insurance coverage. Unlike most of its European neighbors, France has chosen to deliver this vaccination, like most others, via the private medical sector to all patients [1]. This challenging strategy depends on the attitudes and health behaviors of both healthcare professionals and parents [2]. At the end of 2014, 17% of girls aged 16 had received 3 doses [3], one of the lowest coverage rates, with the US [4], among countries recommending this vaccination [1], [2], [5].

Recent developments in France include growing distrust in public health authorities, experts, and science [6], multiple vaccine controversies [7], and “vaccine hesitancy” – defined as doubts about the benefits and risks of vaccination and/or delays in acceptance or refusal of certain vaccines, despite the availability of vaccine services (SAGE Group 2014) [8], [9]. Despite the accumulation of evidence that the HPV vaccine does not have severe adverse effects [10], [11], [12], the French medical community has been debating the benefits and risks of the HPV vaccine; in May 2014 a petition to the Health Ministry demanded a parliamentary investigation into this vaccine [13]. Around that time, several young girls with severe neurological or autoimmune diseases (such as multiple sclerosis) diagnosed after HPV vaccination filed lawsuits blaming it for their diseases.

Studies in France and elsewhere have shown the crucial role of general practitioners (GPs) in HPV vaccine acceptance [14], [15], [16]. At this age (11–20 years) in France, teenage girls no longer consult pediatricians, do not yet consult gynecologists, and most often see GPs, who prescribe more than 90% of HPV vaccine doses [17]. Mothers, who usually make vaccination decisions for their daughters, most often trust their GP as a reliable source of information about this vaccine [15]. However, barriers to HPV vaccination exist among GPs [14], [18], including lack of knowledge about diseases possibly due to HPV and reluctance to address sexual topics with the target population [19], [20], [21]. Most studies of health professionals’ attitudes and behaviors related to HPV vaccination have been conducted in the US, and relatively few in Europe [22], particularly France.

In 2014, we conducted a cross-sectional survey of HPV vaccination among GPs, with two main objectives: (1) to study GPs’ perceptions of its risks and efficacy and their recommendation behavior; (2) to study and quantify the relative importance of factors associated with the frequency of their recommendations. We hypothesized that this frequency would be negatively associated with an unfavorable perception of the vaccine's risk-benefit balance (Hypothesis H1), perceptions of barriers related to addressing sexual issues with young adolescents (H2), perceptions of other vaccines’ safety, lack of trust in authorities and experts (H3), and perception that the utility of vaccines is generally low (H4).