Twenty-six GPs aged 29–66 years were interviewed, 15 were women. The GPs’ characteristics are presented in Table 1.
Table 1
Characteristics of the participating GPs
No. | Gender | Age (years) | Number of years in practice | Type of practice | Department |
1 | M | 66 | 40 | Alone | Seine-St-Denis |
2 | F | 39 | 12 | Grouped, monodisciplinary | Seine-St-Denis |
3 | F | 36 | 6 | Grouped, multidisciplinary | Paris |
4 | F | 50 | 19 | Alone | Paris |
5 | F | 40 | 11 | Grouped, multidisciplinary | Yvelines |
6 | F | 38 | 4 | Grouped, multidisciplinary | Seine-et-Marne |
7 | F | 33 | 2 | Grouped, monodisciplinary | Loire |
8 | F | 43 | 11 | Grouped, monodisciplinary | Loire |
9 | M | 29 | 1 | Grouped, monodisciplinary | Loire |
10 | F | 31 | 3 | Grouped, monodisciplinary | Loire |
11 | F | 46 | 18 | Grouped, monodisciplinary | Loire |
12 | F | 36 | 8 | Grouped, monodisciplinary | Val-d'Oise |
13 | F | 31 | 0 | Grouped, multidisciplinary | Val-d'Oise |
14 | F | 58 | 29 | Grouped, multidisciplinary | Seine-et-Marne |
15 | M | 59 | 30 | Grouped, monodisciplinary | Seine-et-Marne |
16 | M | 37 | 2 | Community Health Centersa | Hauts-de-Seine |
17 | M | 35 | 1 | Grouped, multidisciplinary | Val-d'Oise |
18 | M | 36 | 4 | Community health centers | Hauts-de-Seine |
19 | M | 34 | 3 | Health Care Centerb | Hérault |
20 | F | 33 | 3 | Health Care Center | Hérault |
21 | F | 53 | 16 | Alone | Bouches-du-Rhône |
22 | M | 38 | 5 | Grouped, monodisciplinary | Bouches-du-Rhône |
23 | M | 37 | 2 | Community health centers | Paris |
24 | M | 65 | 35 | Grouped, monodisciplinary | Bouches-du-Rhône |
25 | F | 43 | 10 | Grouped, monodisciplinary | Hauts-de-Seine |
26 | M | 52 | 23 | Grouped, monodisciplinary | Pyrénées-Orientales |
M: male, F: female |
Recent measures taken by the French health authorities facilitate vaccination proposal
The lowering of the vaccination age to the 11–14 years age group (2012)(29), its reimbursement by the health insurance (2007) and the extension of the vaccination to boys (2020)(30) were perceived as facilitators by all the GPs interviewed.
According to some physicians, lowering the age of vaccination will avoid the difficult discussion about sexuality in the presence of the parents.
“Now, it is much easier for us to say that the age of vaccination is between 11 and 14 years old, or from 14 years old because before that, the topic was really underlying sexual relationships.” (I5F, 40)
Opening vaccination to boys could be considered a necessity to ensure the protection of the entire population. This encouraged previously reluctant physicians to learn new scientific data about vaccination.
“I think this will really force me to refresh my knowledge [the rationale for HPV vaccination] because I think that talking about covering an entire population will completely change the benefit-risk ratio.” (I2F, 39)
For some GPs, such a measure, beyond its scientific interest, will contribute to gender equality by ensuring that HPV prevention is not solely the responsibility of women. This could improve their commitment to promote HPV vaccination.
“Everyone must be vaccinated. I would not understand the opposite logic as everyone is a vector… The logic where only women who will experience the consequences, should be vaccinated, and protect themselves. No, for me, it is better to protect everyone.” (I18M, 35)
Organizational barriers: Adolescence, missed appointments and missed opportunities to vaccinate
Unlike the childhood period, consultations during adolescence are spaced and relatively unpredictable, making opportunities to address the topic of this non-mandatory vaccination rarer. Since 2–3 doses must be scheduled, this results in a large number of missed appointments.
“I said it many times before, this is a population that we do not see very often, because from the age of 7–8 years, we no longer see adolescents. [...] We see them again episodically later, sometimes around the age 15–16 years.” (I26M, 52)
Parental vaccine hesitancy and concerns about sexuality
Parents refusing vaccination for their children because of the risks is related to an intuitive and irrational perception of serious AEs of vaccination "in general".(31) More specifically for the HPV vaccine, the "lack of hindsight" and thus concerns about the “safety of the vaccine" were particularly reported.
“And the parental refusals are due to the lack of hindsight regarding the post-marketing experience, to the fact that the vaccine is not 100% effective, to the fact that it remains a product to be inoculated without really knowing...” (I13F, 31)
This hesitancy goes beyond fears about the perceived risks and seems to be related to the symbolic evocation (verbalized or not) of the first sexual intercourse associated with this vaccine. This seems to be very premature for families at the time the vaccination is proposed.
The refusals that I get come from the parents. [...] "She is too young, she is not going to have sex now." (I3F, 36)
The problem is no longer just about the sexual act itself, but rather who they might have sex with, the potential number of partners they might have, or the possibility that their daughters might have sex with "someone". Parents believe that the HPV vaccine is likely to lead to sexual disinhibition. According to the interviewed GPs, this suspected link with sexual disinhibition could be particularly felt by families as it conflicts with the image they wish to give.
Some people tell me: "My child is not like that, she is not a slut." (I22M, 38)
If this perception reported by the physicians is correct, there seems to be a double omission by the parents: first, HPV infection circulates widely in the population and does not seem to affect any particular populations(9); second, they think they can strictly and completely control their children’s choice with respect to their first partner, which is far from being the norm(32).
According to GPs, these reservations about adolescent sexuality are mainly expressed by families for which religion is central. Parents think that they can keep control of their children's sexuality by instilling in them a certain number of moral values that they must respect (the existence of a single sexual partner throughout life, the absence of sexual intercourse before marriage). For these families, the vaccine would not be necessary because of the virtuous behavior of their children.
However, by presenting sexuality as a taboo, a concept shared by all religious families, these GPs contribute to reinforcing this taboo and to essentializing these categories of population. This could lead to a systematic refusal by these families, even before they have actually proposed the vaccination, and they therefore do not propose it.
Oh yes, the religious reason. They say: "My daughter will never have sex, that's obvious!" Or "it will be her only partner, she will only have one partner, because meetings are rare at church." (I15M, 58)
Heterogeneous methods of approach: easy for some, difficult for others
To convince patients, most GPs rely on scientific data. The "lack of hindsight" on the vaccine is thus put into perspective, and the vaccination coverage of other countries is emphasized. As for sexuality, an analogy can be made with the hepatitis B vaccine. However, some GPs reported not being familiar with the latest data on vaccination and therefore having difficulty overcoming the reluctance of some patients.
Emphasizing the responsibility of families: promoting prevention
GPs emphasize the responsibility of families: the fact of mentioning the word "cancer" has a powerful symbolic meaning, likely to influence the decision of families, in particular by involving them in a prevention logic.
- And then, when the parents maintain their position, I explain to them that it is a pity, because cancer is still a leading cause of mortality. (I12F, 36)
Using their personal experience and the strength of the relationship built over time
Some physicians may use their personal experience, such as their daughter's vaccination, when patients ask them about it.
They ask me: "What about you, would you vaccinate your daughter?" And if I say yes, that immediately becomes an argument. (I5F, 40)
The trust built over time is thus taken into account and has a beneficial effect (33, 34). This was expected since trust is an essential element already pointed out in vaccine hesitancy (1, 35). However, they must have confidence in their ability to change their patients' attitudes and behaviours (36).
Typology of GPs according to their behavior regarding the HPV vaccine proposal
We identified three typologies of GPs according to their proposal strategy for HPV vaccination and their perceived effectiveness in convincing patients to get vaccinated: effective physicians, convinced but unpersuasive physicians, and reluctant physicians.
Effective physicians were characterized by the fact of systematically offering vaccination whenever they had the opportunity (quadrivalent vaccine dTacp-IPV at the age of 11–13 in France, menstruation or contraception, sports certificate, etc.), generally from the age of 11. Most of these GPs reported having no problem with the sexual health approach, but when they feel that patients (or their family) are reluctant, they may also desexualize the vaccine, by taking advantage of the younger vaccination age and focusing on the oncogenic process associated with the virus.
These GPs were mainly women, seeing a socially advantaged or mixed patient population. This proximity in terms of gender and social situation could facilitate the proposal of vaccines and their acceptance by the patients. These physicians thus easily talk about sexual health with their patients.
When faced with the reluctance of families, these physicians address the topic again during subsequent consultations, relying on the temporality of brief interventions such as those used for smoking cessation. Repeating the proposal over time is more likely to be accepted as it accompanies the construction of sexualized bodies during adolescence.
- Ah I think I talk about it all the time actually. It is like with cigarettes or alcohol [...] Vaccination is the same, if people tell me "no, it is irrelevant". I tell them, "Do you have any questions?" I will try to answer them, and then I will raise it again, but gently. (I11F, 46)
Not all patients accept it during the first visit. Often, they say, "We will think about it," and then I add a note in the medical record: "Talk about Gardasil during the next visit" and when I see them again, I talk about it again. (I17M, 35)
These physicians provide information by adopting a "deliberative" approach(37), discussing with patients, educating them so as to convince them that vaccination is the right thing to do.
Convinced but unpersuasive physicians
Convinced but unpersuasive physicians also systematically propose HPV vaccination but do not vaccinate much in practice. GPs in this category see mainly socially disadvantaged or mixed patients.
They attribute the low effectiveness of their proposal, that is not followed by a vaccine injection, to the particularly important reservations of their patients and families about HPV vaccination and to the poor attendance of adolescents in their practice. This reservation seems to be more pronounced when it concerns socially disadvantaged families who rarely consult for preventive reasons but rather in urgent situations(38).
This perceived ineffectiveness can sometimes lead to a drop in vaccination proposals, despite the GPs’ conviction of its usefulness, especially when they feel that the time spent trying to convince people cannot be used for other purposes.
Some of these physicians try to address sexuality-related issues, but find it difficult (e.g., when parents think their daughters are too young to talk about it). Others have difficulties talking about the benefit/risk balance or see that patients do not come back to get the vaccine.
Once they suggest getting a patient vaccinated, they do not systematically propose it again during subsequent consultations, due to the non-mandatory nature of this vaccine in France.
These GPs present themselves as experts whose medical knowledge guides the families, who ultimately remain the decision-makers. They are engaged in an "informative" relationship with their patients (37), who make their own choices based on the information received.
Reluctant physicians
Physicians in this category do not systematically propose the HPV vaccination.
First, they are less convinced of the benefit/risk ratio of this vaccine. Most of them expressed doubts after reading articles on the HPV vaccine published in a French journal a few years ago(39, 40)that minimized its interest by reporting an uncertain effect on cervical cancer prevention.
So (she thinks), maybe because I was bred on the review “Prescrire”, I always tend to be suspicious of new things, because new things are not as good as they are supposed to be, especially when there is so much money involved (I2F, 39)
Second, the fear of no longer performing pap smears allowing the early detection of precancerous lesions, was very often reported by these GPs:
In fact, I have a problem with Gardasil, I am a little afraid that people will feel protected, and will thus no longer consult for follow-up pap smears thereafter. (I16M, 37)
Despite their expressed reluctance, they do not discourage patients from getting vaccinated when they specifically request it.
I have mixed feelings about Gardasil, I do not offer it to my patients. I know that my collaborator talks about this vaccine and offers it. If I was alone, I would probably inform my patients more. If they want to get vaccinated, I do it (I2F, 39)
Other strategies may be used: one physician anticipated the degree of adherence to vaccination and offered it only to patients who were likely to accept it. He did not propose it to families for whom he felt religion was important, anticipating a refusal.
However, as these physicians readily explained it, patients and their parents rarely express a desire to be vaccinated, given the lack of information available to the general public on this subject. Patients requesting to be vaccinated against HPV are only people with a certain level of income, and they often have a high level of education. This passive attitude could thus contribute to increase social inequalities in health.
They can sometimes become more actively involved and offer the HPV vaccine to high-risk patients. The proposal is then based on the interpretation of various information collected on the patient’s sexuality and the protection methods used, including condoms. This may be problematic because there is evidence that using condoms is unlikely to be sufficient to prevent HPV infection(41).