Providing parents with HPV vaccine information from a male perspective may render them more inclined to have their daughters vaccinated.

OBJECTIVES: Several high-income countries have implemented a gender-neutral vaccination program against human papillomavirus (HPV) infections. The impact of a gender-neutral program (GNP) on parental intention to vaccinate their daughters has not been studied, especially in countries with low HPV vaccine coverage among girls. PATIENTS AND METHODS: In July 2019, before a GNP was implemented in France (2021), the French National Cancer Institute (INCa) conducted a survey on HPV vaccine acceptance among parents of children aged 11-19 years living in France. In the sample of girls' parents (n = 1424 parents, 1726 girls), we investigated whether parents who declared no initial intention to have their daughter(s) vaccinated changed their minds after reading information including a male perspective on HPV consisting in description of HPV-related disease among men and in ascertainment of the fact that in some countries, the HPV vaccine is recommended for boys, after which they were once again asked about their intentions "if the vaccine were recommended to boys and girls alike". RESULTS: As regards 295 (25.7 %) of the 1147 unvaccinated girls, their parents declared no intention to have them vaccinated, while 509 (44.4 %) were not sure. Among the parents of the 804 girls whose parents had not intended to have them vaccinated, 134 (16.7 %) changed their minds after reading about HPV among men. Fathers were more likely than mothers to change their minds, and finally intend to have their daughters vaccinated (adjusted relative risk, 1.74 [95 % confidence interval, 1.20,2.54]). CONCLUSIONS: These results suggest that parents, and fathers in particular, could be more motivated to have their daughters vaccinated against HPV if the information with which they were provided included a male perspective and a recommendation of vaccination for boys as well as girls.

Can physicians and schools mitigate social inequalities in human papillomavirus vaccine awareness, uptake and vaccination intention among adolescents? A cross-sectional study, France, 2021 to 2022.

BackgroundIn France, human papillomavirus (HPV) vaccination coverage varies across socioeconomic levels.AimWe aimed at assessing HPV vaccine awareness, uptake and vaccination intention among adolescents in France.MethodsIn a cluster-randomised study, 13-15-year-old students in 61 French middle schools completed a web-based questionnaire. We used multivariable logistic regression to evaluate determinants of HPV vaccine awareness, self-reported uptake and vaccination intention among unvaccinated students and interaction terms to explore effects of visits to family physician and remembering school lessons on vaccination. The French deprivation index of school municipalities served as proxy for socioeconomic levels.ResultsAmong 6,992 participants, awareness was significantly associated with parental education (odds ratio (OR) = 0.82; 95% confidence interval (CI): 0.71-0.95), language spoken at home (OR = 0.59; 95% CI: 0.52-0.66) and deprivation level (OR = 0.57; 95% CI: 0.44-0.71), regardless of physician visit or school lessons. Vaccine uptake was associated with parental education without a recent physician visit (OR = 0.31; 95% CI: 0.16-0.59, vs OR = 0.64; 95% CI: 0.52-0.78 with a visit, interaction p = 0.045). Vaccination intention among unvaccinated was associated with deprivation level (moderate-low vs low) among students not remembering school lessons on vaccination (OR = 0.17; 95% CI: 0.05-0.62, vs OR = 0.93; 95% CI: 0.51-1.67 remembering school lessons, interaction p = 0.022). Parental education was associated with vaccination intention among students reporting a physician visit (OR = 0.41; 95% CI: 0.26-0.64 vs OR = 1.05; 95% CI: 0.50-2.20 without a visit, interaction p = 0.034).ConclusionOur results suggest that healthcare and school could promote vaccination and mitigate social inequalities in HPV vaccination coverage.

Co-development of a school-based and primary care-based multicomponent intervention to improve HPV vaccine coverage amongst French adolescents (the PrevHPV Study).

INTRODUCTION: Despite various efforts to improve human papillomavirus (HPV) vaccine coverage in France, it has always been lower than in most other high-income countries. The health authorities launched in 2018 the national PrevHPV research programme to (1) co-develop with stakeholders and (2) evaluate the impact of a multicomponent complex intervention aimed at improving HPV vaccine coverage amongst French adolescents. OBJECTIVE: To describe the development process of the PrevHPV intervention using the GUIDance for rEporting of intervention Development framework as a guide. METHODS: To develop the intervention, we used findings from (1) published evidence on effective strategies to improve vaccination uptake and on theoretical frameworks of health behaviour change; (2) primary data on target populations' knowledge, beliefs, attitudes, preferences, behaviours and practices as well as the facilitators and barriers to HPV vaccination collected as part of the PrevHPV Programme and (3) the advice of working groups involving stakeholders in a participatory approach. We paid attention to developing an intervention that would maximise reach, adoption, implementation and maintenance in real-world contexts. RESULTS: We co-developed three components: (1) adolescents' and parents' education and motivation using eHealth tools (web conferences, videos, and a serious video game) and participatory learning at school; (2) general practitioners' e-learning training on HPV using motivational interviewing techniques and provision of a decision aid tool and (3) easier access to vaccination through vaccination days organised on participating middle schools' premises to propose free of charge initiation of the HPV vaccination. CONCLUSION: We co-developed a multicomponent intervention that addresses a range of barriers and enablers of HPV vaccination. The next step is to build on the results of its evaluation to refine it before scaling it up if proven efficient. If so, it will add to the small number of multicomponent interventions aimed at improving HPV vaccination worldwide. PATIENT OR PUBLIC CONTRIBUTION: The public (adolescents, their parents, school staff and health professionals) participated in the needs assessment using a mixed methods approach. The public was also involved in the components' development process to generate ideas about potential activities/tools, critically revise the successive versions of the tools and provide advice about the intervention practicalities, feasibility and maintenance.

What motivates adults to accept influenza vaccine? An assessment of incentives, ease of access, messaging, and sources of information using a discrete choice experiment.

Seasonal influenza vaccination rates remain low, and contribute to preventable influenza cases, hospitalizations, and deaths in the US. While numerous interventions have been implemented to increase vaccine uptake, there is a need to determine which interventions contribute most to vaccine willingness, particularly among age groups with vaccination rates that have plateaued at suboptimal levels. This study aimed to quantify the relative effect of multiple interventions on vaccine willingness to receive influenza vaccine in three age groups using a series of hypothetical situations with different behavioral interventions. We assessed the relative impact of four categories of interventions: source of vaccine messages, type of vaccination messages, vaccination incentives, and ease of vaccine access using a discrete choice experiment. Within each category, we investigated the role of four different attributes to measure their relative contribution to willingness to be vaccinated by removing one option from each of the intervention categories. Among the 1,763 Minnesota residents who volunteered for our study, participants expressed vaccine willingness in over 80% of the scenarios presented. Easy access to drop-in vaccination sites had the greatest impact on vaccine willingness in all age groups. Among the younger age group, small financial incentives also contributed to high vaccine willingness. Our results suggest that public health programs and vaccination campaigns may improve their chances of successfully increasing vaccine willingness if they offer interventions preferred by adults, including facilitating convenient access to vaccination and offering small monetary incentives, particularly for young adults.

Preferences for COVID-19 epidemic control measures among French adults: a discrete choice experiment.

In this stated preferences study, we describe for the first time French citizens' preferences for various epidemic control measures, to inform longer-term strategies and future epidemics. We used a discrete choice experiment in a representative sample of 908 adults in November 2020 (before vaccination was available) to quantify the trade-off they were willing to make between restrictions on the social, cultural, and economic life, school closing, targeted lockdown of high-incidence areas, constraints to directly protect vulnerable persons (e.g., self-isolation), and measures to overcome the risk of hospital overload. The estimation of mixed logit models with correlated random effects shows that some trade-offs exist to avoid overload of hospitals and intensive care units, at the expense of stricter control measures with the potential to reduce individuals' welfare. The willingness to accept restrictions was shared to a large extent across subgroups according to age, gender, education, vulnerability to the COVID-19 epidemic, and other socio-demographic or economic variables. However, individuals who felt at greater risk from COVID-19, and individuals expressing high confidence in the governmental management of the health and economic crisis, more easily accepted all these restrictions. Finally, we compared the welfare impact of alternative strategies combining different epidemic control measures. Our results suggest that policies close to a targeted lockdown or with medically prescribed self-isolation were those satisfying the largest share of the population and achieving high gain in average welfare, while average welfare was maximized by the combination of all highly restrictive measures. This illustrates the difficulty in making preference-based decisions on restrictions.

Vaccine eagerness: A new framework to analyse preferences in single profile discrete choice experiments. Application to HPV vaccination decisions among French adolescents.

Background: We previously conducted a single-profile discrete choice experiment to elicit preferences of adolescents around HPV vaccine communication, finding that only half of participants made variable choices (non-uniform respondents) from which preferences were elicited. In this paper we provide a framework to evaluate post-choice certainty information to elicit preferences even among respondents who uniformly accepted (serial demanders) or refused (serial non-demanders) hypothetical vaccination scenarios. Methods: During an in-class online questionnaire among 1458 French adolescents aged 13-15 years old, we collected certainty levels (0-10) after decisions on nine hypothetical scenarios, including four vaccination attributes: information on vaccine-preventable disease type, on vaccine safety, on potential for indirect protection and on vaccine coverage. We developed a vaccine eagerness scale (ranging from -10 to 10), by combining information on the binary decision (accept vs. refuse the hypothetical vaccine) and the decision certainty level. We used random effects linear regressions to evaluate attributes' impact on vaccine eagerness. Sensitivity analyses were performed taking into account low response quality, assessed as invariant certainty and low response time. Results: Attributes' impact on decision certainty were similar between serial demanders (N = 659) and non-uniform respondents (N = 711): mentioning a positive benefit-risk balance significantly decreased certainty to accept (coefficient -0.93), while information on 80% coverage in other countries (+0.33) and potential for disease elimination (+0.09) increased it. Among serial non-demanders, significant attribute impacts were observed only after exclusion of low-quality responses (N = 31): a potential for disease elimination (coefficient: +0.24) and 80% coverage in other countries (+0.42) significantly increased certainty of refusing vaccination. Combining decision and certainty into a vaccine eagerness indicator allowed analysing preferences in the full sample, including "hesitant" respondents, who were sensitive to the content of the vaccination profile. Conclusion: Choice certainty informs on respondents' preferences in single-profile discrete-choice experiments, in particular among those with uniform responses.

[Extension of HPV vaccination to boys: Survey of families and general practitioners]. / Extension de la vaccination contre les HPV aux garçons : enquête auprès de familles et de médecins généralistes.

INTRODUCTION: As part of an analysis on the extension of the HPV vaccination to French boys, the French National Cancer Institute (INCa) and the French National Authority for Health (HAS) have conducted in collaboration a survey on HPV vaccine acceptance in July 2019. This survey was completed by parents of children aged 11-19 and general practitioners (GPs). Questions focused on their representations, practices and intentions in the context of the future policy change allowing boys to get vaccinated against HPV. METHODS: The survey was conducted between June 20 and July 12, 2019. It focused on two populations: a nationally representative sample of parents with at least one girl aged 11-19 and/or one boy aged 11-14 (n=1984) and a representative sample of GPs in mainland France. Data were collected through a web-based questionnaire with a mean completion time of 10minutes for parents and GPs. The quota method was applied to ensure the representative nature of the samples based on (i) gender, age, children (girl aged 11-14 and/or boy aged 11-14) of the household, socio-professional category of the "head of the household", size of urban area and region for the parents' sample and based on (ii) gender, age, region and type of practice for the GPs' sample. RESULTS: Although most GPs were very favourable towards HPV vaccination (94%), they considered it one of the most challenging vaccinations to get parents to adhere to (82%). A notable percentage of parents have unfavourable opinions towards HPV vaccination (25%). The three main barriers cited by parents of non-vaccinated girls were: the fear of adverse effects, the lack of information, and the fact that the GP did not propose it. Regarding the extension of HPV vaccination to boys, 84 % of GPs would recommend this vaccination to boys if it was included in the vaccination schedule, and 88 % of those who did not routinely recommend HPV vaccination to girls would be more likely to offer it to girls if the extension was recommended.

Quantifying healthcare and welfare sector workers' preferences around COVID-19 vaccination: a cross-sectional, single-profile discrete-choice experiment in France.

OBJECTIVES: To analyse preferences around promotion of COVID-19 vaccination among workers in the healthcare and welfare sector in Fance at the start of the vaccination campaign. DESIGN: Single-profile discrete-choice experiment. Respondents in three random blocks chose between accepting or rejecting eight hypothetical COVID-19 vaccination scenarios. SETTING: 4346 healthcare and welfare sector workers in France, recruited through nation-wide snowball sampling, December 2020 to January 2021. OUTCOME: The primary outcomes were the effects of attributes' levels on hypothetical acceptance, expressed as ORs relative to the reference level. The secondary outcome was vaccine eagerness as certainty of decision, ranging from -10 to +10. RESULTS: Among all participants, 61.1% made uniform decisions, including 17.2% always refusing vaccination across all scenarios (serial non-demanders). Among 1691 respondents making variable decisions, a strong negative impact on acceptance was observed with 50% vaccine efficacy (compared with 90% efficacy: OR 0.05, 95% CI 0.04 to 0.06) and the mention of a positive benefit-risk balance (compared with absence of severe and frequent side effects: OR 0.40, 0.34 to 0.46). The highest positive impact was the prospect of safely meeting older people and contributing to epidemic control (compared with no indirect protection: OR 4.10, 3.49 to 4.82 and 2.87, 2.34 to 3.50, respectively). Predicted acceptance was 93.8% for optimised communication on messenger RNA vaccines and 16.0% for vector-based vaccines recommended to ≥55-year-old persons. Vaccine eagerness among serial non-demanders slightly but significantly increased with the prospect of safely meeting older people and epidemic control and reduced with lower vaccine efficacy. DISCUSSION: Vaccine promotion towards healthcare and welfare sector workers who hesitate or refuse vaccination should avoid the notion of benefit-risk balance, while collective benefit communication with personal utility can lever acceptance. Vaccines with limited efficacy will unlikely achieve high uptake.

Optimising HPV vaccination communication to adolescents: A discrete choice experiment.

BACKGROUND: Human Papillomavirus (HPV) vaccine coverage in France is below 30%, despite proven effectiveness against HPV infections and (pre-)cancerous cervical lesions. To optimise vaccine promotion among adolescents, we used a discrete choice experiment (DCE) to identify optimal statements regarding a vaccination programme, including vaccine characteristics. METHODS: Girls and boys enrolled in the last two years of five middle schools in three French regions (aged 13-15 years) participated in an in-class cross-sectional self-administered internet-based study. In ten hypothetical scenarios, participants decided for or against signing up for a school-based vaccination campaign against an unnamed disease. Scenarios included different levels of four attributes: the type of vaccine-preventable disease, communication on vaccine safety, potential for indirect protection, and information on vaccine uptake among peers. One scenario was repeated with an added mention of sexual transmission. RESULTS: The 1,458 participating adolescents (estimated response rate: 89.4%) theoretically accepted vaccination in 80.1% of scenarios. All attributes significantly impacted theoretical vaccine acceptance. Compared to a febrile respiratory disease, protection against cancer was motivating (odds ratio (OR) 1.29 [95%-CI 1.09-1.52]), but not against genital warts (OR 0.91 [0.78-1.06]). Compared to risk negation ("vaccine does not provoke serious side effects"), a reference to a positive benefit-risk balance despite a confirmed side effect was strongly dissuasive (OR 0.30 [0.24-0.36]), while reference to ongoing international pharmacovigilance without any scientifically confirmed effect was not significantly dissuasive (OR 0.86 [0.71-1.04]). The potential for indirect protection motivated acceptance among girls but not boys (potential for eliminating the disease compared to no indirect protection, OR 1.57 [1.25-1.96]). Compared to mentioning "insufficient coverage", reporting that ">80% of young people in other countries got vaccinated" motivated vaccine acceptance (OR 1.94 [1.61-2.35]). The notion of sexual transmission did not influence acceptance. CONCLUSION: HPV vaccine communication to adolescents can be tailored to optimise the impact of promotion efforts.

Why do apprentices smoke much more than high school students? Understanding educational disparities in smoking with a Oaxaca-blinder decomposition analysis.

BACKGROUND: Educational disparities in daily smoking begin during adolescence and can lead to educational disparities in health among adults. In particular, vocational students including apprentices have higher daily smoking rates compared to non-vocational students. This study aimed to identify the determinants of the gap in daily smoking between French apprentices and high school students aged 17 in 2008 and in 2017. METHODS: We used data from a cross-sectional repeated survey representative of all French adolescents aged 17 in 2008 and 2017. We conducted a non-linear extension of the Oaxaca-Blinder decomposition technique and included the following variables: sociodemographic and familial characteristics, parental smoking, cannabis and alcohol use, suicidal attempt, grade repetition and money received. RESULTS: Daily smoking was about two times higher among French apprentices compared to high school students in 2008. This gap did not decrease between 2008 and 2017. Differences in measured characteristics between the two groups explained this gap partly, from 28.6 to 51.2%. Cannabis and alcohol use, money received and parental smoking contributed the most to the daily smoking gap. CONCLUSIONS: Prevention programs could target cannabis and alcohol use as well as parental smoking to help decrease educational disparities in smoking status among French adolescents.

Does e-cigarette experimentation increase the transition to daily smoking among young ever-smokers in France?

INTRODUCTION: According to multiple studies, e-cigarette use among adolescents is associated with subsequent smoking initiation. However, little is known about its effect on the transition from smoking initiation to daily smoking. METHODS: Using retrospective data from a French national representative survey collected in 2017 (n = 39,115), we analyzed the role of ever using e-cigarettes on daily cigarette smoking status at 17 among ever smokers (n = 21,401). Risk-ratios (RR) were computed through modified Poisson regressions with an inverse probability of treatment weighting (IPTW) approach. RESULTS: Among French adolescents aged 17, 16.8 % declared current e-cigarette use (1.9 % reported daily use) and 34.1 % cigarette smoking (25.1 % reported daily smoking). Among ever-smokers, adolescents who declared having ever used e-cigarettes were less likely than those who did not to transition to daily smoking at 17: RR = 0.62 95 %CI [0.60 - 0.64]. We found similar results for those who experimented with e-cigarettes before initiating smoking, RR = 0.76 95 %CI [0.66 - 0.89]. CONCLUSIONS: Our results found no evidence of an increased risk of transitioning to daily smoking at 17 among ever-smokers who also experimented with e-cigarettes. Further studies should investigate the longer-term role of vaping on future smoking habits with the use of causal inference methods.

Increasing socioeconomic disparities in tobacco smoking decline among French adolescents (2000-2017).

BACKGROUND: This paper studies the evolution of transitions from first cigarette use to daily use by socioeconomic status (SES) among French adolescents over the course of 17 years, in a context of decreasing prevalence of tobacco use. METHODS: A total of 182 266 adolescents participated in the nationally representative ESCAPAD survey at nine different time points between 2000 and 2017. Discrete time-event analysis was used to model the transition to daily cigarette use as a function of SES, gender, age at onset and the use of other psychoactive substances. RESULTS: Although lifetime cigarette smoking and daily cigarette smoking decreased significantly over the studied time span, suggesting a positive impact of prevention policies, disadvantaged adolescents were consistently more prone to engage in daily cigarette smoking, more so in 2017 than 15 years earlier. In the same time span, transitions from initiation to daily cigarette smoking have shortened, with an accelerated pace among underprivileged adolescents. CONCLUSIONS: Accelerated transitions from initiation to daily cigarette use are a prevalent trend among disadvantaged adolescents in France. Efforts to mitigate the impact of marketing strategies and to promote health literacy should be pursued to reduce social inequalities in health.

[Use of electronic cigarette in France among adolescents aged 17: Results from the ESCAPAD 2017 survey]. / Usages de la cigarette électronique en France à 17 ans : résultats de l'enquête nationale ESCAPAD 2017.

INTRODUCTION: The use of electronic cigarettes has become relatively popular in France since 2010, including among adolescents. However, its use in relation to smoking and other factors is not well understood today. METHODS: The data come from the ESCAPAD 2017 survey, a nationally representative cross-sectional survey taking place at a 1-day session of civic and military information compulsory for all French nationals around 17 (39,115 respondents). Descriptive analyses and multivariate regressions were undertaken to describe the recent use of e-cigarette at 17 and its associated factors. RESULTS: e-cigarettes were experimented by 52.4 % of 17 year-olds, and used by 16.8 % in the preceding month, 1.9 % daily. Most recent users were also daily smokers (62.5 %), and only 7.6 % had never experimented cigarettes before. Among those who experimented with both products, only 13.3 % tried e-cigarettes before cigarettes. The associated uses of other products were the most striking factors: daily smoking (relative risk [RR]=2.73), ever use of hookah (RR=2.31), cannabis use in the last year (RR=1.60), regular alcohol drinking (RR=1.20) and ever use of another illicit drug (RR=1.11). Recent vapers that were also daily smokers had a more pronounced sociodemographic profile and a higher level of other drugs consumptions than recent vapers only. DISCUSSION: Although a majority of French adolescents experiment with vaping, they are fewer to use it regularly and its current use is frequently associated with daily smoking. Future trends and the relationship between smoking and vaping among adolescents will have to be further investigated, including the motivations of its use.

How to reduce biases coming from a before and after design: the impact of the 2007-08 French smoking ban policy.

BACKGROUND: Smoke-free laws aim at protecting against second-hand smoke and at contributing to change smoking behaviors. Impact evaluation studies can help understand to what extent they reach their goals. Simple before and after designs are often used but cannot isolate the effect of the policy of interest. METHODS: The short-term impact of the French smoking ban (2007-08) on smoking behavior outcomes was evaluated among smokers with data from the ITC project. We first conducted a before and after design on the French sample. Second, we added the UK (excluding Scotland) as a control group and finally used external pre-policy data from national surveys to control for bias arising from pre-policy trends. RESULTS: After one year post-implementation, the smoking ban led to a decrease in seeing people smoking in bars, restaurants and workplaces [estimated risk ratios (RR) of 8.81 IC95% (5.34-14.71), 2.02 (1.79-2.31) and 1.24 (1.16-1.33), respectively], as well as an increase in support for the smoke-free policy, but only in bars and restaurants [RR of 1.35 (1.15-1.61) and 1.25 (1.16-1.35)], respectively. No impact was found on smoking behaviors and on having a strict no smoking policy at home. The simple before and after design systematically overestimated the smoking ban's impact [e.g. RR of 29.9 (20.06-44.56) for observed smoking in bar, compared to 13.21 (7.78-22.42) with the control group, and 8.81 (5.34-14.71) with the correction from external data]. CONCLUSION: When data are lacking to conduct quasi-experimental designs for impact evaluation, the use of external data could help understand and correct pre-policy trends.

A French multicentric study and review of pulmonary Nocardia spp. in cystic fibrosis patients.

Some bacterial species recovered from the airways of cystic fibrosis (CF) patients are indisputably associated with lung infections, whereas the clinical relevance of others, such as Nocardia spp., remains unclear. Sixteen French CF cases of colonization/infection with Nocardia spp. were reviewed in order to evaluate the epidemiology, the clinical impact and the potential treatment of these bacteria, and results were compared to those of the literature. Five Nocardia species were identified, Nocardia cyriacigeorgica being the major species (50 % of cases). At first isolation, Nocardia was the sole pathogen recovered in six patients. Seven patients presented pulmonary exacerbation. For 12 patients, antimicrobial treatment against Nocardia was started immediately, mainly based on cotrimoxazole (6 of the 12 cases). In this study, we highlight the heterogeneity of the clinical management of Nocardia spp. in CF. Guidelines for the clinical management of Nocardia infections in CF patients are proposed.