'I Trust Them Because My Mum Trusts Them': Exploring the Role of Trust in HPV Vaccination Decision-making among Adolescent Girls and Their Mothers in France

"Low confidence in HPV vaccination in France can be explained by broader trust issues, which will require long-term efforts to address."

In 2016, France was identified as the country with the lowest level of confidence in vaccination in the world, with parents expressing particular concerns about the human papillomavirus (HPV) vaccine. While vaccination decisions have often been described as the main consequence of an individual's representation of the risks and benefits of vaccination, these representations are also shaped by societal issues such as trust. Not only is France the site of past controversies around vaccines and government health decisions, but people in many countries are increasingly questioning the trustworthiness of scientific experts and information. This circumstance can lead to individuals turning to alternative sources of information such as peers or the internet, potentially exposing them to information discouraging vaccination. This qualitative study explored the role of trust in HPV vaccination decision-making among French adolescent girls and their mothers, who are commonly the household decision-makers around health and vaccination in France.

Semi-structured interviews and focus groups were conducted in two stages between October 2018 and March 2019 with vaccinated and unvaccinated 15- to 16-year-old adolescent girls and their mothers in Paris. Thematic analysis identified four key themes and a range of sub-themes:

• Uncertainty around a mistrusted vaccine - While adolescent girls were rarely involved in HPV vaccination decision-making, mothers described the experience as complex and uncertain - in part due to perceptions that HPV vaccination was different from other vaccines (less trusted and more controversial).
• Navigating mistrust and influences from a negative information environment - A large number of participants reported a lack of information about HPV vaccination, with mothers raising the need for more in-depth information, particularly from their doctors. Mothers who looked for additional information about HPV vaccination used search engines on the internet, official or medical websites, or social media and forums. Online information was generally negative, recommending people not to accept the vaccine or discussing alleged side effects of the vaccine. Although girls did not report seeing information on social media, they believed it would be the best channel to reach their generation, particularly Instagram and Snapchat. That said, participants also raised the concern that all information can be manipulated. Many girls believed that influencers such as celebrities or public figures could have a strong impact by sharing their personal experiences. Mothers were also exposed to negative information about vaccination in the mainstream media on television, radio, or magazines. Mothers explained that information would be more objective in schools and it would allow more serious and informed discussions with their daughters at home.
• The importance of trust and deferring decision-making to those perceived as more knowledgeable - Adolescent girls' decisions and opinions around HPV vaccination were strongly influenced by their mothers, described as reassuring "protectors"; involvement of fathers in decision-making was not reported. In turn, mothers showed very strong trust in their doctors and often deferred HPV vaccination decision-making to them. That said, mothers also described events that made them question health authorities' trustworthiness, such as concerns about the way the H1N1 vaccination campaign was handled or reports of the blood contamination scandal of the 1980s.
• Trusting oneself in the context of external influences and social norms - Social norms were important, as one mother explained that diverging from group opinions was frowned upon and others described worries about being judged for their decisions. One mother also described making the decision to vaccinate their daughters as a group decision with her friends, following one of her friend's diagnosis with cervical cancer. Guilt and anxiety was also found to be associated with the social meaning of good parenting, particularly in the face of cancer. Despite acknowledging influences from others, many mothers stressed the importance of one's own intuition, beliefs, and choice.

The researchers suggest that the dynamics identified herein will need to be explored further among all adolescents, as HPV vaccination is recommended to boys in France as of 2020. They also urge additional research to evaluate the effects of long-term trust-building strategies focusing on HPV vaccination, vaccine providers, policymakers, and other sources of information.

In conclusion, the researchers call for closer attention to the fact that France's controversial environment around vaccines - as well as healthcare professionals' own uncertainty and failure to recommend HPV vaccination as reported by some mothers in the study - could also lead mothers to question the trustworthiness of the vaccine. "Rebuilding trust in authorities may take a long time, but should start with an acknowledgment of previous mistakes and a reviews of lessons learnt from past events."