Vaccine Hesitancy among General Practitioners in Southern France and Their Reluctant Trust in the Health Authorities

"[I]f the state's role is not seen as legitimate and trustworthy with regards to vaccine recommendations, then not only patients distrust health interventions such as vaccination or certain vaccines, but HCPs can feel uncertain and unsupported....This inevitably has negative consequences for trust in, and acceptance of vaccination."

Distrust in some vaccines or the vaccination process can lead to vaccine hesitancy - not only among patients but also some health care professionals (HCPs), including general practitioners (GPs). A 2014 survey of GPs in France found that 1 in 8 displayed moderate to severe vaccine hesitancy. While GPs possess vaccination expertise beyond that of most patients, like patients, they are not part of the institutional process that leads to their production and recommendation. This means they must trust that the data at the foundation of these recommendations are reliable and that experts and policymakers are making correct decisions. This paper shares the results of a qualitative study conducted to understand the context of vaccination in France and how it has contributed to vaccine hesitancy among GPs.

As the paper explains, trusting health authorities may be especially difficult for GPs in France "in a context of repeated, high-profile health care scandals and the health authorities' problematic handling of them, as well as GPs' exclusion from the management of various epidemics over the past few decades." For example, in 2009, "there was a heated controversy over the cost of the government's large influenza vaccination campaign, the lack of transparency in the purchasing of the vaccines, perceived alarmist communication by public health authorities, conflicts of interest on the part of some MoH [Ministry of Health] advisers, and the safety of the vaccine (Ward, Colgrove, et al., 2018). The campaign failed, with only eight percent of the population vaccinating....GPs felt excluded from the organization of the campaign..."

Between November 2016 and April 2017, the researchers conducted telephone and face-to-face interviews with 19 GPs n the South of France from both rural and urban areas in two regions: Provence-Alpes-Côte d'Azur (PACA) and Occitanie, which both had relatively low vaccine coverage rates compared to the rest of France. Results are presented according to the following overarching themes, which are illustrated in the paper with quotations from GPs:

• GPs' "reluctant trust" in the health authorities in France, which has two sub-themes: (i) "ignored and unsupported", relating to how GPs were not sufficiently informed or supported by the health authorities in navigating their difficult position at the interface of various unfolding healthcare incidents and the patient concerns that came with them, and (ii) "the need to trust to an extent", relating to participants feelings that, despite lack of clear information and support, GPs were still expected to recommend vaccination, reassure vaccine-hesitant patients, and achieve high vaccination rates.
• GPs' adoption of socially constructed knowledge, which has two sub-themes: (i) "unofficial sources of information", relating to the unofficial scientific information and advice they seek from non-government and non-academic sources, and (ii) "the influence of positive and negative personal experiences on vaccine perceptions and recommendations", relating to how participants rely on their own vaccine experiences, as well as those of colleagues, to inform their views of various vaccines and whether they recommend them to patients.
• Tensions between vaccination promotion and patient choice, which references participants' sense that vaccine recommendations, and especially mandatory vaccination, possibly clash with a simultaneous rhetoric of autonomy and patient choice in healthcare settings in the West and GPs' commitment to patients' interests by taking their preferences into account. This could endanger the trusting relationship between the GP and his or her patient and restrict capacity for exercising professional judgement. Along these lines, most GPs (14/19) felt that their job was to inform patients rather than to encourage vaccination.

In discussing and contextualising these findings, the researchers delve deeper into what they mean by "reluctant trust". They note, in part, that "GPs in this study - while distrusting the health care authorities to an extent - depended on them for the legally binding guidelines that define their practice and that of all other GPs in the country. This means that the implicit contract between authorities and GPs may not only be ruptured but broken; instead of mutual understanding, GPs may simply be given instructions that they are expected to follow. This can inevitably lead to further negative consequences regarding their levels of trust in health authorities and vaccination....[Furthermore,] the distrust in the healthcare authorities and a lack of support from them meant that following or adapting vaccination guidelines and dealing with uncertainties was often aided by GPs drawing on trusted personal, non-certified sources of expertise rather than official guidelines, which traversed boundaries between professional and lay fields of expertise and experiences....GPs' are thus in a paradoxical position of being both health care representatives who are expected to implement vaccine guidelines and possess vaccine expertise, and citizens who are challenged by continued uncertainties about what information and advice to trust."

Some suggestions for overcoming these issues include:

• Ensure that GPs are more involved in decisions around vaccination policy. Such an approach could take the form of working groups where HCPs, concerned publics, and social science academics are invited into the design process of vaccination campaigns.
• Replace provision of one-way information to HCPs about vaccines with dialogue that appreciates and understands the social processes around vaccination concerns. This approach could foster relationships of collaboration, address circumstances that may hinder GPs' autonomy, and help healthcare authorities to build trusting relationships with GPs.
• Conduct further research exploring how HCPs rely on personal sources of guidance rather than official guidelines, and how this affects their vaccine discussions with patients, as this study showed that the effects on patients of HCPs relying on personal sources of guidance are mixed.

In conclusion: "Ultimately, by shifting the burden of distrust from the individual or community, onto the trustworthiness of institutions, the genuine drivers of trust and distrust may become clear. In highlighting the perception and expectation gulfs between HCPs and health authorities, coupled with tailored suggestions of how to overcome them, ruptured or broken implicit contracts between both parties could gradually be re-built, contributing to increased trust in health care authorities and thus vaccination."