Routine childhood vaccination is a crucial component of public health in Canada and worldwide. To facilitate catch-up from the global decline in routine vaccination caused by the COVID-19 pandemic, and toward the ongoing pursuit of coverage goals, vaccination programs must understand barriers to vaccine access imposed or exacerbated by the pandemic. We conducted a regionally representative online survey in January 2023 including 2036 Canadian parents with children under the age of 18. We used the COM-B model of behaviour to examine factors influencing vaccination timeliness during the pandemic. We assessed Capability with measures of vaccine understanding and decision difficulty, and Motivation with a measure of vaccine confidence. Opportunity was assessed through parents' self-reported experience with barriers to vaccination. Twenty-four percent of surveyed parents reported having missed or delayed one of their children's scheduled routine vaccinations since the beginning of the pandemic, though most parents reported having either caught up or the intention to catch up soon. In the absence of opportunity barriers, motivation was associated with timely vaccination for children aged 0-4 years (aOR = 1.81, 95 % CI: 1.14-2.84). However, experience with one or more opportunity barriers, particularly clinic closures and difficulties getting an appointment, eliminated this relationship, suggesting perennial and new pandemic-associated barriers are a critical challenge to vaccine coverage goals in Canada.

Human Papillomavirus (HPV) vaccine coverage was <50% in France in 2022 and even lower among socially disadvantaged populations. We aimed to evaluate socio-demographic determinants of HPV vaccine awareness, uptake, and intention among parents of adolescents, and related attitudes and knowledge items. Parents of adolescents attending middle schools across France, who participated in a randomized trial responded to an anonymous baseline survey, conducted between November 2021 and February 2022. We used logistic regression models adjusting for a child’s age and sex to explore sociodemographic determinants (including at-home multilingualism, occupational categories, local deprivation index and urbanity) of HPV vaccine awareness, uptake, and intention. Among the 1889 participants from 61 schools, parents working as factory workers/farmers had significantly lower odds of vaccine awareness compared to executives/professionals, both if they reported (OR = 0.07; 0.03–0.15) or not (OR = 0.20; 0.11–0.36) speaking also another language than French at home. Parents in lower occupational categories with multilingual families were less likely to have the intention to vaccinate their child (OR = 0.19; 0.07–0.56). Recent physician visit or vaccine offer was strong positive determinants of awareness, uptake and intention. A substantial gradient across occupational categories was observed for attitudes and knowledge around HPV vaccine usefulness, safety, and accessibility. This study confirms the disparities on HPV vaccine uptake in France and provides insight into mechanisms of social disparities in HPV vaccine awareness, access and intention.

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.

With the aim to optimize communication during HPV vaccination campaigns in France, we elicited parental preferences around HPV vaccination. We conducted a single-profile discrete choice experiment (DCE) among parents of 11- to 14-year-old middle-school pupils, who completed an anonymous, self-administered, internet-based questionnaire during 2020–2021. The DCE comprised five attributes (vaccine-preventable disease, justification of optimal age, information on safety, indirect protection and coverage) of vaccination against an unnamed disease that were presented to respondents in ten choice tasks, or scenarios. We use fixed effect logit models to estimate attribute weights on theoretical vaccine acceptance, and random effect linear regression to estimate attribute coefficients on vaccine eagerness (decision and decision certainty). We estimated marginal effects of attributes on expected vaccine acceptance. Vaccination scenarios were accepted by 55.6–89.2

Importance The human papillomavirus (HPV) vaccine is safe and effective, yet vaccination coverage remains below public health objectives in many countries. Objective To examine the effectiveness of a 3-component intervention on HPV vaccination coverage among adolescents aged 11 to 14 years 2 months after the intervention ended, each component being applied alone or in combination. Design, Setting, and Participants A cluster randomized trial with incomplete factorial design (PrevHPV) was conducted between July 1, 2021, and April 30, 2022, in French municipalities receiving 0, 1, 2, or 3 components of the intervention. Randomization was stratified by school district and municipalities’ socioeconomic level. Analyses were carried out on 11- to 14-year-old adolescents living in all participating municipalities, regardless of what had been implemented. Intervention The PrevHPV intervention had 3 components: (1) educating and motivating 11- to 14-year-old adolescents in middle schools, along with their parents; (2) training general practitioners (GPs) on up-to-date HPV information and motivational interviewing techniques; and (3) free HPV vaccination at school. Main Outcomes and Measures The primary outcome was HPV vaccination coverage (≥1 dose) 2 months after the intervention ended among 11- to 14-year-old adolescents living in participating municipalities, based on the French national reimbursement database and data collected during the trial in groups randomized to implement at-school vaccination. Results A total of 91 municipalities comprising 30 739 adolescents aged 11 to 14 years (15 876 boys and 14 863 girls) were included and analyzed. Half the municipalities were in the 2 lowest socioeconomic quintiles and access to GPs was poor in more than two-thirds of the municipalities. Thirty-eight of 61 schools (62.3%) implemented actions and 26 of 45 municipalities (57.8%) had at least 1 trained GP. The median vaccination coverage increased by 4.0 percentage points (IQR, 2.0-7.3 percentage points) to 14.2 percentage points (IQR, 9.1-17.3 percentage points) at 2 months. At-school vaccination significantly increased vaccination coverage (5.50 percentage points [95% CI, 3.13-7.88 percentage points]) while no effect was observed for adolescents’ education and motivation (−0.08 percentage points [95% CI, −2.54 to 2.39 percentage points]) and GPs’ training (−1.46 percentage points [95% CI, −3.44 to 0.53 percentage points]). Subgroup analyses found a significant interaction between at-school vaccination and access to GPs, with a higher effect when access was poor (8.62 percentage points [95% CI, 5.37-11.86 percentage points] vs 2.13 percentage points [95% CI, −1.25 to 5.50 percentage points]; P = .007 for interaction). Conclusions and Relevance In this cluster randomized trial, within the context of the late COVID-19 pandemic period and limited school and GP participation, at-school HPV vaccination significantly increased vaccination coverage. The trial did not show a significant effect for training GPs and education and motivation, although it may be observed after more time has elapsed after the intervention. Trial Registration ClinicalTrials.gov Identifier: NCT04945655

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.

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.

Background In France, human papillomavirus (HPV) vaccination coverage varies across socioeconomic levels. Aim We aimed at assessing HPV vaccine awareness, uptake and vaccination intention among adolescents in France. Methods In 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. Results Among 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). Conclusion Our results suggest that healthcare and school could promote vaccination and mitigate social inequalities in HPV vaccination coverage.

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 (nonuniform 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 nonuniform 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.

À partir d’une enquête originale menée fin novembre 2020, nous identifions les déterminants socio-démographiques et comportementaux d’adhésion aux mesures contre la Covid-19. Notre analyse porte sur l’acceptation du télétravail, les intentions de vaccination et la confiance dans la gestion de la crise par les autorités. Le goût pour les actions collectives est fortement et significativement associé à l’intention d’accepter la vaccination et à la confiance en les autorités. L’aversion pour le risque n’a jamais de rôle significatif et la préférence pour le présent seulement sur la confiance. Des facteurs exposant à un impact plus fort de la maladie (âge, sexe, présence d’autres facteurs de risque pour une Covid-19 grave, proche en Ehpad) permettent également d’expliquer les réponses des enquêtés.

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 10 minutes 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.

While the COVID-19 epidemic enters its second year, confidence in national authorities to manage the health and economic COVID-19 crisis may impact COVID-19 vaccine acceptance. To assess the relation between confidence in national authorities, socio-economic status and vaccine intention, we conducted an online survey among French adults during November 2020. Our results suggest that confidence, educational level and subjective deprivation are independent determinants of vaccine intention and indecision, including among ≥65-year-old participants. We suggest that providing all citizens with equal opportunities and incentives for a health-focussed vaccine decision is essential to obtain high and equal vaccine coverage against COVID-19. Introduction The rollout of COVID-19 vaccination in France is overshadowed by the poor vaccine coverage achieved during the H1N1-pandemic flu vaccine campaign in 2009, accredited to both unsuccessful organisation and disloyal mediatisation by medical experts [1]. What are the threats for the current campaign? While on one side, the government is accused of tardiness in organising the vaccine campaign, on the other, there is worry about low vaccine acceptance in the population. For example, in December 2020, intention to accept Covid-19 vaccination in the general French population was 40%, compared to 77% and 65% in the UK and Germany [2]. Confidence in vaccine safety is an important component in the vaccine hesitancy concept [3] and in an international comparison in 2016, the percentage of the general population agreeing with the statement “vaccines are safe” was particularly low in France [4]. We hypothesize that confidence in national authorities in a larger perspective may play an additional role, in particular in the context of an epidemic that has been ongoing for almost one year with various public debates about control measures. Methods We designed a survey to assess the relation between confidence in national authorities, socioeconomic status and vaccine intention. A representative sample of the French population (n=908) completed the anonymous online questionnaire between November 26th and December 1st, at the end of the second lockdown and before first efficacy data from COVID19 vaccine trials were published. The survey did not require ethical review according to French regulations, as it collected only anonymous information and no medical data. Confidence was assessed by the question: “On a 0-10 scale how much confidence do you have in the authorities to manage the health and economic crisis due to COVID-19?”: 32%, 33% and 36%, respectively, had a confidence level 0-3 (low), 4-6 (medium) and 7-10 (high). Socio-economic status was approximated through level of the highest diploma obtained (below, at or above French baccalaureate), subjective deprivation (« Did your household have financial problems during the last 12 months that hindered paying in time the rent, mortgage, consumer credits or every-day bills such as water, gas or electricity?”) and theoretical possibility to stay at/work from home (beyond employer’s attitude). Intention to accept COVID-19 vaccination was assessed as “Would you accept COVID-19 vaccine if it was recommended to you by your general practitioner?”: 47% accepted and 12% did not know. We evaluated determinants of vaccine intention (yes vs. no/do not know) and indecision (do not know vs. no) based on relative risks estimated from modified multivariate Poisson models [Barros]. For this, we included in a full model all variables associated at P<0.2 and kept them in a parsimonious model only if associated at P<0.05. Results COVID-19 vaccine intention strongly increased with confidence in authorities’ crisis management across gender and age groups (Suppl. File). Even among ≥65-year-old persons, acceptance in low-confidence strata (47% and 58%, respectively, among women and men) contrasted with high acceptance in high-confidence strata (68% and 95%, respectively). The determinants of vaccine intention were high confidence (vs. low: relative risk (RR) 2.35, 95%-confidence interval 1.94-2.84), older age (65+yrs vs <45 yrs: RR 1.54, 1.28-1.86), male gender (RR 1.45, 1.28-1.66), higher educational level (higher vs. lower than baccalaureate: RR 1.33, 1.13-1.57), living in a small town (defined as 2,000-20,000 inhabitants vs. rural: RR 0.75, 0.63-0.90), having a close relative in nursing home (RR 1.24, 1.04-1.49) and believing that one has a risk factor for severe COVID-19 (RR 1.24, 1.08-1.41) (Table 1). Neither subjective deprivation nor possibility of home office contributed significantly. Specifically among ≥65-year-old individuals, determinants were educational level (higher vs. lower than baccalaureate, RR 1.58, 1.13-2.20), confidence in authorities’ crisis management (high vs. low level, RR 1.52, 1.10-2.11) and male gender (RR 1.45, 1.11-1.89). In the full sample, expressing indecision with regard to vaccination vs. refusing was positively associated with medium (RR 2.06, 1.36-3.11) and high confidence (RR 1.80, 1.12-2.87), and negatively with feeling deprived (RR 0.46, 0.21-0.99) (Table 1). Discussion Our results suggest that confidence in national authorities to manage the health and economic COVID-19 crisis, educational level and subjective deprivation act as independent determinants of COVID-19 vaccine intention and indecision among French adults, including among those at high risk of severe COVID-19 by their age. The association of vaccine intention with higher educational levels and the observation that subjectively deprived persons rather said no than expressed indecision support concerns that unequal uptake of COVID-19 vaccination due to vaccine hesitancy could increase the already great inequality of burden of disease between socio-economic groups [5,6]. The strong association of vaccine intention with confidence in authorities’ crisis management points to the previously described close interaction between politics and vaccination programmes: Holmberg, Stuart and Blume described how governments historically used vaccination, especially during epidemics, for demonstrating their power to protect and bring together the nation [7]. A French survey during the first COVID-19 epidemic wave in spring 2020 found that participants’ willingness to get vaccinated against COVID-19 varied to some extent by their political choices made during the 2017 presidential election, with lower willingness expressed by those in extreme right or left wing votes [8]. In the light of these elements, our data show the risk of a vicious circle between lack of confidence in the crisis management by national authorities, vaccine refusal and failure or delay to control the epidemic. The ongoing highly mediatised debate about the perceived tardiness of the vaccine rollout in France may push this even further. Which could be a way forward? Without doubt, granting rapid and uncomplicated access to individuals in the target group with clear COVID-19 vaccine intention is essential and campaigns need to be organised consequently. However, to avoid unequal vaccine uptake determined by health-unrelated factors (such as confidence in authorities, educational level or deprivation), decision-making with health care providers should become central for those hesitating or refusing. This could imply a free and easily accessible vaccine consultation with physicians or other trained health care professionals, including teleconsultations and community-based sessions. Discussions would focus on the individual and collective benefits of vaccination and clear information about to be expected side effects. Providing all citizens with equal opportunities and incentives for a vaccine decision focussing on health may be a worthwhile investment to obtain high and equal vaccine coverage against COVID-19. Funding and conflict of interest We conducted the survey with financial support from the Conseil regional des Pays de la Loire, France (PANORisk project). The authors declare no conflict of interest. Data availability statement Data available on request.

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. (c) 2021 Elsevier Ltd. All rights reserved.

Background: Healthcare workers (HCWs) are prioritised for COVID-19 vaccination. Analysing their vaccination preferences is crucial to understand suboptimal uptake and identify levers to increase acceptance among those hesitating. Methods: We administered an online single-profile discrete choice experiment among a snowballing sample of French HCWs, recruited December 2020 through January 2021. Respondents in three random blocks chose between accepting or rejecting COVID-19 vaccination across eight hypothetical scenarios. Vaccine eagerness was derived from decision certainty. Results: Among 4346 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 to 90% efficacy: odds ratio 0·05, 95%-CI 0.04-0.06), and the mention of a positive benefit-risk balance (compared to absence of severe and frequent side effects: OR 0·40, 0·34-0·46. The highest positive impact was the prospect of safely meeting older people and contributing to epidemic control (compared to no indirect protection: OR 4·10, 3·49-4·82 and 2·87, 2·34-3·50, respectively. Predicted acceptance was 93·8% for optimized communication on mRNA 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 HCWs who hesitate or refuse vaccination, should avoid the notion of benefit-risk balance, while indirect protection effects with individual utility can lever acceptance. Vaccines with limited efficacy will unlikely achieve high uptake. Funding: This study was conducted with financial support from French Public Health Agency (Santé Publique France). Declaration of Interest: None to declare. Ethical Approval: The study protocol was approved by the IRB of CHU St Etienne (N° IRBN1092021/CHUSTE ) and the database was registered by EHESP French School of Public Health according to the GRDP regulation. Because the data collection was observational, collected no sensitive and only self-declared biomedical information, no informed consent was required. Participants visiting the study website saw the complete study information and agreed to study participation before starting the questionnaire. Study participation was anonymous without any risk of indirect identification.

ObjectivesTo 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.DesignSingle-profile discrete-choice experiment. Respondents in three random blocks chose between accepting or rejecting eight hypothetical COVID-19 vaccination scenarios.Setting4346 healthcare and welfare sector workers in France, recruited through nation-wide snowball sampling, December 2020 to January 2021.OutcomeThe 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.ResultsAmong 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.DiscussionVaccine 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.

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.

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.

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.

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.

Introduction Electronic nicotine delivery systems (ENDS) use has spread out 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 used 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 (Poisson with robust variance) were undertaken to describe the recent use of ENDS at 17 and it associated factors. Results ENDS were experimented by 52.4 % of 17 years old, 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 % never experimented smoking before. They were mostly boys (PR=1.39). No difference related to the parental socioeconomic status was highlighted. Recent vapers were more likely to have retaken a school year (PR=1,25) and were less likely out of school (PR=0,80). The associate uses of other products were the most striking factors: daily smoking (PR=2,73), regular alcohol drinking (PR=1,20), cannabis use in the last year (PR=1,60), ever use of hookah (PR=2,31) and ever use of another illicit drug (PR=1,11). Conclusions Those robust and representative results about vaping among French adolescents are essential to understand this trend. Although most French adolescents experiment with vaping, they are fewer to use it regularly and most of regular vapers are also daily smokers. The relationship between smoking and vaping will have to be further investigated. Funding This work was supported by the French Cancer League as part of the PETAL research program on adolescent smoking.