Strategies implemented to address vaccine hesitancy in France: A review article

Figures & data

Table 1. Key words used for the research.

In English	In French	Key words used in the vocabulary thesaurus of databases
“immunization campaign” OR “vaccination program” OR “vaccination campaign” OR “vaccination awareness” OR “vaccination promotion” OR “vaccination uptake” OR “vaccine hesitant” OR “vaccine hesitancy” OR “immunization program” OR “advertising campaign” OR “education” OR “knowledge” OR “attitude” OR “behavior” OR “behaviour” OR “beliefs” AND (frenc* OR french* OR France)	(“campagne de vaccination” OU “programme vaccination” OU “hésitation vaccinale”) ET Franc*	In PubMed: “Immunization Programs”[Mesh]) AND “France”[Mesh]; In Embase: “public health campaign” AND “vaccination” AND “France”; In the BDSP: ([campagne information] OU [programme élargi vaccination]) ET [France])

Figure 1. Flow chart diagram of study inclusion and exclusion.

Table 2. Summary of published articles on strategies to address vaccine hesitancy in France.

	Description of articles
First author/ title/year of publication	Location	Period	General setting	Outcomes	Main conclusions
	Location Period General setting
Jean Beytout, Enseignements de la campagne de vaccination anti-méningococcique dans le Puy-de-Dôme [Lessons from the anti-meningococcal immunization campaignin the Puy-de-Dôme], 2002^33	Clermont-Ferrand	January 2002	Purpose: vaccinate 70000 persons in the agglomeration and the neighboring municipalities; Targeted population: young under 21, adults more than 25, in close contact with the at-risk population	Concerns from parents, because of the adverse effects registered during Phase III trial of the vaccine in Great Britain; Occurrence of side effects (flu symptoms, gastro-enteritis), which caused a delay in the administration of the first dose in some cases	Successful campaign with a great mobilization of HCPs, teaching and administrative staff; More than 80% of the targeted vaccinated
D. Lévy-Bruhl, Vaccination campaign following an increasein incidence of serogroup C meningococcaldisease in the department of Puy-de-Dôme^69	Department of Puy-De-Dôme	From January, 16^th 2002 to March 9^th, 2002	Purpose: vaccinate 100000 people; Targeted population: young adults, from 2 months-20 years old, studying in a limited area of the department, geographically defined as including all reported cases of invasive Men C disease since March 2001; Use of the Men C conjugate vaccine; Vaccination recommended for young people aged 2–24, living in boarding schools, communities, or working with children; New arrivals in the county for a period of more than 1month were also targeted; 1390 adverse effects identified (mostly migraines and dizziness: 1.73% of all vaccinated)	80000 persons vaccinated	Successful campaign (80% of the target population were vaccinated)
D. Lévy-Bruhl, Campagne de vaccinationcontre le méningogoque C dans le Sud-Ouest, un premier bilan [Vaccination campaign against meningococcal C in the South-West, an initial assessment], 2003^34	South-West region, 3 departments	October 21 to December 21, 2002	Purpose: vaccinate 315000 persons; Targeted population: children from 2 months-20 years old, some people aged 20–24, particularly those living in children's communities	Four cases of MD diagnosed: one person was not vaccinated, 2 persons received the vaccine 3 days before (the vaccine needs much more time to be effective), 2 persons were aged 25 and 29 years old, and were not among the population targeted by the campaign; Local and immediate adverse reactions were mostly not worse, with a favorable evolution^35	Successful campaign,good deployment; No case of MD observed in the 0–18years old; 70% of the target population were vaccinated
S. Laurence, Measles vaccination campaign among vulnerable populationsduring the peak of the 2011 epidemic in Marseille, 2012^36	Marseille	May to September 2011	Targeted population: The Roma population, non-vaccinated or with unknown vaccination status (n = 720)	326/720 people reached by the first injection (45.28%); Campaign prematurely interrupted, because the population was evicted from its places of life, and the follow-up couldn't be efficient	The campaign didn't have a great success; Only 37 persons received the second dose of the vaccine, as Roma people were evicted from their location
J. Belmin, Educational vaccine tools: the French initiative, 2009^43J. Belmin, Vaccination in older adults: development of an educational tool, Vaxisenior, in France, 2014^64		2000, update in 2008	Targeted population: geriatricians, physicians who teach geriatrics, internal medicine or infectious diseases; Tool organized in 8 sections including general information, immunity and oldness, and some specific vaccines (DTP, influenza, pertussis, pneumococcus, herpes zoster, and vaccines for travelers); Organized in slides collected into a CD; Content: Information about VPDs, consequences, benefits and adverse effects of vaccination; national immunization programs and recommendations also included; First set up in 2000^43, update in 2008 with the recommendation schedule for immunization^64
S. Krypciak,Improvement of pneumococcal immunization coverage in older patients, 2014^70	Department of Val de Marne	November 2009 to August 2010	Targeted population: elderly aged more than 75, in short geriatric stay, mainly affected by cardiac insufficiency (75.5% of cases); 2 actions used: sensitization of the attending physician and proposal of vaccination during the hospital stay	The sensitization of the attending physician improved VCR from 15.9 to 18.2%; A systemic proposal of vaccination during the hospital stay improved VCR from 6.1 to 84.5%	Both actions improved VCR
A Chamoux, Impact study of an active antiflu vaccination program on the Clermont-Ferrand teaching hospital staff, 2006^41	Clermont-Ferrand university Hospital	October 14 to October 20, 2003	Targeted population: hospital staff; Letters sent to participants to make them aware of the campaign; Medical information meetings planned to discuss about the way of transmission of influenza, vaccination and its benefits, the risk for the most fragile patients, and also for HCPs and their surroundings	VCR multiplied by 2.6, in comparison with the previous year: (4.8→12.6%) Post-vaccination, reactions observed in one third of cases (1/3)	Successful campaign, increase of the VCR
F Baudier, Pilot campaign to promote vaccination:description and preliminary results of a regional French program, 2007^71	Franche-Comté region	Launch in 2003, consisted in a one-week immunization campaign every year during 3 years	Targeted population: the general population; Lot of activities proposed: trainings, writing materials (posters, brochures); exhibitions, media campaign; Actions mphasized on schools and pharmacies in the second year	The reimbursement data showed, 2 months after the week-immunization, an increase in VCR of 5% for 2004, and more than 10% in 2005	The results after two years were satisfactory; An increase of vaccination-related discussion between physicians and their patients was observed
A. Decréquy, Cocooning strategy: Effectiveness of a pertussis vaccination program for parents in the maternity unit of a university hospital, 2016^39	Caen university hospital	2012	Vaccination of parents: vaccination of fathers during the pregnancy, and vaccination of mothers after the birth, before the discharge from the hospital, or prescription given to them to practice vaccination in town	VCR multiplied by 4	Successful campaign; lack of time was the main reason for non-vaccination
S. Laurence, Campagne de vaccination rougeole des populations précaires, retour d'expérience[Measles vaccination campaign for precarious populations, feedback], 2013^37	Department of Seine-Saint-Denis	January to June 2012	Purpose: increase VCR against measles in precarious population (The Roma population); 22 shantytown targeted	250/720 persons vaccinated(34.7%); Only 5% received the second dose	Low success; Reasons for low success: two shantytowns previously targeted by a similar campaign, expulsions, other health concerns in the shantytown (scabies epidemy), refusal
A Bone, Population and risk group uptake of H1N1 influenza vaccine in mainland France 2009–2010: Results of a national vaccination campaign, 2010^38	The whole France	End of 2009 to the beginning of 2010	Purpose: lower the burden of H1N1 disease in France; Targeted population: the whole French population; Vaccination made by mobile medical teams and vaccination centers	High vaccine uptake among children (20.7%), with a decrease in adults aged 18–24 (3.1% vaccinated)	Low overall vaccine uptake; VCR lower than those observed with the seasonal influenza vaccine for people aged 65 or over (3.9% vaccinated)
B Leboucher, Impact of postpartum information about pertussis booster to parents in a university maternity hospital, 2012^40	Angers university hospital	Two periods: Period A: January 1^st toMarch 31^st, 2008; Period B: January 19^th to April 19^th, 2009	Use of a protocol that combined information about the booster dose, and a prescription of pertussis vaccine, prior discharge from the hospital; Deployment of a telephone survey during two periods of 3 months (corresponding to periods A and B), 2 months after the delivery	VCR in period A: 67,9% (mothers), 63.1% (fathers); VCR in period B: 68.9% (mothers), 62.4% (fathers); The vaccination was mainly done in the first month after the delivery	The majority of mothers reported that the documents delivered to them helped them understand the benefits and importance of vaccination; Reasons for non-vaccination were lack of time, vaccination already received less than 2 years before, forgetting, breastfeeding
M Rothan-Tondeur,Randomised active programs on healthcare workers’ flu vaccination in geriatrics healthcare settings in France: the VESTA study, 2010^72	Geriatrics healthcare settings, long term care and rehabilitation care, throughout the whole France	2 programs both conducted in flu seasons; Program 1: 2005–2006 flu seasons; Program 2: 2006–2007 flu season;	Purpose: identify obstacles to influenza vaccination for HCPs, and develop specific actions to counteract this; Targeted population: HCPs; Program 1 aimed to give information to the HCPs, and remove fears and doubts; it was organized in 52 slides and 4 short movies; Program 2 was incentive, with a reward in case of an increase of vaccination coverage	Program 1 failed to increase VCR; In program 2, VCR increased by 44% in the interventional group, compared to the control group (27%), only in non-previously vaccinated subgroup	The program 1 didn't show any significant difference in term of VCR during the 2005– 2006 influenza season: it was inefficient; Non-vaccinated nursing auxiliaries and non-vaccinated nurses were mainly receptive to the program
B Dunais, Influenza  vaccination: impact of an intervention campaign targeting hospital staff, 2006^42	Nice university hospital	October 16^th to December 5^th, 2002	Active intervention led by a mobile medical team, to raise awareness about the importance to be vaccinated against flu, combined to an on-site vaccination; Targeted population: HCPs working in Nice University Hospital: staff of 6 departments responsible for the care of patients with higher risk of getting influenza during an epidemic period, or patients at risk of complications related to influenza; Information sessions with all the staff in close contact with patients: consisted in slideshow that explain the matters related to the disease, responses to doubts and questions regarding the vaccination	35% of the total targeted staff decided to receive the vaccination	Main reason to explain low coverage rates was lack of time; Reasons for non-adherence to the program: fear of side effects, doubts about vaccination safety, polemics concerning HBV in France
O Launay, Impact of free on-site vaccine and/or healthcare workers training on hepatitis B vaccination acceptability in high-risk subjects: a pre-post cluster randomized study, 2014(Launay et al., 2014)	Anonymous HIV and HBV testing centers	September 2009 to March 2011	Purpose: assess the impact of free on-site hepatitis B vaccine availability and/or HCPs training, on vaccination acceptability in high risk groups, with 3 different interventions (training of HCPs, availability of a free hepatitis B vaccine, or both interventions); Vaccination offered on the spot	Increase of vaccine acceptability and vaccine coverage, mainly in the group that received both interventions; No significant change in the group for which the solely intervention was the training of HCPs	Both interventions combined were more effective; Training of HCPs as a single strategy was not effective

Table 3. Summary of main recommendations from health authorities and medical associations on strategies to address vaccine hesitancy in France.

Title/Author/year	Main recommendations
La vaccination : un acte individuel pour un bénéfice collectif  [Vaccination: an individual act for a collective benefit], Academy of pharmacy, 2012^47	For HCPs: reinforce initial and continuous vaccination trainings empowerment of pharmacists to practice vaccination use of electronic booklets use of a single term to describe mandatory vaccines and recommended vaccines
Programme national d'amélioration de la politique vaccinale 2012–2017 [National Program for Improving Immunization Policy 2012-2017], National direction of health, 2012^51	Simplify the vaccination schedule Improve access to vaccination Redefine the terms of “mandatory vaccines” and “recommended vaccines”
Avis relatif à la politique vaccinale et à l'obligation vaccinale en population Générale (hors milieu professionnel et règlement sanitaire international) et à la levée des obstacles financiers à la vaccination [Opinion on immunization policy and mandatory vaccination in the general population (outside the professional environment and international health regulations) and to the removal of financial obstacles to vaccination], High Council of Public Health, March 13^th, 2013 and March, 6^th, 2014^15	Organization of a debate about the lift of mandatory vaccines, within the frame of health authorities Extend vaccinations places to life communities Full coverage of the fees engaged into the vaccination act Empowerment for other HCPs to practice vaccination
Rapport sur la politique de vaccination [Report on Immunization policy], S. Hurel, 2016^50	Set up of a website dedicated to vaccination, with a Questions & Answers section Monitor the content of social media Publication of a periodic electronic bulletin of information for HCPs, on the latest developments concerning vaccines and immunization policies, with limitless access Use of new technologies that combined an increase in life duration of vaccines and shortens the time needed to expand production, to avoid vaccine shortages Facilitate the deployment of information tools for HCPs
Rapport sur la vaccination [Report on immunization], Citizens' consultation committee on immunization, 2016^31	Implementation of a website to inform HCPs and the public on immunization matters Full coverage of the purchasing costs of vaccines through compulsory health insurance schemes Temporary extension of the child's immunization obligations with the possibility of invoking an exemption clause Development of research programs covering different aspects of immunization Facilitate vaccination in all prevention, care or shelter settings, by putting the vaccines available for physicians, pediatricians, specialists, by enabling nurses to make revaccinations, by giving a financial support to centers and nursing homes Empowerment of pharmacists in vaccination, after adequate training, to promote access to vaccination, in collaboration with physicians
Avis relatif à la vaccination anti- Méningococcique C [Opinion on the vaccination against Meningococcal C], High Council on Public Health, 2016.^68	Recommendation of Men C vaccination for children under 1, with one dose at 5 months followed by a booster dose at 12 months

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