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Ward)] TJ ET 0.271 0.267 0.267 rg BT 258.144 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 263.565 663.247 Td /F1 9.8 Tf [(William S Schulz)] TJ ET 0.271 0.267 0.267 rg BT 336.154 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 341.575 663.247 Td /F1 9.8 Tf [(Pierre Verger)] TJ ET 0.271 0.267 0.267 rg BT 26.250 651.342 Td /F1 9.8 Tf [(Peretti-Watel P, Larson HJ, Ward JK, Schulz WS, Verger P. Vaccine Hesitancy: Clarifying a Theoretical Framework for an )] TJ ET BT 26.250 639.438 Td /F1 9.8 Tf [(Ambiguous Notion. PLOS Currents Outbreaks. 2015 Feb 25 . Edition 1. doi: )] TJ ET BT 26.250 627.533 Td /F1 9.8 Tf [(10.1371/currents.outbreaks.6844c80ff9f5b273f34c91f71b7fc289.)] TJ ET q 15.000 46.187 577.500 578.965 re W n 0.271 0.267 0.267 rg BT 26.250 598.430 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 578.476 Td /F1 9.8 Tf [(Today, according to many public health experts, public confidence in vaccines is waning. The term vaccine hesitancy \(VH\) is )] TJ ET BT 26.250 566.571 Td /F1 9.8 Tf [(increasingly used to describe the spread of such vaccine reluctance. But VH is an ambiguous notion and its theoretical )] TJ ET BT 26.250 554.667 Td /F1 9.8 Tf [(background appears uncertain. To clarify this concept, we first review the current definitions of VH in the public health literature )] TJ ET BT 26.250 542.762 Td /F1 9.8 Tf [(and examine its most prominent characteristics. VH has been defined as a set of beliefs, attitudes, or behaviours, or some )] TJ ET BT 26.250 530.857 Td /F1 9.8 Tf [(combination of them, shared by a large and heterogeneous portion of the population and including people who exhibit reluctant )] TJ ET BT 26.250 518.952 Td /F1 9.8 Tf [(conformism \(they may either decline a vaccine, delay it or accept it despite their doubts\) and vaccine-specific behaviours. )] TJ ET BT 26.250 507.048 Td /F1 9.8 Tf [(Secondly, we underline some of the ambiguities of this notion and argue that it is more a catchall category than a real concept. )] TJ ET BT 26.250 495.143 Td /F1 9.8 Tf [(We also call into question the usefulness of understanding VH as an intermediate position along a continuum ranging from anti-)] TJ ET BT 26.250 483.238 Td /F1 9.8 Tf [(vaccine to pro-vaccine attitudes, and we discuss its qualification as a belief, attitude or behaviour. Thirdly, we propose a )] TJ ET BT 26.250 471.333 Td /F1 9.8 Tf [(theoretical framework, based on previous literature and taking into account some major structural features of contemporary )] TJ ET BT 26.250 459.429 Td /F1 9.8 Tf [(societies, that considers VH as a kind of decision-making process that depends on peoples level of commitment to )] TJ ET BT 26.250 447.524 Td /F1 9.8 Tf [(healthism/risk culture and on their level of confidence in the health authorities and mainstream medicine.)] TJ ET BT 26.250 410.921 Td /F4 12.0 Tf [(Funding Statement)] TJ ET BT 26.250 390.967 Td /F1 9.8 Tf [(Funding: Agence Nationale de Scurit du Mdicament et des Produits de Sant \(ANSM\) in the frame of the call for research )] TJ ET BT 26.250 379.062 Td /F1 9.8 Tf [(projects in 2013 \(grant 2013S064\).)] TJ ET BT 26.250 349.960 Td /F4 12.0 Tf [(Related Articles)] TJ ET BT 26.250 330.006 Td /F1 9.8 Tf [(The article is part of the )] TJ ET BT 130.838 330.006 Td /F5 9.8 Tf [(PLOS Currents Outbreaks )] TJ ET BT 247.341 330.006 Td /F1 9.8 Tf [()] TJ ET 0.267 0.267 0.267 rg BT 250.588 330.006 Td /F1 9.8 Tf [(Vaccine Hesitancy Collection)] TJ ET 0.271 0.267 0.267 rg BT 376.294 330.006 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 293.403 Td /F4 12.0 Tf [(Introduction)] TJ ET BT 26.250 273.449 Td /F1 9.8 Tf [(Today, according to many public health experts, public confidence in vaccines is waning)] TJ ET 0.267 0.267 0.267 rg BT 405.584 274.956 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 410.402 277.337 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 412.812 274.956 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 417.630 277.337 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 420.040 274.956 Td /F4 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 424.858 273.449 Td /F1 9.8 Tf [(. Researchers investigating this )] TJ ET BT 26.250 261.544 Td /F1 9.8 Tf [(phenomenon are now abandoning expressions such as vaccine resistance or vaccine opposition, increasingly replacing )] TJ ET BT 26.250 249.639 Td /F1 9.8 Tf [(them by the new term vaccine hesitancy \(VH\) to describe the spread of vaccine reluctance. According to the Working Group )] TJ ET BT 26.250 237.735 Td /F1 9.8 Tf [(on Vaccine Hesitancy appointed by the World Health Organisations Strategic Advisory Group of Experts \(SAGE\) on )] TJ ET BT 26.250 225.830 Td /F1 9.8 Tf [(Immunisation, VH refers to delay in acceptance or refusal of vaccines despite availability of vaccination services, and this )] TJ ET BT 26.250 213.925 Td /F1 9.8 Tf [(phenomenon is complex and context specific varying across time, place and vaccines )] TJ ET 0.267 0.267 0.267 rg BT 404.482 215.432 Td /F4 8.7 Tf [(4)] TJ ET 0.271 0.267 0.267 rg BT 409.300 213.925 Td /F1 9.8 Tf [(. Several literature reviews have )] TJ ET BT 26.250 202.020 Td /F1 9.8 Tf [(already been devoted to this issue )] TJ ET 0.267 0.267 0.267 rg BT 176.917 203.528 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 181.735 205.909 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 184.145 203.528 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 188.963 205.909 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 191.373 203.528 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 196.191 205.909 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 198.601 203.528 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 203.419 202.020 Td /F1 9.8 Tf [(. Articles using the VH terminology have mainly been published in journals specialised )] TJ ET BT 26.250 190.116 Td /F1 9.8 Tf [(in vaccination or paediatric issues, but also in more generalist journals \(Lancet, )] TJ ET BT 369.265 190.116 Td /F5 9.8 Tf [(British Medical Journal,)] TJ ET BT 470.041 190.116 Td /F5 9.8 Tf [(Science\).)] TJ ET 0.267 0.267 0.267 rg BT 510.679 191.623 Td /F6 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 515.497 194.004 Td /F5 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 517.907 191.623 Td /F6 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 522.725 194.004 Td /F5 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 525.135 191.623 Td /F6 8.7 Tf [(10)] TJ ET 0.271 0.267 0.267 rg BT 26.250 170.711 Td /F1 9.8 Tf [(Despite or perhaps because of this success, VH is an ambiguous notion and its theoretical background appears uncertain. )] TJ ET BT 26.250 158.806 Td /F1 9.8 Tf [(It may have originated as a catchy expression coined by experts to capture policy-makers attention, as current vaccine )] TJ ET BT 26.250 146.901 Td /F1 9.8 Tf [(coverage rates do not yet reflect the growing reluctance toward vaccination witnessed by empirical researchers. But hasty use )] TJ ET BT 26.250 134.997 Td /F1 9.8 Tf [(of this notion may lead to misunderstandings and ineffective policies if, for example, one considers hesitancy as a necessarily )] TJ ET BT 26.250 123.092 Td /F1 9.8 Tf [(transient state between full support and strong opposition.)] TJ ET BT 26.250 103.687 Td /F1 9.8 Tf [(In this paper, we first review the current definitions of VH in the public health literature and examine its most prominent )] TJ ET BT 26.250 91.782 Td /F1 9.8 Tf [(characteristics; we also underline some of its ambiguities. We then call into question the usefulness of the common )] TJ ET BT 26.250 79.878 Td /F1 9.8 Tf [(understanding of VH as an intermediate position along a continuum ranging from anti-vaccine to pro-vaccine attitudes, and we )] TJ ET BT 26.250 67.973 Td /F1 9.8 Tf [(discuss its qualification as a belief, attitude, or behaviour. Finally, we propose a theoretical framework related to two different )] TJ ET BT 26.250 56.068 Td /F1 9.8 Tf [(concepts: healthism/risk culture and \(dis\)trust toward health authorities and mainstream medicine.)] TJ ET Q q 15.000 684.354 577.500 53.646 re W n 0.267 0.267 0.267 rg BT 15.000 718.042 Td /F2 21.0 Tf [(Vaccine Hesitancy: Clarifying a Theoretical Framework for an )] TJ ET BT 15.000 693.094 Td /F2 21.0 Tf [(Ambiguous Notion)] TJ ET Q 0.271 0.267 0.267 rg BT 15.000 675.088 Td /F3 9.8 Tf [(February 25, 2015)] TJ ET BT 93.263 675.088 Td /F3 9.8 Tf [()] TJ ET 0.267 0.267 0.267 rg BT 98.138 675.088 Td /F3 9.8 Tf [(Discussion)] TJ ET BT 26.250 663.247 Td /F1 9.8 Tf [(Patrick Peretti-Watel)] TJ ET 0.271 0.267 0.267 rg BT 115.102 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 120.523 663.247 Td /F1 9.8 Tf [(Heidi J Larson)] TJ ET 0.271 0.267 0.267 rg BT 182.835 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 188.256 663.247 Td /F1 9.8 Tf [(Jeremy K. Ward)] TJ ET 0.271 0.267 0.267 rg BT 258.144 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 263.565 663.247 Td /F1 9.8 Tf [(William S Schulz)] TJ ET 0.271 0.267 0.267 rg BT 336.154 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 341.575 663.247 Td /F1 9.8 Tf [(Pierre Verger)] TJ ET 0.271 0.267 0.267 rg BT 26.250 651.342 Td /F1 9.8 Tf [(Peretti-Watel P, Larson HJ, Ward JK, Schulz WS, Verger P. Vaccine Hesitancy: Clarifying a Theoretical Framework for an )] TJ ET BT 26.250 639.438 Td /F1 9.8 Tf [(Ambiguous Notion. PLOS Currents Outbreaks. 2015 Feb 25 . Edition 1. doi: )] TJ ET BT 26.250 627.533 Td /F1 9.8 Tf [(10.1371/currents.outbreaks.6844c80ff9f5b273f34c91f71b7fc289.)] TJ ET q 15.000 46.187 577.500 578.965 re W n 0.271 0.267 0.267 rg BT 26.250 598.430 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 578.476 Td /F1 9.8 Tf [(Today, according to many public health experts, public confidence in vaccines is waning. The term vaccine hesitancy \(VH\) is )] TJ ET BT 26.250 566.571 Td /F1 9.8 Tf [(increasingly used to describe the spread of such vaccine reluctance. But VH is an ambiguous notion and its theoretical )] TJ ET BT 26.250 554.667 Td /F1 9.8 Tf [(background appears uncertain. To clarify this concept, we first review the current definitions of VH in the public health literature )] TJ ET BT 26.250 542.762 Td /F1 9.8 Tf [(and examine its most prominent characteristics. VH has been defined as a set of beliefs, attitudes, or behaviours, or some )] TJ ET BT 26.250 530.857 Td /F1 9.8 Tf [(combination of them, shared by a large and heterogeneous portion of the population and including people who exhibit reluctant )] TJ ET BT 26.250 518.952 Td /F1 9.8 Tf [(conformism \(they may either decline a vaccine, delay it or accept it despite their doubts\) and vaccine-specific behaviours. )] TJ ET BT 26.250 507.048 Td /F1 9.8 Tf [(Secondly, we underline some of the ambiguities of this notion and argue that it is more a catchall category than a real concept. )] TJ ET BT 26.250 495.143 Td /F1 9.8 Tf [(We also call into question the usefulness of understanding VH as an intermediate position along a continuum ranging from anti-)] TJ ET BT 26.250 483.238 Td /F1 9.8 Tf [(vaccine to pro-vaccine attitudes, and we discuss its qualification as a belief, attitude or behaviour. Thirdly, we propose a )] TJ ET BT 26.250 471.333 Td /F1 9.8 Tf [(theoretical framework, based on previous literature and taking into account some major structural features of contemporary )] TJ ET BT 26.250 459.429 Td /F1 9.8 Tf [(societies, that considers VH as a kind of decision-making process that depends on peoples level of commitment to )] TJ ET BT 26.250 447.524 Td /F1 9.8 Tf [(healthism/risk culture and on their level of confidence in the health authorities and mainstream medicine.)] TJ ET BT 26.250 410.921 Td /F4 12.0 Tf [(Funding Statement)] TJ ET BT 26.250 390.967 Td /F1 9.8 Tf [(Funding: Agence Nationale de Scurit du Mdicament et des Produits de Sant \(ANSM\) in the frame of the call for research )] TJ ET BT 26.250 379.062 Td /F1 9.8 Tf [(projects in 2013 \(grant 2013S064\).)] TJ ET BT 26.250 349.960 Td /F4 12.0 Tf [(Related Articles)] TJ ET BT 26.250 330.006 Td /F1 9.8 Tf [(The article is part of the )] TJ ET BT 130.838 330.006 Td /F5 9.8 Tf [(PLOS Currents Outbreaks )] TJ ET BT 247.341 330.006 Td /F1 9.8 Tf [()] TJ ET 0.267 0.267 0.267 rg BT 250.588 330.006 Td /F1 9.8 Tf [(Vaccine Hesitancy Collection)] TJ ET 0.271 0.267 0.267 rg BT 376.294 330.006 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 293.403 Td /F4 12.0 Tf [(Introduction)] TJ ET BT 26.250 273.449 Td /F1 9.8 Tf [(Today, according to many public health experts, public confidence in vaccines is waning)] TJ ET 0.267 0.267 0.267 rg BT 405.584 274.956 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 410.402 277.337 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 412.812 274.956 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 417.630 277.337 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 420.040 274.956 Td /F4 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 424.858 273.449 Td /F1 9.8 Tf [(. Researchers investigating this )] TJ ET BT 26.250 261.544 Td /F1 9.8 Tf [(phenomenon are now abandoning expressions such as vaccine resistance or vaccine opposition, increasingly replacing )] TJ ET BT 26.250 249.639 Td /F1 9.8 Tf [(them by the new term vaccine hesitancy \(VH\) to describe the spread of vaccine reluctance. According to the Working Group )] TJ ET BT 26.250 237.735 Td /F1 9.8 Tf [(on Vaccine Hesitancy appointed by the World Health Organisations Strategic Advisory Group of Experts \(SAGE\) on )] TJ ET BT 26.250 225.830 Td /F1 9.8 Tf [(Immunisation, VH refers to delay in acceptance or refusal of vaccines despite availability of vaccination services, and this )] TJ ET BT 26.250 213.925 Td /F1 9.8 Tf [(phenomenon is complex and context specific varying across time, place and vaccines )] TJ ET 0.267 0.267 0.267 rg BT 404.482 215.432 Td /F4 8.7 Tf [(4)] TJ ET 0.271 0.267 0.267 rg BT 409.300 213.925 Td /F1 9.8 Tf [(. Several literature reviews have )] TJ ET BT 26.250 202.020 Td /F1 9.8 Tf [(already been devoted to this issue )] TJ ET 0.267 0.267 0.267 rg BT 176.917 203.528 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 181.735 205.909 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 184.145 203.528 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 188.963 205.909 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 191.373 203.528 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 196.191 205.909 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 198.601 203.528 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 203.419 202.020 Td /F1 9.8 Tf [(. Articles using the VH terminology have mainly been published in journals specialised )] TJ ET BT 26.250 190.116 Td /F1 9.8 Tf [(in vaccination or paediatric issues, but also in more generalist journals \(Lancet, )] TJ ET BT 369.265 190.116 Td /F5 9.8 Tf [(British Medical Journal,)] TJ ET BT 470.041 190.116 Td /F5 9.8 Tf [(Science\).)] TJ ET 0.267 0.267 0.267 rg BT 510.679 191.623 Td /F6 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 515.497 194.004 Td /F5 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 517.907 191.623 Td /F6 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 522.725 194.004 Td /F5 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 525.135 191.623 Td /F6 8.7 Tf [(10)] TJ ET 0.271 0.267 0.267 rg BT 26.250 170.711 Td /F1 9.8 Tf [(Despite or perhaps because of this success, VH is an ambiguous notion and its theoretical background appears uncertain. )] TJ ET BT 26.250 158.806 Td /F1 9.8 Tf [(It may have originated as a catchy expression coined by experts to capture policy-makers attention, as current vaccine )] TJ ET BT 26.250 146.901 Td /F1 9.8 Tf [(coverage rates do not yet reflect the growing reluctance toward vaccination witnessed by empirical researchers. But hasty use )] TJ ET BT 26.250 134.997 Td /F1 9.8 Tf [(of this notion may lead to misunderstandings and ineffective policies if, for example, one considers hesitancy as a necessarily )] TJ ET BT 26.250 123.092 Td /F1 9.8 Tf [(transient state between full support and strong opposition.)] TJ ET BT 26.250 103.687 Td /F1 9.8 Tf [(In this paper, we first review the current definitions of VH in the public health literature and examine its most prominent )] TJ ET BT 26.250 91.782 Td /F1 9.8 Tf [(characteristics; we also underline some of its ambiguities. We then call into question the usefulness of the common )] TJ ET BT 26.250 79.878 Td /F1 9.8 Tf [(understanding of VH as an intermediate position along a continuum ranging from anti-vaccine to pro-vaccine attitudes, and we )] TJ ET BT 26.250 67.973 Td /F1 9.8 Tf [(discuss its qualification as a belief, attitude, or behaviour. Finally, we propose a theoretical framework related to two different )] TJ ET BT 26.250 56.068 Td /F1 9.8 Tf [(concepts: healthism/risk culture and \(dis\)trust toward health authorities and mainstream medicine.)] TJ ET Q q 15.000 684.354 577.500 53.646 re W n 0.267 0.267 0.267 rg BT 15.000 718.042 Td /F2 21.0 Tf [(Vaccine Hesitancy: Clarifying a Theoretical Framework for an )] TJ ET BT 15.000 693.094 Td /F2 21.0 Tf [(Ambiguous Notion)] TJ ET Q 0.271 0.267 0.267 rg BT 15.000 675.088 Td /F3 9.8 Tf [(February 25, 2015)] TJ ET BT 93.263 675.088 Td /F3 9.8 Tf [()] TJ ET 0.267 0.267 0.267 rg BT 98.138 675.088 Td /F3 9.8 Tf [(Discussion)] TJ ET BT 26.250 663.247 Td /F1 9.8 Tf [(Patrick Peretti-Watel)] TJ ET 0.271 0.267 0.267 rg BT 115.102 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 120.523 663.247 Td /F1 9.8 Tf [(Heidi J Larson)] TJ ET 0.271 0.267 0.267 rg BT 182.835 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 188.256 663.247 Td /F1 9.8 Tf [(Jeremy K. Ward)] TJ ET 0.271 0.267 0.267 rg BT 258.144 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 263.565 663.247 Td /F1 9.8 Tf [(William S Schulz)] TJ ET 0.271 0.267 0.267 rg BT 336.154 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 341.575 663.247 Td /F1 9.8 Tf [(Pierre Verger)] TJ ET 0.271 0.267 0.267 rg BT 26.250 651.342 Td /F1 9.8 Tf [(Peretti-Watel P, Larson HJ, Ward JK, Schulz WS, Verger P. Vaccine Hesitancy: Clarifying a Theoretical Framework for an )] TJ ET BT 26.250 639.438 Td /F1 9.8 Tf [(Ambiguous Notion. PLOS Currents Outbreaks. 2015 Feb 25 . Edition 1. doi: )] TJ ET BT 26.250 627.533 Td /F1 9.8 Tf [(10.1371/currents.outbreaks.6844c80ff9f5b273f34c91f71b7fc289.)] TJ ET q 15.000 46.187 577.500 578.965 re W n 0.271 0.267 0.267 rg BT 26.250 598.430 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 578.476 Td /F1 9.8 Tf [(Today, according to many public health experts, public confidence in vaccines is waning. The term vaccine hesitancy \(VH\) is )] TJ ET BT 26.250 566.571 Td /F1 9.8 Tf [(increasingly used to describe the spread of such vaccine reluctance. But VH is an ambiguous notion and its theoretical )] TJ ET BT 26.250 554.667 Td /F1 9.8 Tf [(background appears uncertain. To clarify this concept, we first review the current definitions of VH in the public health literature )] TJ ET BT 26.250 542.762 Td /F1 9.8 Tf [(and examine its most prominent characteristics. VH has been defined as a set of beliefs, attitudes, or behaviours, or some )] TJ ET BT 26.250 530.857 Td /F1 9.8 Tf [(combination of them, shared by a large and heterogeneous portion of the population and including people who exhibit reluctant )] TJ ET BT 26.250 518.952 Td /F1 9.8 Tf [(conformism \(they may either decline a vaccine, delay it or accept it despite their doubts\) and vaccine-specific behaviours. )] TJ ET BT 26.250 507.048 Td /F1 9.8 Tf [(Secondly, we underline some of the ambiguities of this notion and argue that it is more a catchall category than a real concept. )] TJ ET BT 26.250 495.143 Td /F1 9.8 Tf [(We also call into question the usefulness of understanding VH as an intermediate position along a continuum ranging from anti-)] TJ ET BT 26.250 483.238 Td /F1 9.8 Tf [(vaccine to pro-vaccine attitudes, and we discuss its qualification as a belief, attitude or behaviour. Thirdly, we propose a )] TJ ET BT 26.250 471.333 Td /F1 9.8 Tf [(theoretical framework, based on previous literature and taking into account some major structural features of contemporary )] TJ ET BT 26.250 459.429 Td /F1 9.8 Tf [(societies, that considers VH as a kind of decision-making process that depends on peoples level of commitment to )] TJ ET BT 26.250 447.524 Td /F1 9.8 Tf [(healthism/risk culture and on their level of confidence in the health authorities and mainstream medicine.)] TJ ET BT 26.250 410.921 Td /F4 12.0 Tf [(Funding Statement)] TJ ET BT 26.250 390.967 Td /F1 9.8 Tf [(Funding: Agence Nationale de Scurit du Mdicament et des Produits de Sant \(ANSM\) in the frame of the call for research )] TJ ET BT 26.250 379.062 Td /F1 9.8 Tf [(projects in 2013 \(grant 2013S064\).)] TJ ET BT 26.250 349.960 Td /F4 12.0 Tf [(Related Articles)] TJ ET BT 26.250 330.006 Td /F1 9.8 Tf [(The article is part of the )] TJ ET BT 130.838 330.006 Td /F5 9.8 Tf [(PLOS Currents Outbreaks )] TJ ET BT 247.341 330.006 Td /F1 9.8 Tf [()] TJ ET 0.267 0.267 0.267 rg BT 250.588 330.006 Td /F1 9.8 Tf [(Vaccine Hesitancy Collection)] TJ ET 0.271 0.267 0.267 rg BT 376.294 330.006 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 293.403 Td /F4 12.0 Tf [(Introduction)] TJ ET BT 26.250 273.449 Td /F1 9.8 Tf [(Today, according to many public health experts, public confidence in vaccines is waning)] TJ ET 0.267 0.267 0.267 rg BT 405.584 274.956 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 410.402 277.337 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 412.812 274.956 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 417.630 277.337 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 420.040 274.956 Td /F4 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 424.858 273.449 Td /F1 9.8 Tf [(. Researchers investigating this )] TJ ET BT 26.250 261.544 Td /F1 9.8 Tf [(phenomenon are now abandoning expressions such as vaccine resistance or vaccine opposition, increasingly replacing )] TJ ET BT 26.250 249.639 Td /F1 9.8 Tf [(them by the new term vaccine hesitancy \(VH\) to describe the spread of vaccine reluctance. According to the Working Group )] TJ ET BT 26.250 237.735 Td /F1 9.8 Tf [(on Vaccine Hesitancy appointed by the World Health Organisations Strategic Advisory Group of Experts \(SAGE\) on )] TJ ET BT 26.250 225.830 Td /F1 9.8 Tf [(Immunisation, VH refers to delay in acceptance or refusal of vaccines despite availability of vaccination services, and this )] TJ ET BT 26.250 213.925 Td /F1 9.8 Tf [(phenomenon is complex and context specific varying across time, place and vaccines )] TJ ET 0.267 0.267 0.267 rg BT 404.482 215.432 Td /F4 8.7 Tf [(4)] TJ ET 0.271 0.267 0.267 rg BT 409.300 213.925 Td /F1 9.8 Tf [(. Several literature reviews have )] TJ ET BT 26.250 202.020 Td /F1 9.8 Tf [(already been devoted to this issue )] TJ ET 0.267 0.267 0.267 rg BT 176.917 203.528 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 181.735 205.909 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 184.145 203.528 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 188.963 205.909 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 191.373 203.528 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 196.191 205.909 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 198.601 203.528 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 203.419 202.020 Td /F1 9.8 Tf [(. Articles using the VH terminology have mainly been published in journals specialised )] TJ ET BT 26.250 190.116 Td /F1 9.8 Tf [(in vaccination or paediatric issues, but also in more generalist journals \(Lancet, )] TJ ET BT 369.265 190.116 Td /F5 9.8 Tf [(British Medical Journal,)] TJ ET BT 470.041 190.116 Td /F5 9.8 Tf [(Science\).)] TJ ET 0.267 0.267 0.267 rg BT 510.679 191.623 Td /F6 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 515.497 194.004 Td /F5 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 517.907 191.623 Td /F6 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 522.725 194.004 Td /F5 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 525.135 191.623 Td /F6 8.7 Tf [(10)] TJ ET 0.271 0.267 0.267 rg BT 26.250 170.711 Td /F1 9.8 Tf [(Despite or perhaps because of this success, VH is an ambiguous notion and its theoretical background appears uncertain. )] TJ ET BT 26.250 158.806 Td /F1 9.8 Tf [(It may have originated as a catchy expression coined by experts to capture policy-makers attention, as current vaccine )] TJ ET BT 26.250 146.901 Td /F1 9.8 Tf [(coverage rates do not yet reflect the growing reluctance toward vaccination witnessed by empirical researchers. But hasty use )] TJ ET BT 26.250 134.997 Td /F1 9.8 Tf [(of this notion may lead to misunderstandings and ineffective policies if, for example, one considers hesitancy as a necessarily )] TJ ET BT 26.250 123.092 Td /F1 9.8 Tf [(transient state between full support and strong opposition.)] TJ ET BT 26.250 103.687 Td /F1 9.8 Tf [(In this paper, we first review the current definitions of VH in the public health literature and examine its most prominent )] TJ ET BT 26.250 91.782 Td /F1 9.8 Tf [(characteristics; we also underline some of its ambiguities. We then call into question the usefulness of the common )] TJ ET BT 26.250 79.878 Td /F1 9.8 Tf [(understanding of VH as an intermediate position along a continuum ranging from anti-vaccine to pro-vaccine attitudes, and we )] TJ ET BT 26.250 67.973 Td /F1 9.8 Tf [(discuss its qualification as a belief, attitude, or behaviour. Finally, we propose a theoretical framework related to two different )] TJ ET BT 26.250 56.068 Td /F1 9.8 Tf [(concepts: healthism/risk culture and \(dis\)trust toward health authorities and mainstream medicine.)] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(1)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Outbreaks)] TJ ET Q endstream endobj 8 0 obj << /Type /Font /Subtype /Type1 /Name /F1 /BaseFont /Helvetica /Encoding /WinAnsiEncoding >> endobj 9 0 obj << /Type /Font /Subtype /Type1 /Name /F2 /BaseFont /Times-Bold /Encoding /WinAnsiEncoding >> endobj 10 0 obj << /Type /Font /Subtype /Type1 /Name /F3 /BaseFont /Times-Italic /Encoding /WinAnsiEncoding >> endobj 11 0 obj << /Type /Font /Subtype /Type1 /Name /F4 /BaseFont /Helvetica-Bold /Encoding /WinAnsiEncoding >> endobj 12 0 obj << /Type /Font /Subtype /Type1 /Name /F5 /BaseFont /Helvetica-Oblique /Encoding /WinAnsiEncoding >> endobj 13 0 obj << /Type /Font /Subtype /Type1 /Name /F6 /BaseFont 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R 368 0 R 370 0 R 372 0 R 374 0 R 376 0 R 378 0 R 380 0 R 382 0 R 384 0 R 386 0 R 388 0 R 390 0 R 392 0 R 394 0 R 396 0 R 398 0 R 400 0 R 402 0 R 404 0 R 406 0 R 408 0 R 410 0 R 412 0 R 414 0 R 416 0 R 418 0 R 420 0 R 422 0 R 424 0 R 426 0 R 428 0 R 430 0 R 432 0 R 434 0 R 436 0 R 438 0 R 440 0 R 442 0 R 444 0 R 446 0 R 448 0 R ] /Contents 137 0 R >> endobj 137 0 obj << /Length 43468 >> stream 0.271 0.267 0.267 rg q 15.000 24.958 577.500 752.042 re W n 0.271 0.267 0.267 rg BT 26.250 750.278 Td /F4 12.0 Tf [(The ambiguities of current definitions of VH.)] TJ ET BT 26.250 730.324 Td /F4 9.8 Tf [(VH definitions in the public health literature.)] TJ ET BT 26.250 710.919 Td /F1 9.8 Tf [(VH has been defined as a set of beliefs )] TJ ET 0.267 0.267 0.267 rg BT 198.601 712.427 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 208.238 710.919 Td /F1 9.8 Tf [(, attitudes )] TJ ET 0.267 0.267 0.267 rg BT 253.225 712.427 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 258.043 714.808 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 260.453 712.427 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 270.090 710.919 Td /F1 9.8 Tf [(, behaviours )] TJ ET 0.267 0.267 0.267 rg BT 325.909 712.427 Td /F4 8.7 Tf [(13)] TJ ET 0.271 0.267 0.267 rg BT 335.546 710.919 Td /F1 9.8 Tf [(, or some combination of them )] TJ ET 0.267 0.267 0.267 rg BT 469.394 712.427 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 479.031 714.808 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 481.441 712.427 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 491.078 710.919 Td /F1 9.8 Tf [(, exhibited by lay )] TJ ET BT 26.250 699.015 Td /F1 9.8 Tf [(people in regard to their own or their childrens immunisations, but also sometimes by healthcare professionals. VH is an )] TJ ET BT 26.250 687.110 Td /F1 9.8 Tf [(attribute ascribed to a large and heterogeneous category )] TJ ET 0.267 0.267 0.267 rg BT 273.929 688.617 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 278.748 690.998 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 281.157 688.617 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 285.976 690.998 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 288.385 688.617 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 293.204 690.998 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 295.613 688.617 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 305.251 687.110 Td /F1 9.8 Tf [( that regroups people who share varying degrees and motives )] TJ ET BT 26.250 675.205 Td /F1 9.8 Tf [(of indecision and who hold an intermediate position along a continuum ranging from full support for vaccination to strong )] TJ ET BT 26.250 663.300 Td /F1 9.8 Tf [(opposition to any vaccine )] TJ ET 0.267 0.267 0.267 rg BT 138.433 664.808 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 143.252 667.189 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 145.662 664.808 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 150.480 667.189 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 152.890 664.808 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 162.527 663.300 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 643.896 Td /F1 9.8 Tf [(These people are characterised by what we may call reluctant conformism and vaccine-specific behaviours )] TJ ET 0.267 0.267 0.267 rg BT 490.087 645.403 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 494.905 647.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 497.315 645.403 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 502.133 647.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 504.543 645.403 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 509.361 647.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 511.771 645.403 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 521.408 643.896 Td /F1 9.8 Tf [(. They may )] TJ ET BT 26.250 631.991 Td /F1 9.8 Tf [(decline a vaccine, but they may also delay it or even accept it in due time despite their doubts/reluctance. In other words, they )] TJ ET BT 26.250 620.086 Td /F1 9.8 Tf [(may endorse a wide range of non-specific behaviours, all of which can result from something else than VH. This behavioural )] TJ ET BT 26.250 608.181 Td /F1 9.8 Tf [(outcome can vary from one vaccine to another: they may accept one vaccine, but decline/delay another, as they base their )] TJ ET BT 26.250 596.277 Td /F1 9.8 Tf [(decision on vaccine-specific features.)] TJ ET BT 26.250 576.872 Td /F4 9.8 Tf [(A catchall category, not a concept.)] TJ ET BT 26.250 557.467 Td /F1 9.8 Tf [(Definitions that try to describe VH as it is used by researchers tend to be very broad and to embrace heterogeneous )] TJ ET BT 26.250 545.562 Td /F1 9.8 Tf [(people/situations and many different explanatory factors \(including historic, political and socio-cultural contexts, as well as )] TJ ET BT 26.250 533.658 Td /F1 9.8 Tf [(individual/social group influences )] TJ ET 0.267 0.267 0.267 rg BT 171.476 535.165 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 176.295 537.546 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 178.704 535.165 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 183.523 537.546 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 185.932 535.165 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 190.751 533.658 Td /F1 9.8 Tf [(\). Moreover, some previous empirical studies have found quite contrasting profiles of )] TJ ET BT 26.250 521.753 Td /F1 9.8 Tf [(attitudes among those who could be categorised as vaccine-hesitant )] TJ ET 0.267 0.267 0.267 rg BT 324.317 523.260 Td /F4 8.7 Tf [(13)] TJ ET 0.271 0.267 0.267 rg BT 333.955 525.641 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 336.364 523.260 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 346.001 521.753 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 502.348 Td /F1 9.8 Tf [(Previous studies also show several contradictions in their use of VH. First, some authors argue that it is something new, distinct )] TJ ET BT 26.250 490.443 Td /F1 9.8 Tf [(from old-fashioned anti-vaccination )] TJ ET 0.267 0.267 0.267 rg BT 180.144 491.951 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 189.781 494.332 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 192.191 491.951 Td /F4 8.7 Tf [(15)] TJ ET 0.271 0.267 0.267 rg BT 201.828 494.332 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 204.237 491.951 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 213.875 490.443 Td /F1 9.8 Tf [(, while others state that it is as old as vaccination itself )] TJ ET 0.267 0.267 0.267 rg BT 450.146 491.951 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 454.965 494.332 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 457.374 491.951 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 467.012 494.332 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 469.421 491.951 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 479.058 490.443 Td /F1 9.8 Tf [(. Second, some )] TJ ET BT 26.250 478.539 Td /F1 9.8 Tf [(authors consider that VH corresponds to an intermediate position, in the middle of the continuum between the pro-vaccination )] TJ ET BT 26.250 466.634 Td /F1 9.8 Tf [(and anti-vaccination positions \(that is, on what we shall refer to as the pro/anti continuum )] TJ ET 0.267 0.267 0.267 rg BT 415.343 468.141 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 420.162 470.522 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 422.571 468.141 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 427.390 470.522 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 429.799 468.141 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 439.437 466.634 Td /F1 9.8 Tf [( , while others consider that VH )] TJ ET BT 26.250 454.729 Td /F1 9.8 Tf [(includes strong opposition to vaccination )] TJ ET 0.267 0.267 0.267 rg BT 204.002 456.236 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 213.640 458.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 216.049 456.236 Td /F4 8.7 Tf [(19)] TJ ET 0.271 0.267 0.267 rg BT 225.686 454.729 Td /F1 9.8 Tf [(. Third, authors argue that VH is due to ignorance, misperceptions or )] TJ ET BT 26.250 442.824 Td /F1 9.8 Tf [(disinformation )] TJ ET 0.267 0.267 0.267 rg BT 89.644 444.332 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 99.282 446.713 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 101.691 444.332 Td /F4 8.7 Tf [(21)] TJ ET 0.271 0.267 0.267 rg BT 111.329 442.824 Td /F1 9.8 Tf [(, and others that it may result from too much information )] TJ ET 0.267 0.267 0.267 rg BT 355.722 444.332 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 365.359 446.713 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 367.769 444.332 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 377.406 446.713 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 379.815 444.332 Td /F4 8.7 Tf [(22)] TJ ET 0.271 0.267 0.267 rg BT 389.453 442.824 Td /F1 9.8 Tf [(. One author even states that VH is driven )] TJ ET BT 26.250 430.920 Td /F1 9.8 Tf [(basically by emotions and irrationality and vaccine refusers should be liable for the harm they cause to others )] TJ ET 0.267 0.267 0.267 rg BT 499.330 432.427 Td /F4 8.7 Tf [(23)] TJ ET 0.271 0.267 0.267 rg BT 508.967 430.920 Td /F1 9.8 Tf [(. Fourth, VH is )] TJ ET BT 26.250 419.015 Td /F1 9.8 Tf [(sometimes described with a neutral tone, or even praised )] TJ ET 0.267 0.267 0.267 rg BT 276.065 420.522 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 280.883 422.903 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 283.293 420.522 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 292.930 422.903 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 295.339 420.522 Td /F4 8.7 Tf [(24)] TJ ET 0.271 0.267 0.267 rg BT 304.977 419.015 Td /F1 9.8 Tf [(, but it has also been described \(metaphorically?\) as a )] TJ ET BT 26.250 407.110 Td /F1 9.8 Tf [(condition more or less severe that should be diagnosed among people at risk )] TJ ET 0.267 0.267 0.267 rg BT 380.643 408.617 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 385.462 410.998 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 387.871 408.617 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 397.508 410.998 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 399.918 408.617 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 409.555 407.110 Td /F1 9.8 Tf [( and as a weed deeply rooted in the )] TJ ET BT 26.250 395.205 Td /F1 9.8 Tf [(defects of human nature )] TJ ET 0.267 0.267 0.267 rg BT 134.105 396.713 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 143.742 395.205 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 375.801 Td /F1 9.8 Tf [(Finally, while some empirical studies report that VH is more frequent among people with a high socioeconomic status \(SES\), )] TJ ET BT 26.250 363.896 Td /F1 9.8 Tf [(others report the opposite or observe no relation, especially regarding educational level )] TJ ET 0.267 0.267 0.267 rg BT 404.511 365.403 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 409.330 367.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 411.739 365.403 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 416.558 367.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 418.967 365.403 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 423.786 367.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 426.195 365.403 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 435.832 367.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 438.242 365.403 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 447.879 367.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 450.288 365.403 Td /F4 8.7 Tf [(27)] TJ ET 0.271 0.267 0.267 rg BT 459.926 363.896 Td /F1 9.8 Tf [(. Such inconsistent results )] TJ ET BT 26.250 351.991 Td /F1 9.8 Tf [(are disturbing for social scientists, as SES is supposed to strongly shape our beliefs, attitudes and behaviours, in meaningful )] TJ ET BT 26.250 340.086 Td /F1 9.8 Tf [(ways.)] TJ ET BT 26.250 320.682 Td /F1 9.8 Tf [(These different attitudes tend to assort into specific profiles; for example, those who consider VH an old phenomenon that )] TJ ET BT 26.250 308.777 Td /F1 9.8 Tf [(encompasses anti-vaccination attitudes often attribute it to ignorance, misinformation or irrationality, while those who describe it )] TJ ET BT 26.250 296.872 Td /F1 9.8 Tf [(as a new attitude, distinct from strong opposition to vaccination, also argue that it is positively correlated with vaccine-related )] TJ ET BT 26.250 284.967 Td /F1 9.8 Tf [(knowledge.)] TJ ET BT 26.250 265.563 Td /F1 9.8 Tf [(More generally, VH is not really an empirical concept, as the term concept traditionally refers to a general mental )] TJ ET BT 26.250 253.658 Td /F1 9.8 Tf [(representation derived from the variety of perceived objects and defines what is common to them the features necessary and )] TJ ET BT 26.250 241.753 Td /F1 9.8 Tf [(sufficient for membership in the class/concept through comparison, reflection and abstraction. The current definitions of VH, )] TJ ET BT 26.250 229.848 Td /F1 9.8 Tf [(rather than delineating a set of core elements, cover a wide range of heterogeneous, and even sometimes contradictory, )] TJ ET BT 26.250 217.944 Td /F1 9.8 Tf [(elements.)] TJ ET BT 26.250 181.341 Td /F4 12.0 Tf [(Two issues raised by the VH definitions: what is VH, and where to position it?)] TJ ET BT 26.250 161.387 Td /F4 9.8 Tf [(A belief/attitude, a behaviour, or a decision-making process?)] TJ ET BT 26.250 141.982 Td /F1 9.8 Tf [(It is not fully satisfactory to define VH as a behaviour, as it is associated in the literature with various and non-specific )] TJ ET BT 26.250 130.077 Td /F1 9.8 Tf [(behaviours and outcomes \(due to reluctant conformism and vaccine-specific behaviours\). Moreover, VH is not the only possible )] TJ ET BT 26.250 118.173 Td /F1 9.8 Tf [(explanation for each of these different outcomes: acceptance might also be due to strong support, refusal to strong opposition, )] TJ ET BT 26.250 106.268 Td /F1 9.8 Tf [(and delay to procrastination, oversight, or ignorance. Nevertheless, VH may be associated with other kinds of behaviours, such )] TJ ET BT 26.250 94.363 Td /F1 9.8 Tf [(as information seeking, and the notion of attitude can be defined in many different ways \(including a positive or negative )] TJ ET BT 26.250 82.458 Td /F1 9.8 Tf [(evaluation, or a disposition to act\). This ambiguity regarding the nature of VH may create problems in dealing with it: when )] TJ ET BT 26.250 70.554 Td /F1 9.8 Tf [(researchers design an intervention aimed at promoting vaccination or a specific vaccine, for example, should they target an )] TJ ET BT 26.250 58.649 Td /F1 9.8 Tf [(attitudinal or a behavioural outcome?)] TJ ET BT 26.250 39.244 Td /F1 9.8 Tf [(Nevertheless, beyond this ambiguity, it would be probably more useful to consider VH as a decision-making process \(how/why )] TJ ET Q q 15.000 24.958 577.500 752.042 re W n 0.271 0.267 0.267 rg BT 26.250 750.278 Td /F4 12.0 Tf [(The ambiguities of current definitions of VH.)] TJ ET BT 26.250 730.324 Td /F4 9.8 Tf [(VH definitions in the public health literature.)] TJ ET BT 26.250 710.919 Td /F1 9.8 Tf [(VH has been defined as a set of beliefs )] TJ ET 0.267 0.267 0.267 rg BT 198.601 712.427 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 208.238 710.919 Td /F1 9.8 Tf [(, attitudes )] TJ ET 0.267 0.267 0.267 rg BT 253.225 712.427 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 258.043 714.808 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 260.453 712.427 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 270.090 710.919 Td /F1 9.8 Tf [(, behaviours )] TJ ET 0.267 0.267 0.267 rg BT 325.909 712.427 Td /F4 8.7 Tf [(13)] TJ ET 0.271 0.267 0.267 rg BT 335.546 710.919 Td /F1 9.8 Tf [(, or some combination of them )] TJ ET 0.267 0.267 0.267 rg BT 469.394 712.427 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 479.031 714.808 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 481.441 712.427 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 491.078 710.919 Td /F1 9.8 Tf [(, exhibited by lay )] TJ ET BT 26.250 699.015 Td /F1 9.8 Tf [(people in regard to their own or their childrens immunisations, but also sometimes by healthcare professionals. VH is an )] TJ ET BT 26.250 687.110 Td /F1 9.8 Tf [(attribute ascribed to a large and heterogeneous category )] TJ ET 0.267 0.267 0.267 rg BT 273.929 688.617 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 278.748 690.998 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 281.157 688.617 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 285.976 690.998 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 288.385 688.617 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 293.204 690.998 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 295.613 688.617 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 305.251 687.110 Td /F1 9.8 Tf [( that regroups people who share varying degrees and motives )] TJ ET BT 26.250 675.205 Td /F1 9.8 Tf [(of indecision and who hold an intermediate position along a continuum ranging from full support for vaccination to strong )] TJ ET BT 26.250 663.300 Td /F1 9.8 Tf [(opposition to any vaccine )] TJ ET 0.267 0.267 0.267 rg BT 138.433 664.808 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 143.252 667.189 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 145.662 664.808 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 150.480 667.189 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 152.890 664.808 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 162.527 663.300 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 643.896 Td /F1 9.8 Tf [(These people are characterised by what we may call reluctant conformism and vaccine-specific behaviours )] TJ ET 0.267 0.267 0.267 rg BT 490.087 645.403 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 494.905 647.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 497.315 645.403 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 502.133 647.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 504.543 645.403 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 509.361 647.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 511.771 645.403 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 521.408 643.896 Td /F1 9.8 Tf [(. They may )] TJ ET BT 26.250 631.991 Td /F1 9.8 Tf [(decline a vaccine, but they may also delay it or even accept it in due time despite their doubts/reluctance. In other words, they )] TJ ET BT 26.250 620.086 Td /F1 9.8 Tf [(may endorse a wide range of non-specific behaviours, all of which can result from something else than VH. This behavioural )] TJ ET BT 26.250 608.181 Td /F1 9.8 Tf [(outcome can vary from one vaccine to another: they may accept one vaccine, but decline/delay another, as they base their )] TJ ET BT 26.250 596.277 Td /F1 9.8 Tf [(decision on vaccine-specific features.)] TJ ET BT 26.250 576.872 Td /F4 9.8 Tf [(A catchall category, not a concept.)] TJ ET BT 26.250 557.467 Td /F1 9.8 Tf [(Definitions that try to describe VH as it is used by researchers tend to be very broad and to embrace heterogeneous )] TJ ET BT 26.250 545.562 Td /F1 9.8 Tf [(people/situations and many different explanatory factors \(including historic, political and socio-cultural contexts, as well as )] TJ ET BT 26.250 533.658 Td /F1 9.8 Tf [(individual/social group influences )] TJ ET 0.267 0.267 0.267 rg BT 171.476 535.165 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 176.295 537.546 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 178.704 535.165 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 183.523 537.546 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 185.932 535.165 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 190.751 533.658 Td /F1 9.8 Tf [(\). Moreover, some previous empirical studies have found quite contrasting profiles of )] TJ ET BT 26.250 521.753 Td /F1 9.8 Tf [(attitudes among those who could be categorised as vaccine-hesitant )] TJ ET 0.267 0.267 0.267 rg BT 324.317 523.260 Td /F4 8.7 Tf [(13)] TJ ET 0.271 0.267 0.267 rg BT 333.955 525.641 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 336.364 523.260 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 346.001 521.753 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 502.348 Td /F1 9.8 Tf [(Previous studies also show several contradictions in their use of VH. First, some authors argue that it is something new, distinct )] TJ ET BT 26.250 490.443 Td /F1 9.8 Tf [(from old-fashioned anti-vaccination )] TJ ET 0.267 0.267 0.267 rg BT 180.144 491.951 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 189.781 494.332 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 192.191 491.951 Td /F4 8.7 Tf [(15)] TJ ET 0.271 0.267 0.267 rg BT 201.828 494.332 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 204.237 491.951 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 213.875 490.443 Td /F1 9.8 Tf [(, while others state that it is as old as vaccination itself )] TJ ET 0.267 0.267 0.267 rg BT 450.146 491.951 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 454.965 494.332 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 457.374 491.951 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 467.012 494.332 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 469.421 491.951 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 479.058 490.443 Td /F1 9.8 Tf [(. Second, some )] TJ ET BT 26.250 478.539 Td /F1 9.8 Tf [(authors consider that VH corresponds to an intermediate position, in the middle of the continuum between the pro-vaccination )] TJ ET BT 26.250 466.634 Td /F1 9.8 Tf [(and anti-vaccination positions \(that is, on what we shall refer to as the pro/anti continuum )] TJ ET 0.267 0.267 0.267 rg BT 415.343 468.141 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 420.162 470.522 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 422.571 468.141 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 427.390 470.522 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 429.799 468.141 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 439.437 466.634 Td /F1 9.8 Tf [( , while others consider that VH )] TJ ET BT 26.250 454.729 Td /F1 9.8 Tf [(includes strong opposition to vaccination )] TJ ET 0.267 0.267 0.267 rg BT 204.002 456.236 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 213.640 458.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 216.049 456.236 Td /F4 8.7 Tf [(19)] TJ ET 0.271 0.267 0.267 rg BT 225.686 454.729 Td /F1 9.8 Tf [(. Third, authors argue that VH is due to ignorance, misperceptions or )] TJ ET BT 26.250 442.824 Td /F1 9.8 Tf [(disinformation )] TJ ET 0.267 0.267 0.267 rg BT 89.644 444.332 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 99.282 446.713 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 101.691 444.332 Td /F4 8.7 Tf [(21)] TJ ET 0.271 0.267 0.267 rg BT 111.329 442.824 Td /F1 9.8 Tf [(, and others that it may result from too much information )] TJ ET 0.267 0.267 0.267 rg BT 355.722 444.332 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 365.359 446.713 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 367.769 444.332 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 377.406 446.713 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 379.815 444.332 Td /F4 8.7 Tf [(22)] TJ ET 0.271 0.267 0.267 rg BT 389.453 442.824 Td /F1 9.8 Tf [(. One author even states that VH is driven )] TJ ET BT 26.250 430.920 Td /F1 9.8 Tf [(basically by emotions and irrationality and vaccine refusers should be liable for the harm they cause to others )] TJ ET 0.267 0.267 0.267 rg BT 499.330 432.427 Td /F4 8.7 Tf [(23)] TJ ET 0.271 0.267 0.267 rg BT 508.967 430.920 Td /F1 9.8 Tf [(. Fourth, VH is )] TJ ET BT 26.250 419.015 Td /F1 9.8 Tf [(sometimes described with a neutral tone, or even praised )] TJ ET 0.267 0.267 0.267 rg BT 276.065 420.522 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 280.883 422.903 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 283.293 420.522 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 292.930 422.903 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 295.339 420.522 Td /F4 8.7 Tf [(24)] TJ ET 0.271 0.267 0.267 rg BT 304.977 419.015 Td /F1 9.8 Tf [(, but it has also been described \(metaphorically?\) as a )] TJ ET BT 26.250 407.110 Td /F1 9.8 Tf [(condition more or less severe that should be diagnosed among people at risk )] TJ ET 0.267 0.267 0.267 rg BT 380.643 408.617 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 385.462 410.998 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 387.871 408.617 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 397.508 410.998 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 399.918 408.617 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 409.555 407.110 Td /F1 9.8 Tf [( and as a weed deeply rooted in the )] TJ ET BT 26.250 395.205 Td /F1 9.8 Tf [(defects of human nature )] TJ ET 0.267 0.267 0.267 rg BT 134.105 396.713 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 143.742 395.205 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 375.801 Td /F1 9.8 Tf [(Finally, while some empirical studies report that VH is more frequent among people with a high socioeconomic status \(SES\), )] TJ ET BT 26.250 363.896 Td /F1 9.8 Tf [(others report the opposite or observe no relation, especially regarding educational level )] TJ ET 0.267 0.267 0.267 rg BT 404.511 365.403 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 409.330 367.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 411.739 365.403 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 416.558 367.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 418.967 365.403 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 423.786 367.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 426.195 365.403 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 435.832 367.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 438.242 365.403 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 447.879 367.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 450.288 365.403 Td /F4 8.7 Tf [(27)] TJ ET 0.271 0.267 0.267 rg BT 459.926 363.896 Td /F1 9.8 Tf [(. Such inconsistent results )] TJ ET BT 26.250 351.991 Td /F1 9.8 Tf [(are disturbing for social scientists, as SES is supposed to strongly shape our beliefs, attitudes and behaviours, in meaningful )] TJ ET BT 26.250 340.086 Td /F1 9.8 Tf [(ways.)] TJ ET BT 26.250 320.682 Td /F1 9.8 Tf [(These different attitudes tend to assort into specific profiles; for example, those who consider VH an old phenomenon that )] TJ ET BT 26.250 308.777 Td /F1 9.8 Tf [(encompasses anti-vaccination attitudes often attribute it to ignorance, misinformation or irrationality, while those who describe it )] TJ ET BT 26.250 296.872 Td /F1 9.8 Tf [(as a new attitude, distinct from strong opposition to vaccination, also argue that it is positively correlated with vaccine-related )] TJ ET BT 26.250 284.967 Td /F1 9.8 Tf [(knowledge.)] TJ ET BT 26.250 265.563 Td /F1 9.8 Tf [(More generally, VH is not really an empirical concept, as the term concept traditionally refers to a general mental )] TJ ET BT 26.250 253.658 Td /F1 9.8 Tf [(representation derived from the variety of perceived objects and defines what is common to them the features necessary and )] TJ ET BT 26.250 241.753 Td /F1 9.8 Tf [(sufficient for membership in the class/concept through comparison, reflection and abstraction. The current definitions of VH, )] TJ ET BT 26.250 229.848 Td /F1 9.8 Tf [(rather than delineating a set of core elements, cover a wide range of heterogeneous, and even sometimes contradictory, )] TJ ET BT 26.250 217.944 Td /F1 9.8 Tf [(elements.)] TJ ET BT 26.250 181.341 Td /F4 12.0 Tf [(Two issues raised by the VH definitions: what is VH, and where to position it?)] TJ ET BT 26.250 161.387 Td /F4 9.8 Tf [(A belief/attitude, a behaviour, or a decision-making process?)] TJ ET BT 26.250 141.982 Td /F1 9.8 Tf [(It is not fully satisfactory to define VH as a behaviour, as it is associated in the literature with various and non-specific )] TJ ET BT 26.250 130.077 Td /F1 9.8 Tf [(behaviours and outcomes \(due to reluctant conformism and vaccine-specific behaviours\). Moreover, VH is not the only possible )] TJ ET BT 26.250 118.173 Td /F1 9.8 Tf [(explanation for each of these different outcomes: acceptance might also be due to strong support, refusal to strong opposition, )] TJ ET BT 26.250 106.268 Td /F1 9.8 Tf [(and delay to procrastination, oversight, or ignorance. Nevertheless, VH may be associated with other kinds of behaviours, such )] TJ ET BT 26.250 94.363 Td /F1 9.8 Tf [(as information seeking, and the notion of attitude can be defined in many different ways \(including a positive or negative )] TJ ET BT 26.250 82.458 Td /F1 9.8 Tf [(evaluation, or a disposition to act\). This ambiguity regarding the nature of VH may create problems in dealing with it: when )] TJ ET BT 26.250 70.554 Td /F1 9.8 Tf [(researchers design an intervention aimed at promoting vaccination or a specific vaccine, for example, should they target an )] TJ ET BT 26.250 58.649 Td /F1 9.8 Tf [(attitudinal or a behavioural outcome?)] TJ ET BT 26.250 39.244 Td /F1 9.8 Tf [(Nevertheless, beyond this ambiguity, it would be probably more useful to consider VH as a decision-making process \(how/why )] TJ ET Q q 15.000 24.958 577.500 752.042 re W n 0.271 0.267 0.267 rg BT 26.250 750.278 Td /F4 12.0 Tf [(The ambiguities of current definitions of VH.)] TJ ET BT 26.250 730.324 Td /F4 9.8 Tf [(VH definitions in the public health literature.)] TJ ET BT 26.250 710.919 Td /F1 9.8 Tf [(VH has been defined as a set of beliefs )] TJ ET 0.267 0.267 0.267 rg BT 198.601 712.427 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 208.238 710.919 Td /F1 9.8 Tf [(, attitudes )] TJ ET 0.267 0.267 0.267 rg BT 253.225 712.427 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 258.043 714.808 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 260.453 712.427 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 270.090 710.919 Td /F1 9.8 Tf [(, behaviours )] TJ ET 0.267 0.267 0.267 rg BT 325.909 712.427 Td /F4 8.7 Tf [(13)] TJ ET 0.271 0.267 0.267 rg BT 335.546 710.919 Td /F1 9.8 Tf [(, or some combination of them )] TJ ET 0.267 0.267 0.267 rg BT 469.394 712.427 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 479.031 714.808 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 481.441 712.427 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 491.078 710.919 Td /F1 9.8 Tf [(, exhibited by lay )] TJ ET BT 26.250 699.015 Td /F1 9.8 Tf [(people in regard to their own or their childrens immunisations, but also sometimes by healthcare professionals. VH is an )] TJ ET BT 26.250 687.110 Td /F1 9.8 Tf [(attribute ascribed to a large and heterogeneous category )] TJ ET 0.267 0.267 0.267 rg BT 273.929 688.617 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 278.748 690.998 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 281.157 688.617 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 285.976 690.998 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 288.385 688.617 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 293.204 690.998 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 295.613 688.617 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 305.251 687.110 Td /F1 9.8 Tf [( that regroups people who share varying degrees and motives )] TJ ET BT 26.250 675.205 Td /F1 9.8 Tf [(of indecision and who hold an intermediate position along a continuum ranging from full support for vaccination to strong )] TJ ET BT 26.250 663.300 Td /F1 9.8 Tf [(opposition to any vaccine )] TJ ET 0.267 0.267 0.267 rg BT 138.433 664.808 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 143.252 667.189 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 145.662 664.808 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 150.480 667.189 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 152.890 664.808 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 162.527 663.300 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 643.896 Td /F1 9.8 Tf [(These people are characterised by what we may call reluctant conformism and vaccine-specific behaviours )] TJ ET 0.267 0.267 0.267 rg BT 490.087 645.403 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 494.905 647.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 497.315 645.403 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 502.133 647.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 504.543 645.403 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 509.361 647.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 511.771 645.403 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 521.408 643.896 Td /F1 9.8 Tf [(. They may )] TJ ET BT 26.250 631.991 Td /F1 9.8 Tf [(decline a vaccine, but they may also delay it or even accept it in due time despite their doubts/reluctance. In other words, they )] TJ ET BT 26.250 620.086 Td /F1 9.8 Tf [(may endorse a wide range of non-specific behaviours, all of which can result from something else than VH. This behavioural )] TJ ET BT 26.250 608.181 Td /F1 9.8 Tf [(outcome can vary from one vaccine to another: they may accept one vaccine, but decline/delay another, as they base their )] TJ ET BT 26.250 596.277 Td /F1 9.8 Tf [(decision on vaccine-specific features.)] TJ ET BT 26.250 576.872 Td /F4 9.8 Tf [(A catchall category, not a concept.)] TJ ET BT 26.250 557.467 Td /F1 9.8 Tf [(Definitions that try to describe VH as it is used by researchers tend to be very broad and to embrace heterogeneous )] TJ ET BT 26.250 545.562 Td /F1 9.8 Tf [(people/situations and many different explanatory factors \(including historic, political and socio-cultural contexts, as well as )] TJ ET BT 26.250 533.658 Td /F1 9.8 Tf [(individual/social group influences )] TJ ET 0.267 0.267 0.267 rg BT 171.476 535.165 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 176.295 537.546 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 178.704 535.165 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 183.523 537.546 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 185.932 535.165 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 190.751 533.658 Td /F1 9.8 Tf [(\). Moreover, some previous empirical studies have found quite contrasting profiles of )] TJ ET BT 26.250 521.753 Td /F1 9.8 Tf [(attitudes among those who could be categorised as vaccine-hesitant )] TJ ET 0.267 0.267 0.267 rg BT 324.317 523.260 Td /F4 8.7 Tf [(13)] TJ ET 0.271 0.267 0.267 rg BT 333.955 525.641 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 336.364 523.260 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 346.001 521.753 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 502.348 Td /F1 9.8 Tf [(Previous studies also show several contradictions in their use of VH. First, some authors argue that it is something new, distinct )] TJ ET BT 26.250 490.443 Td /F1 9.8 Tf [(from old-fashioned anti-vaccination )] TJ ET 0.267 0.267 0.267 rg BT 180.144 491.951 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 189.781 494.332 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 192.191 491.951 Td /F4 8.7 Tf [(15)] TJ ET 0.271 0.267 0.267 rg BT 201.828 494.332 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 204.237 491.951 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 213.875 490.443 Td /F1 9.8 Tf [(, while others state that it is as old as vaccination itself )] TJ ET 0.267 0.267 0.267 rg BT 450.146 491.951 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 454.965 494.332 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 457.374 491.951 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 467.012 494.332 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 469.421 491.951 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 479.058 490.443 Td /F1 9.8 Tf [(. Second, some )] TJ ET BT 26.250 478.539 Td /F1 9.8 Tf [(authors consider that VH corresponds to an intermediate position, in the middle of the continuum between the pro-vaccination )] TJ ET BT 26.250 466.634 Td /F1 9.8 Tf [(and anti-vaccination positions \(that is, on what we shall refer to as the pro/anti continuum )] TJ ET 0.267 0.267 0.267 rg BT 415.343 468.141 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 420.162 470.522 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 422.571 468.141 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 427.390 470.522 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 429.799 468.141 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 439.437 466.634 Td /F1 9.8 Tf [( , while others consider that VH )] TJ ET BT 26.250 454.729 Td /F1 9.8 Tf [(includes strong opposition to vaccination )] TJ ET 0.267 0.267 0.267 rg BT 204.002 456.236 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 213.640 458.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 216.049 456.236 Td /F4 8.7 Tf [(19)] TJ ET 0.271 0.267 0.267 rg BT 225.686 454.729 Td /F1 9.8 Tf [(. Third, authors argue that VH is due to ignorance, misperceptions or )] TJ ET BT 26.250 442.824 Td /F1 9.8 Tf [(disinformation )] TJ ET 0.267 0.267 0.267 rg BT 89.644 444.332 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 99.282 446.713 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 101.691 444.332 Td /F4 8.7 Tf [(21)] TJ ET 0.271 0.267 0.267 rg BT 111.329 442.824 Td /F1 9.8 Tf [(, and others that it may result from too much information )] TJ ET 0.267 0.267 0.267 rg BT 355.722 444.332 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 365.359 446.713 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 367.769 444.332 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 377.406 446.713 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 379.815 444.332 Td /F4 8.7 Tf [(22)] TJ ET 0.271 0.267 0.267 rg BT 389.453 442.824 Td /F1 9.8 Tf [(. One author even states that VH is driven )] TJ ET BT 26.250 430.920 Td /F1 9.8 Tf [(basically by emotions and irrationality and vaccine refusers should be liable for the harm they cause to others )] TJ ET 0.267 0.267 0.267 rg BT 499.330 432.427 Td /F4 8.7 Tf [(23)] TJ ET 0.271 0.267 0.267 rg BT 508.967 430.920 Td /F1 9.8 Tf [(. Fourth, VH is )] TJ ET BT 26.250 419.015 Td /F1 9.8 Tf [(sometimes described with a neutral tone, or even praised )] TJ ET 0.267 0.267 0.267 rg BT 276.065 420.522 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 280.883 422.903 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 283.293 420.522 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 292.930 422.903 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 295.339 420.522 Td /F4 8.7 Tf [(24)] TJ ET 0.271 0.267 0.267 rg BT 304.977 419.015 Td /F1 9.8 Tf [(, but it has also been described \(metaphorically?\) as a )] TJ ET BT 26.250 407.110 Td /F1 9.8 Tf [(condition more or less severe that should be diagnosed among people at risk )] TJ ET 0.267 0.267 0.267 rg BT 380.643 408.617 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 385.462 410.998 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 387.871 408.617 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 397.508 410.998 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 399.918 408.617 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 409.555 407.110 Td /F1 9.8 Tf [( and as a weed deeply rooted in the )] TJ ET BT 26.250 395.205 Td /F1 9.8 Tf [(defects of human nature )] TJ ET 0.267 0.267 0.267 rg BT 134.105 396.713 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 143.742 395.205 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 375.801 Td /F1 9.8 Tf [(Finally, while some empirical studies report that VH is more frequent among people with a high socioeconomic status \(SES\), )] TJ ET BT 26.250 363.896 Td /F1 9.8 Tf [(others report the opposite or observe no relation, especially regarding educational level )] TJ ET 0.267 0.267 0.267 rg BT 404.511 365.403 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 409.330 367.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 411.739 365.403 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 416.558 367.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 418.967 365.403 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 423.786 367.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 426.195 365.403 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 435.832 367.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 438.242 365.403 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 447.879 367.784 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 450.288 365.403 Td /F4 8.7 Tf [(27)] TJ ET 0.271 0.267 0.267 rg BT 459.926 363.896 Td /F1 9.8 Tf [(. Such inconsistent results )] TJ ET BT 26.250 351.991 Td /F1 9.8 Tf [(are disturbing for social scientists, as SES is supposed to strongly shape our beliefs, attitudes and behaviours, in meaningful )] TJ ET BT 26.250 340.086 Td /F1 9.8 Tf [(ways.)] TJ ET BT 26.250 320.682 Td /F1 9.8 Tf [(These different attitudes tend to assort into specific profiles; for example, those who consider VH an old phenomenon that )] TJ ET BT 26.250 308.777 Td /F1 9.8 Tf [(encompasses anti-vaccination attitudes often attribute it to ignorance, misinformation or irrationality, while those who describe it )] TJ ET BT 26.250 296.872 Td /F1 9.8 Tf [(as a new attitude, distinct from strong opposition to vaccination, also argue that it is positively correlated with vaccine-related )] TJ ET BT 26.250 284.967 Td /F1 9.8 Tf [(knowledge.)] TJ ET BT 26.250 265.563 Td /F1 9.8 Tf [(More generally, VH is not really an empirical concept, as the term concept traditionally refers to a general mental )] TJ ET BT 26.250 253.658 Td /F1 9.8 Tf [(representation derived from the variety of perceived objects and defines what is common to them the features necessary and )] TJ ET BT 26.250 241.753 Td /F1 9.8 Tf [(sufficient for membership in the class/concept through comparison, reflection and abstraction. The current definitions of VH, )] TJ ET BT 26.250 229.848 Td /F1 9.8 Tf [(rather than delineating a set of core elements, cover a wide range of heterogeneous, and even sometimes contradictory, )] TJ ET BT 26.250 217.944 Td /F1 9.8 Tf [(elements.)] TJ ET BT 26.250 181.341 Td /F4 12.0 Tf [(Two issues raised by the VH definitions: what is VH, and where to position it?)] TJ ET BT 26.250 161.387 Td /F4 9.8 Tf [(A belief/attitude, a behaviour, or a decision-making process?)] TJ ET BT 26.250 141.982 Td /F1 9.8 Tf [(It is not fully satisfactory to define VH as a behaviour, as it is associated in the literature with various and non-specific )] TJ ET BT 26.250 130.077 Td /F1 9.8 Tf [(behaviours and outcomes \(due to reluctant conformism and vaccine-specific behaviours\). Moreover, VH is not the only possible )] TJ ET BT 26.250 118.173 Td /F1 9.8 Tf [(explanation for each of these different outcomes: acceptance might also be due to strong support, refusal to strong opposition, )] TJ ET BT 26.250 106.268 Td /F1 9.8 Tf [(and delay to procrastination, oversight, or ignorance. Nevertheless, VH may be associated with other kinds of behaviours, such )] TJ ET BT 26.250 94.363 Td /F1 9.8 Tf [(as information seeking, and the notion of attitude can be defined in many different ways \(including a positive or negative )] TJ ET BT 26.250 82.458 Td /F1 9.8 Tf [(evaluation, or a disposition to act\). This ambiguity regarding the nature of VH may create problems in dealing with it: when )] TJ ET BT 26.250 70.554 Td /F1 9.8 Tf [(researchers design an intervention aimed at promoting vaccination or a specific vaccine, for example, should they target an )] TJ ET BT 26.250 58.649 Td /F1 9.8 Tf [(attitudinal or a behavioural outcome?)] TJ ET BT 26.250 39.244 Td /F1 9.8 Tf [(Nevertheless, beyond this ambiguity, it would be probably more useful to consider VH as a decision-making process \(how/why )] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(2)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Outbreaks)] TJ ET Q endstream endobj 138 0 obj << /Type /Annot /Subtype /Link /A 139 0 R /Border [0 0 0] /H /I /Rect [ 198.6008 711.6249 208.2381 720.4433 ] >> endobj 139 0 obj << /Type /Action >> endobj 140 0 obj << /Type /Annot /Subtype /Link /A 141 0 R /Border [0 0 0] /H /I /Rect [ 253.2246 711.6249 258.0433 720.4433 ] >> endobj 141 0 obj << /Type /Action >> endobj 142 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0 R 498 0 R 500 0 R 502 0 R 504 0 R ] /Contents 451 0 R >> endobj 451 0 obj << /Length 28957 >> stream 0.271 0.267 0.267 rg q 15.000 21.991 577.500 755.009 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(do people come to accept/refuse/delay vaccination\) which is influenced by various contextual factors \(including local )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(vaccination cultures )] TJ ET 0.267 0.267 0.267 rg BT 117.822 757.079 Td /F4 8.7 Tf [(28)] TJ ET 0.271 0.267 0.267 rg BT 127.459 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 129.869 757.079 Td /F4 8.7 Tf [(29)] TJ ET 0.271 0.267 0.267 rg BT 139.506 755.571 Td /F1 9.8 Tf [(\) and leads to a variety of behavioural outcomes. From a public health perspective, behavioural )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(outcomes are important targets in terms of prevention. But it is worth studying VH even among people who have not yet refused )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(or delayed any vaccines, because they are more likely to do so in the future, and public health experts would like to prevent that )] TJ ET 0.267 0.267 0.267 rg BT 26.250 721.364 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 31.069 719.857 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(The decision-making process we are referring to may be easy or simple \(without hesitancy\) or practically automatic amongst )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(both pro-vaccine and anti-vaccine people because they have strong convictions about vaccines in general. On the contrary, this )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(process may be difficult, more uncertain and more worthy of interest among people who have doubts that is, who are )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(genuinely hesitant. Thus, although VH can be considered to be an intermediate position between the pro- and anti-vaccine )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(positions in terms of vaccine assessment \(positive/negative\), it is not in terms of the decision-making process. Moreover, a still )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(different group, those with no definite opinion, little knowledge and little interest about vaccination issues and who randomly )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(forget or delay some vaccines, share the same intermediate position on the anti/pro continuum, but they show the same )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(behavioural pattern as people who are uncertain but very interested and committed in vaccination issues, prone to information )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(seeking and long and balanced decision-making.)] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(In other words, the behavioural outcomes generally associated with VH may reflect the genuine inconsistency of uncommitted )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(people, as described above, but may also reflect a decision-making process that is not guided by a general attitude toward )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(vaccination, but that instead takes the specificities of each vaccine/context into account, among people strongly committed to )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(vaccination issues.)] TJ ET BT 26.250 530.691 Td /F4 9.8 Tf [(VH and the anti/pro continuum.)] TJ ET BT 26.250 511.286 Td /F1 9.8 Tf [(To a certain extent, keeping VH on the anti/pro continuum is convenient, as VH can be conceived as a temporary attitude of )] TJ ET BT 26.250 499.381 Td /F1 9.8 Tf [(individuals who have not yet chosen between the anti- and pro- attitudes and who can more easily be convinced to endorse the )] TJ ET BT 26.250 487.476 Td /F1 9.8 Tf [(latter than strong opponents )] TJ ET 0.267 0.267 0.267 rg BT 150.368 488.984 Td /F4 8.7 Tf [(30)] TJ ET 0.271 0.267 0.267 rg BT 160.005 487.476 Td /F1 9.8 Tf [(. One might then hope to help people to move along this continuum through interventions )] TJ ET BT 26.250 475.572 Td /F1 9.8 Tf [(designed to bring them what they lack: self-efficacy, knowledge or trust of the authorities.)] TJ ET BT 26.250 456.167 Td /F1 9.8 Tf [(Nevertheless, using this continuum to describe VH is not self-evident. First, from a statistical point of view, it is quite odd to )] TJ ET BT 26.250 444.262 Td /F1 9.8 Tf [(choose to describe a population by representing it on an axis where most individuals are supposed to be clumped in an )] TJ ET BT 26.250 432.357 Td /F1 9.8 Tf [(intermediate position. It is usually more informative to use axes that contrast individual positions.)] TJ ET BT 26.250 412.953 Td /F1 9.8 Tf [(Moreover, that vaccine-hesitant people are neither pro- nor anti-vaccination does not necessary imply that they endorse )] TJ ET BT 26.250 401.048 Td /F1 9.8 Tf [(intermediate attitudes regarding vaccination in general. We can use an analogy with politics to illustrate this point. One may )] TJ ET BT 26.250 389.143 Td /F1 9.8 Tf [(claim that there are hesitant voters: instead of being either leftists or rightists and always voting according to their orientation, )] TJ ET BT 26.250 377.238 Td /F1 9.8 Tf [(they may make an informed choice for each election, depending on the candidates, their election platforms, and the context and )] TJ ET BT 26.250 365.334 Td /F1 9.8 Tf [(territory level: they may choose to vote for a leftist candidate for the municipal election and a rightist candidate for the )] TJ ET BT 26.250 353.429 Td /F1 9.8 Tf [(presidential election, and to stay home from the elections for European Parliament members. Such hesitant voters are neither )] TJ ET BT 26.250 341.524 Td /F1 9.8 Tf [(leftists nor rightists, but claiming they are centrists would be highly arguable. The standard left-right clivage appears irrelevant to )] TJ ET BT 26.250 329.619 Td /F1 9.8 Tf [(describing their behaviour. Similarly, the anti/pro continuum about vaccination may not be relevant for describing VH.)] TJ ET BT 26.250 310.215 Td /F1 9.8 Tf [(Finally, these peoples attitudes are claimed to be strongly vaccine-dependent, for they may accept one vaccine, be suspicious )] TJ ET BT 26.250 298.310 Td /F1 9.8 Tf [(of another and strongly reject a third. Positioning them along a continuum corresponding to attitudes toward vaccination in )] TJ ET BT 26.250 286.405 Td /F1 9.8 Tf [(general thus appears quite inappropriate.)] TJ ET BT 26.250 249.803 Td /F4 12.0 Tf [(A theoretical model for VH)] TJ ET BT 26.250 229.848 Td /F4 9.8 Tf [(The indifference/commitment axis.)] TJ ET BT 26.250 210.444 Td /F1 9.8 Tf [(As specified above, considering VH a decision-making process helps to distinguish two very different kinds of VH: first, that of )] TJ ET BT 26.250 198.539 Td /F1 9.8 Tf [(people with poor knowledge of and indifference to vaccination issues, and erratic vaccination behaviours, and, second hand, )] TJ ET BT 26.250 186.634 Td /F1 9.8 Tf [(that of people who are very interested and committed to vaccination issues, prone to information seeking and long and balanced )] TJ ET BT 26.250 174.729 Td /F1 9.8 Tf [(decision-making. From a psychological point of view, this axis echoes the notion of locus of control: some people believe that )] TJ ET BT 26.250 162.825 Td /F1 9.8 Tf [(they can control events related to their life \(internal locus of control\), while others endorse a more fatalistic attitude, tending to )] TJ ET BT 26.250 150.920 Td /F1 9.8 Tf [(believe that their life is driven by forces outside themselves \(others, fate or luck: external locus of control\) )] TJ ET 0.267 0.267 0.267 rg BT 480.892 152.427 Td /F4 8.7 Tf [(31)] TJ ET 0.271 0.267 0.267 rg BT 490.530 150.920 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 131.515 Td /F1 9.8 Tf [(From a sociological point of view, this axis echoes two cultural features of contemporary societies, concepts known as risk )] TJ ET BT 26.250 119.610 Td /F1 9.8 Tf [(culture and healthism. Risk culture is a concept coined by the British sociologist Anthony Giddens )] TJ ET 0.267 0.267 0.267 rg BT 458.672 121.118 Td /F4 8.7 Tf [(32)] TJ ET 0.271 0.267 0.267 rg BT 468.310 119.610 Td /F1 9.8 Tf [(. According to him, )] TJ ET BT 26.250 107.706 Td /F1 9.8 Tf [(people in contemporary societies are encouraged to exert autonomy over their own lives, to use available expert knowledge to )] TJ ET BT 26.250 95.801 Td /F1 9.8 Tf [(stay continuously aware of risks and opportunities in their daily life, to assess risks and benefits in order to make their future )] TJ ET BT 26.250 83.896 Td /F1 9.8 Tf [(secure. Authorities promote risk culture, as it is easier to govern rational and autonomous individuals, whose rationality makes )] TJ ET BT 26.250 71.991 Td /F1 9.8 Tf [(them more predictable )] TJ ET 0.267 0.267 0.267 rg BT 125.954 73.499 Td /F4 8.7 Tf [(33)] TJ ET 0.271 0.267 0.267 rg BT 135.591 71.991 Td /F1 9.8 Tf [(. This is especially true concerning health, which has become a super value: the rhetoric of self-)] TJ ET BT 26.250 60.087 Td /F1 9.8 Tf [(empowerment conveyed by health promotion praises enterprising and entrepreneurial individuals who exercise control over )] TJ ET BT 26.250 48.182 Td /F1 9.8 Tf [(their own behaviours and use information spread by health authorities to maximise their life expectancy. This specific cultural )] TJ ET BT 26.250 36.277 Td /F1 9.8 Tf [(feature is described as healthism )] TJ ET 0.267 0.267 0.267 rg BT 171.476 37.784 Td /F4 8.7 Tf [(34)] TJ ET 0.271 0.267 0.267 rg BT 181.114 40.165 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 183.523 37.784 Td /F4 8.7 Tf [(35)] TJ ET 0.271 0.267 0.267 rg BT 193.160 36.277 Td /F1 9.8 Tf [(. Thus the indifference/commitment axis can also be viewed as measuring the extent to )] TJ ET Q q 15.000 21.991 577.500 755.009 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(do people come to accept/refuse/delay vaccination\) which is influenced by various contextual factors \(including local )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(vaccination cultures )] TJ ET 0.267 0.267 0.267 rg BT 117.822 757.079 Td /F4 8.7 Tf [(28)] TJ ET 0.271 0.267 0.267 rg BT 127.459 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 129.869 757.079 Td /F4 8.7 Tf [(29)] TJ ET 0.271 0.267 0.267 rg BT 139.506 755.571 Td /F1 9.8 Tf [(\) and leads to a variety of behavioural outcomes. From a public health perspective, behavioural )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(outcomes are important targets in terms of prevention. But it is worth studying VH even among people who have not yet refused )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(or delayed any vaccines, because they are more likely to do so in the future, and public health experts would like to prevent that )] TJ ET 0.267 0.267 0.267 rg BT 26.250 721.364 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 31.069 719.857 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(The decision-making process we are referring to may be easy or simple \(without hesitancy\) or practically automatic amongst )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(both pro-vaccine and anti-vaccine people because they have strong convictions about vaccines in general. On the contrary, this )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(process may be difficult, more uncertain and more worthy of interest among people who have doubts that is, who are )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(genuinely hesitant. Thus, although VH can be considered to be an intermediate position between the pro- and anti-vaccine )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(positions in terms of vaccine assessment \(positive/negative\), it is not in terms of the decision-making process. Moreover, a still )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(different group, those with no definite opinion, little knowledge and little interest about vaccination issues and who randomly )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(forget or delay some vaccines, share the same intermediate position on the anti/pro continuum, but they show the same )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(behavioural pattern as people who are uncertain but very interested and committed in vaccination issues, prone to information )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(seeking and long and balanced decision-making.)] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(In other words, the behavioural outcomes generally associated with VH may reflect the genuine inconsistency of uncommitted )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(people, as described above, but may also reflect a decision-making process that is not guided by a general attitude toward )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(vaccination, but that instead takes the specificities of each vaccine/context into account, among people strongly committed to )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(vaccination issues.)] TJ ET BT 26.250 530.691 Td /F4 9.8 Tf [(VH and the anti/pro continuum.)] TJ ET BT 26.250 511.286 Td /F1 9.8 Tf [(To a certain extent, keeping VH on the anti/pro continuum is convenient, as VH can be conceived as a temporary attitude of )] TJ ET BT 26.250 499.381 Td /F1 9.8 Tf [(individuals who have not yet chosen between the anti- and pro- attitudes and who can more easily be convinced to endorse the )] TJ ET BT 26.250 487.476 Td /F1 9.8 Tf [(latter than strong opponents )] TJ ET 0.267 0.267 0.267 rg BT 150.368 488.984 Td /F4 8.7 Tf [(30)] TJ ET 0.271 0.267 0.267 rg BT 160.005 487.476 Td /F1 9.8 Tf [(. One might then hope to help people to move along this continuum through interventions )] TJ ET BT 26.250 475.572 Td /F1 9.8 Tf [(designed to bring them what they lack: self-efficacy, knowledge or trust of the authorities.)] TJ ET BT 26.250 456.167 Td /F1 9.8 Tf [(Nevertheless, using this continuum to describe VH is not self-evident. First, from a statistical point of view, it is quite odd to )] TJ ET BT 26.250 444.262 Td /F1 9.8 Tf [(choose to describe a population by representing it on an axis where most individuals are supposed to be clumped in an )] TJ ET BT 26.250 432.357 Td /F1 9.8 Tf [(intermediate position. It is usually more informative to use axes that contrast individual positions.)] TJ ET BT 26.250 412.953 Td /F1 9.8 Tf [(Moreover, that vaccine-hesitant people are neither pro- nor anti-vaccination does not necessary imply that they endorse )] TJ ET BT 26.250 401.048 Td /F1 9.8 Tf [(intermediate attitudes regarding vaccination in general. We can use an analogy with politics to illustrate this point. One may )] TJ ET BT 26.250 389.143 Td /F1 9.8 Tf [(claim that there are hesitant voters: instead of being either leftists or rightists and always voting according to their orientation, )] TJ ET BT 26.250 377.238 Td /F1 9.8 Tf [(they may make an informed choice for each election, depending on the candidates, their election platforms, and the context and )] TJ ET BT 26.250 365.334 Td /F1 9.8 Tf [(territory level: they may choose to vote for a leftist candidate for the municipal election and a rightist candidate for the )] TJ ET BT 26.250 353.429 Td /F1 9.8 Tf [(presidential election, and to stay home from the elections for European Parliament members. Such hesitant voters are neither )] TJ ET BT 26.250 341.524 Td /F1 9.8 Tf [(leftists nor rightists, but claiming they are centrists would be highly arguable. The standard left-right clivage appears irrelevant to )] TJ ET BT 26.250 329.619 Td /F1 9.8 Tf [(describing their behaviour. Similarly, the anti/pro continuum about vaccination may not be relevant for describing VH.)] TJ ET BT 26.250 310.215 Td /F1 9.8 Tf [(Finally, these peoples attitudes are claimed to be strongly vaccine-dependent, for they may accept one vaccine, be suspicious )] TJ ET BT 26.250 298.310 Td /F1 9.8 Tf [(of another and strongly reject a third. Positioning them along a continuum corresponding to attitudes toward vaccination in )] TJ ET BT 26.250 286.405 Td /F1 9.8 Tf [(general thus appears quite inappropriate.)] TJ ET BT 26.250 249.803 Td /F4 12.0 Tf [(A theoretical model for VH)] TJ ET BT 26.250 229.848 Td /F4 9.8 Tf [(The indifference/commitment axis.)] TJ ET BT 26.250 210.444 Td /F1 9.8 Tf [(As specified above, considering VH a decision-making process helps to distinguish two very different kinds of VH: first, that of )] TJ ET BT 26.250 198.539 Td /F1 9.8 Tf [(people with poor knowledge of and indifference to vaccination issues, and erratic vaccination behaviours, and, second hand, )] TJ ET BT 26.250 186.634 Td /F1 9.8 Tf [(that of people who are very interested and committed to vaccination issues, prone to information seeking and long and balanced )] TJ ET BT 26.250 174.729 Td /F1 9.8 Tf [(decision-making. From a psychological point of view, this axis echoes the notion of locus of control: some people believe that )] TJ ET BT 26.250 162.825 Td /F1 9.8 Tf [(they can control events related to their life \(internal locus of control\), while others endorse a more fatalistic attitude, tending to )] TJ ET BT 26.250 150.920 Td /F1 9.8 Tf [(believe that their life is driven by forces outside themselves \(others, fate or luck: external locus of control\) )] TJ ET 0.267 0.267 0.267 rg BT 480.892 152.427 Td /F4 8.7 Tf [(31)] TJ ET 0.271 0.267 0.267 rg BT 490.530 150.920 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 131.515 Td /F1 9.8 Tf [(From a sociological point of view, this axis echoes two cultural features of contemporary societies, concepts known as risk )] TJ ET BT 26.250 119.610 Td /F1 9.8 Tf [(culture and healthism. Risk culture is a concept coined by the British sociologist Anthony Giddens )] TJ ET 0.267 0.267 0.267 rg BT 458.672 121.118 Td /F4 8.7 Tf [(32)] TJ ET 0.271 0.267 0.267 rg BT 468.310 119.610 Td /F1 9.8 Tf [(. According to him, )] TJ ET BT 26.250 107.706 Td /F1 9.8 Tf [(people in contemporary societies are encouraged to exert autonomy over their own lives, to use available expert knowledge to )] TJ ET BT 26.250 95.801 Td /F1 9.8 Tf [(stay continuously aware of risks and opportunities in their daily life, to assess risks and benefits in order to make their future )] TJ ET BT 26.250 83.896 Td /F1 9.8 Tf [(secure. Authorities promote risk culture, as it is easier to govern rational and autonomous individuals, whose rationality makes )] TJ ET BT 26.250 71.991 Td /F1 9.8 Tf [(them more predictable )] TJ ET 0.267 0.267 0.267 rg BT 125.954 73.499 Td /F4 8.7 Tf [(33)] TJ ET 0.271 0.267 0.267 rg BT 135.591 71.991 Td /F1 9.8 Tf [(. This is especially true concerning health, which has become a super value: the rhetoric of self-)] TJ ET BT 26.250 60.087 Td /F1 9.8 Tf [(empowerment conveyed by health promotion praises enterprising and entrepreneurial individuals who exercise control over )] TJ ET BT 26.250 48.182 Td /F1 9.8 Tf [(their own behaviours and use information spread by health authorities to maximise their life expectancy. This specific cultural )] TJ ET BT 26.250 36.277 Td /F1 9.8 Tf [(feature is described as healthism )] TJ ET 0.267 0.267 0.267 rg BT 171.476 37.784 Td /F4 8.7 Tf [(34)] TJ ET 0.271 0.267 0.267 rg BT 181.114 40.165 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 183.523 37.784 Td /F4 8.7 Tf [(35)] TJ ET 0.271 0.267 0.267 rg BT 193.160 36.277 Td /F1 9.8 Tf [(. Thus the indifference/commitment axis can also be viewed as measuring the extent to )] TJ ET Q q 15.000 21.991 577.500 755.009 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(do people come to accept/refuse/delay vaccination\) which is influenced by various contextual factors \(including local )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(vaccination cultures )] TJ ET 0.267 0.267 0.267 rg BT 117.822 757.079 Td /F4 8.7 Tf [(28)] TJ ET 0.271 0.267 0.267 rg BT 127.459 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 129.869 757.079 Td /F4 8.7 Tf [(29)] TJ ET 0.271 0.267 0.267 rg BT 139.506 755.571 Td /F1 9.8 Tf [(\) and leads to a variety of behavioural outcomes. From a public health perspective, behavioural )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(outcomes are important targets in terms of prevention. But it is worth studying VH even among people who have not yet refused )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(or delayed any vaccines, because they are more likely to do so in the future, and public health experts would like to prevent that )] TJ ET 0.267 0.267 0.267 rg BT 26.250 721.364 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 31.069 719.857 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(The decision-making process we are referring to may be easy or simple \(without hesitancy\) or practically automatic amongst )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(both pro-vaccine and anti-vaccine people because they have strong convictions about vaccines in general. On the contrary, this )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(process may be difficult, more uncertain and more worthy of interest among people who have doubts that is, who are )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(genuinely hesitant. Thus, although VH can be considered to be an intermediate position between the pro- and anti-vaccine )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(positions in terms of vaccine assessment \(positive/negative\), it is not in terms of the decision-making process. Moreover, a still )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(different group, those with no definite opinion, little knowledge and little interest about vaccination issues and who randomly )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(forget or delay some vaccines, share the same intermediate position on the anti/pro continuum, but they show the same )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(behavioural pattern as people who are uncertain but very interested and committed in vaccination issues, prone to information )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(seeking and long and balanced decision-making.)] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(In other words, the behavioural outcomes generally associated with VH may reflect the genuine inconsistency of uncommitted )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(people, as described above, but may also reflect a decision-making process that is not guided by a general attitude toward )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(vaccination, but that instead takes the specificities of each vaccine/context into account, among people strongly committed to )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(vaccination issues.)] TJ ET BT 26.250 530.691 Td /F4 9.8 Tf [(VH and the anti/pro continuum.)] TJ ET BT 26.250 511.286 Td /F1 9.8 Tf [(To a certain extent, keeping VH on the anti/pro continuum is convenient, as VH can be conceived as a temporary attitude of )] TJ ET BT 26.250 499.381 Td /F1 9.8 Tf [(individuals who have not yet chosen between the anti- and pro- attitudes and who can more easily be convinced to endorse the )] TJ ET BT 26.250 487.476 Td /F1 9.8 Tf [(latter than strong opponents )] TJ ET 0.267 0.267 0.267 rg BT 150.368 488.984 Td /F4 8.7 Tf [(30)] TJ ET 0.271 0.267 0.267 rg BT 160.005 487.476 Td /F1 9.8 Tf [(. One might then hope to help people to move along this continuum through interventions )] TJ ET BT 26.250 475.572 Td /F1 9.8 Tf [(designed to bring them what they lack: self-efficacy, knowledge or trust of the authorities.)] TJ ET BT 26.250 456.167 Td /F1 9.8 Tf [(Nevertheless, using this continuum to describe VH is not self-evident. First, from a statistical point of view, it is quite odd to )] TJ ET BT 26.250 444.262 Td /F1 9.8 Tf [(choose to describe a population by representing it on an axis where most individuals are supposed to be clumped in an )] TJ ET BT 26.250 432.357 Td /F1 9.8 Tf [(intermediate position. It is usually more informative to use axes that contrast individual positions.)] TJ ET BT 26.250 412.953 Td /F1 9.8 Tf [(Moreover, that vaccine-hesitant people are neither pro- nor anti-vaccination does not necessary imply that they endorse )] TJ ET BT 26.250 401.048 Td /F1 9.8 Tf [(intermediate attitudes regarding vaccination in general. We can use an analogy with politics to illustrate this point. One may )] TJ ET BT 26.250 389.143 Td /F1 9.8 Tf [(claim that there are hesitant voters: instead of being either leftists or rightists and always voting according to their orientation, )] TJ ET BT 26.250 377.238 Td /F1 9.8 Tf [(they may make an informed choice for each election, depending on the candidates, their election platforms, and the context and )] TJ ET BT 26.250 365.334 Td /F1 9.8 Tf [(territory level: they may choose to vote for a leftist candidate for the municipal election and a rightist candidate for the )] TJ ET BT 26.250 353.429 Td /F1 9.8 Tf [(presidential election, and to stay home from the elections for European Parliament members. Such hesitant voters are neither )] TJ ET BT 26.250 341.524 Td /F1 9.8 Tf [(leftists nor rightists, but claiming they are centrists would be highly arguable. The standard left-right clivage appears irrelevant to )] TJ ET BT 26.250 329.619 Td /F1 9.8 Tf [(describing their behaviour. Similarly, the anti/pro continuum about vaccination may not be relevant for describing VH.)] TJ ET BT 26.250 310.215 Td /F1 9.8 Tf [(Finally, these peoples attitudes are claimed to be strongly vaccine-dependent, for they may accept one vaccine, be suspicious )] TJ ET BT 26.250 298.310 Td /F1 9.8 Tf [(of another and strongly reject a third. Positioning them along a continuum corresponding to attitudes toward vaccination in )] TJ ET BT 26.250 286.405 Td /F1 9.8 Tf [(general thus appears quite inappropriate.)] TJ ET BT 26.250 249.803 Td /F4 12.0 Tf [(A theoretical model for VH)] TJ ET BT 26.250 229.848 Td /F4 9.8 Tf [(The indifference/commitment axis.)] TJ ET BT 26.250 210.444 Td /F1 9.8 Tf [(As specified above, considering VH a decision-making process helps to distinguish two very different kinds of VH: first, that of )] TJ ET BT 26.250 198.539 Td /F1 9.8 Tf [(people with poor knowledge of and indifference to vaccination issues, and erratic vaccination behaviours, and, second hand, )] TJ ET BT 26.250 186.634 Td /F1 9.8 Tf [(that of people who are very interested and committed to vaccination issues, prone to information seeking and long and balanced )] TJ ET BT 26.250 174.729 Td /F1 9.8 Tf [(decision-making. From a psychological point of view, this axis echoes the notion of locus of control: some people believe that )] TJ ET BT 26.250 162.825 Td /F1 9.8 Tf [(they can control events related to their life \(internal locus of control\), while others endorse a more fatalistic attitude, tending to )] TJ ET BT 26.250 150.920 Td /F1 9.8 Tf [(believe that their life is driven by forces outside themselves \(others, fate or luck: external locus of control\) )] TJ ET 0.267 0.267 0.267 rg BT 480.892 152.427 Td /F4 8.7 Tf [(31)] TJ ET 0.271 0.267 0.267 rg BT 490.530 150.920 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 131.515 Td /F1 9.8 Tf [(From a sociological point of view, this axis echoes two cultural features of contemporary societies, concepts known as risk )] TJ ET BT 26.250 119.610 Td /F1 9.8 Tf [(culture and healthism. Risk culture is a concept coined by the British sociologist Anthony Giddens )] TJ ET 0.267 0.267 0.267 rg BT 458.672 121.118 Td /F4 8.7 Tf [(32)] TJ ET 0.271 0.267 0.267 rg BT 468.310 119.610 Td /F1 9.8 Tf [(. According to him, )] TJ ET BT 26.250 107.706 Td /F1 9.8 Tf [(people in contemporary societies are encouraged to exert autonomy over their own lives, to use available expert knowledge to )] TJ ET BT 26.250 95.801 Td /F1 9.8 Tf [(stay continuously aware of risks and opportunities in their daily life, to assess risks and benefits in order to make their future )] TJ ET BT 26.250 83.896 Td /F1 9.8 Tf [(secure. Authorities promote risk culture, as it is easier to govern rational and autonomous individuals, whose rationality makes )] TJ ET BT 26.250 71.991 Td /F1 9.8 Tf [(them more predictable )] TJ ET 0.267 0.267 0.267 rg BT 125.954 73.499 Td /F4 8.7 Tf [(33)] TJ ET 0.271 0.267 0.267 rg BT 135.591 71.991 Td /F1 9.8 Tf [(. This is especially true concerning health, which has become a super value: the rhetoric of self-)] TJ ET BT 26.250 60.087 Td /F1 9.8 Tf [(empowerment conveyed by health promotion praises enterprising and entrepreneurial individuals who exercise control over )] TJ ET BT 26.250 48.182 Td /F1 9.8 Tf [(their own behaviours and use information spread by health authorities to maximise their life expectancy. This specific cultural )] TJ ET BT 26.250 36.277 Td /F1 9.8 Tf [(feature is described as healthism )] TJ ET 0.267 0.267 0.267 rg BT 171.476 37.784 Td /F4 8.7 Tf [(34)] TJ ET 0.271 0.267 0.267 rg BT 181.114 40.165 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 183.523 37.784 Td /F4 8.7 Tf [(35)] TJ ET 0.271 0.267 0.267 rg BT 193.160 36.277 Td /F1 9.8 Tf [(. Thus the indifference/commitment axis can also be viewed as measuring the extent to )] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(3)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Outbreaks)] TJ ET Q endstream endobj 452 0 obj << /Type /Annot /Subtype /Link /A 453 0 R /Border [0 0 0] /H /I /Rect [ 117.8220 756.2769 127.4593 765.0952 ] >> endobj 453 0 obj << /Type /Action >> endobj 454 0 obj << /Type /Annot /Subtype /Link /A 455 0 R /Border [0 0 0] /H /I /Rect [ 129.8687 756.2769 139.5060 765.0952 ] >> endobj 455 0 obj << /Type /Action >> endobj 456 0 obj << /Type /Annot /Subtype /Link /A 457 0 R /Border [0 0 0] /H /I /Rect [ 26.2500 720.5627 31.0687 729.3810 ] >> endobj 457 0 obj << /Type /Action >> endobj 458 0 obj << /Type /Annot /Subtype /Link /A 459 0 R /Border [0 0 0] /H /I /Rect [ 150.3675 488.1819 160.0048 497.0002 ] >> endobj 459 0 obj << /Type /Action >> endobj 460 0 obj << /Type /Annot /Subtype /Link /A 461 0 R /Border [0 0 0] /H /I /Rect [ 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0 R 562 0 R 564 0 R 566 0 R 568 0 R 570 0 R 572 0 R 574 0 R 576 0 R 578 0 R 580 0 R 582 0 R 584 0 R 586 0 R 588 0 R 590 0 R 592 0 R 594 0 R 596 0 R 598 0 R 600 0 R 604 0 R 606 0 R 608 0 R 610 0 R 612 0 R 614 0 R 616 0 R 618 0 R 620 0 R 622 0 R 624 0 R 626 0 R 628 0 R 630 0 R 632 0 R 634 0 R 636 0 R 638 0 R 640 0 R 642 0 R 644 0 R 646 0 R 648 0 R ] /Contents 507 0 R >> endobj 507 0 obj << /Length 33292 >> stream 0.271 0.267 0.267 rg q 15.000 -145.735 577.500 922.735 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(which individuals are committed or indifferent to contemporary healthism.)] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(The link between healthism and VH is quite obvious in several studies. Gilkey et al. )] TJ ET 0.267 0.267 0.267 rg BT 386.610 749.579 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 396.247 748.071 Td /F1 9.8 Tf [( observed that forgoing vaccines was )] TJ ET BT 26.250 736.167 Td /F1 9.8 Tf [(more common among parents more attentive to their childrens health and nutrition, and others underline the weight of rational )] TJ ET BT 26.250 724.262 Td /F1 9.8 Tf [(assessment and the importance of perceived control among people who were reluctant to be vaccinated against the H1N1 )] TJ ET BT 26.250 712.357 Td /F1 9.8 Tf [(influenza )] TJ ET 0.267 0.267 0.267 rg BT 67.980 713.864 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 77.617 716.245 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 80.027 713.864 Td /F4 8.7 Tf [(27)] TJ ET 0.271 0.267 0.267 rg BT 89.664 712.357 Td /F1 9.8 Tf [(. Moreover, when Opel et al. )] TJ ET 0.267 0.267 0.267 rg BT 214.844 713.864 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 224.482 712.357 Td /F1 9.8 Tf [( built a questionnaire designed to identify VH, they not only used existing items )] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(but also conducted focus groups to create new items. Because parents frequently claimed that they prefer to rely on their own )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(research on vaccines to come to an informed decision, rather than deferring to their childs doctor, the authors added the )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(following item: It is my role as a parent to question shots. We believe this item captures an aspect of commitment to risk )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(culture. Conversely, and rather remarkably, parents reluctance to get their child immunised has been used as a typical example )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(to illustrate contemporary healthism )] TJ ET 0.267 0.267 0.267 rg BT 182.845 654.341 Td /F4 8.7 Tf [(36)] TJ ET 0.271 0.267 0.267 rg BT 192.482 652.833 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 633.429 Td /F4 9.8 Tf [(The trust issue.)] TJ ET BT 26.250 614.024 Td /F1 9.8 Tf [(According to Giddens, contemporary individuals are exhorted to become the entrepreneur of their own life, but they must do so )] TJ ET BT 26.250 602.119 Td /F1 9.8 Tf [(in a context characterised by trust issues, as many if not all aspects of our daily lives depend on machines or systems that )] TJ ET BT 26.250 590.214 Td /F1 9.8 Tf [(are distant from us and beyond our understanding. Giddenss analysis is based on a concept of trust borrowed from the )] TJ ET BT 26.250 578.310 Td /F1 9.8 Tf [(psychologist Erik Erikson: depending on people/things that are not under our direct scrutiny or not fully understandable to us )] TJ ET BT 26.250 566.405 Td /F1 9.8 Tf [(induces anxiety, and we must trust them, trust a whole expert system, through a leap of faith. As our societies are characterised )] TJ ET BT 26.250 554.500 Td /F1 9.8 Tf [(by overspecialisation and the disembedding of social relationships, trust issues become essential )] TJ ET 0.267 0.267 0.267 rg BT 447.304 556.007 Td /F4 8.7 Tf [(32)] TJ ET 0.271 0.267 0.267 rg BT 456.941 554.500 Td /F1 9.8 Tf [(. Moreover, in Giddenss )] TJ ET BT 26.250 542.595 Td /F1 9.8 Tf [(perspective, the contemporary controversies regarding vaccination or other health-related issues are not the causes of distrust, )] TJ ET BT 26.250 530.691 Td /F1 9.8 Tf [(but only consequences of a wider structural phenomenon.)] TJ ET BT 26.250 511.286 Td /F1 9.8 Tf [(Trust issues are also crucial in Becks analyses of contemporary risk societies, especially regarding science and knowledge. )] TJ ET BT 26.250 499.381 Td /F1 9.8 Tf [(According to him, our societies are characterised by reflexive scientisation: scientific scepticism has been extended to science )] TJ ET BT 26.250 487.476 Td /F1 9.8 Tf [(itself and fuelled the disenchantment of science. As a result, there is a process of demonopolisation/feudalisation of scientific )] TJ ET BT 26.250 475.572 Td /F1 9.8 Tf [(knowledge, with conflictual equalisation tendencies in the gradient of rationality between experts and lay people. Sciences, )] TJ ET BT 26.250 463.667 Td /F1 9.8 Tf [(quasi-sciences and pseudo-sciences are competing sources that produce a flood of overspecialised, hyper-complex and )] TJ ET BT 26.250 451.762 Td /F1 9.8 Tf [(contradictory findings. Consequently, distrust toward science is no longer a sign of ignorance or even obscurantism, but is )] TJ ET BT 26.250 439.857 Td /F1 9.8 Tf [(endorsed by highly educated individuals )] TJ ET 0.267 0.267 0.267 rg BT 201.838 441.365 Td /F4 8.7 Tf [(37)] TJ ET 0.271 0.267 0.267 rg BT 211.475 439.857 Td /F1 9.8 Tf [(. Beck also pointed out the increasingly important issue of conflicts of interest, i.e., )] TJ ET BT 26.250 427.953 Td /F1 9.8 Tf [(situations in which scientists or experts are perceived as untrustworthy because of their financial links to industries. In this )] TJ ET BT 26.250 416.048 Td /F1 9.8 Tf [(context, people who endorse risk culture and decide to take their health in hand are confronted with discordant sources of )] TJ ET BT 26.250 404.143 Td /F1 9.8 Tf [(knowledge: they may distrust official sciences and experts, and put their faith in alternative sources of information or medical )] TJ ET BT 26.250 392.238 Td /F1 9.8 Tf [(practice \(such as homeopathy or acupuncture\).)] TJ ET BT 26.250 372.834 Td /F1 9.8 Tf [(Vaccination-related issues have not escaped from these structural features of contemporary societies, especially the crisis of )] TJ ET BT 26.250 360.929 Td /F1 9.8 Tf [(legitimacy faced by science, expertise and medical authorities. Vaccination may involve trust as a leap of faith, experienced )] TJ ET BT 26.250 349.024 Td /F1 9.8 Tf [(through relationality and familiarity with a physician [5,38]. An annual survey conducted by the IRSN \(Institute of Radiation )] TJ ET BT 26.250 337.119 Td /F1 9.8 Tf [(Protection and Nuclear Safety\) illustrates this crisis of legitimacy; it found that, generally speaking, the French people do not )] TJ ET BT 26.250 325.215 Td /F1 9.8 Tf [(trust the way authorities manage various kinds of risks, nor do they trust the information given to them. For example, only 38% )] TJ ET BT 26.250 313.310 Td /F1 9.8 Tf [(of the French had confidence that what authorities did about the H1N1 episode in 2009 was for their safety, and only 34% )] TJ ET BT 26.250 301.405 Td /F1 9.8 Tf [(believed that the information released was true. )] TJ ET 0.267 0.267 0.267 rg BT 233.808 302.912 Td /F4 8.7 Tf [(39)] TJ ET 0.271 0.267 0.267 rg BT 26.250 282.000 Td /F1 9.8 Tf [(Trust is generally considered as a crucial component of peoples attitudes toward vaccination, including VH )] TJ ET 0.267 0.267 0.267 rg BT 489.570 283.508 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 494.389 285.889 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 496.798 283.508 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 501.617 285.889 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 504.026 283.508 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 508.845 285.889 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 511.254 283.508 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 520.891 285.889 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 523.301 283.508 Td /F4 8.7 Tf [(40)] TJ ET 0.271 0.267 0.267 rg BT 532.938 282.000 Td /F1 9.8 Tf [(. For )] TJ ET BT 26.250 270.096 Td /F1 9.8 Tf [(example, trust is a key dimension in the questionnaire developed by Opel et al to assess VH )] TJ ET 0.267 0.267 0.267 rg BT 426.185 271.603 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 435.823 270.096 Td /F1 9.8 Tf [(. More precisely, lay people may )] TJ ET BT 26.250 258.191 Td /F1 9.8 Tf [(not distrust vaccines per se, but rather distrust the health authorities who are believed to be strongly influenced by vaccines )] TJ ET BT 26.250 246.286 Td /F1 9.8 Tf [(producers )] TJ ET 0.267 0.267 0.267 rg BT 72.309 247.793 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 77.128 250.174 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 79.537 247.793 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 89.174 246.286 Td /F1 9.8 Tf [(. This feature of contemporary societies is closely related to healthism, and some authors have even combined )] TJ ET BT 26.250 234.381 Td /F1 9.8 Tf [(these concepts: in such cases, healthism refers to individuals who seek to control their \(childrens\) health, who want to become )] TJ ET BT 26.250 222.477 Td /F1 9.8 Tf [(its informed and rational entrepreneur, but who also express strong doubts about medical authorities and mainstream medicine )] TJ ET BT 26.250 210.572 Td /F1 9.8 Tf [(and are more prone to turn to alternative experts, including on vaccination issues )] TJ ET 0.267 0.267 0.267 rg BT 377.416 212.079 Td /F4 8.7 Tf [(36)] TJ ET 0.271 0.267 0.267 rg BT 387.053 210.572 Td /F1 9.8 Tf [(. This relation between empowerment and )] TJ ET BT 26.250 198.667 Td /F1 9.8 Tf [(distrust is also explicitly promoted by some groups critical of vaccines, which claim that trusting blindly can be the biggest risk )] TJ ET BT 26.250 186.762 Td /F1 9.8 Tf [(of all )] TJ ET 0.267 0.267 0.267 rg BT 52.799 188.270 Td /F4 8.7 Tf [(41)] TJ ET 0.271 0.267 0.267 rg BT 62.437 186.762 Td /F1 9.8 Tf [(. Moreover, several previous studies have already found a positive correlation between VH and use of alternative )] TJ ET BT 26.250 174.858 Td /F1 9.8 Tf [(medicines \(such as acupuncture, homeopathy or naturopathy )] TJ ET 0.267 0.267 0.267 rg BT 293.420 176.365 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 303.057 178.746 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 305.466 176.365 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 315.104 178.746 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 317.513 176.365 Td /F4 8.7 Tf [(40)] TJ ET 0.271 0.267 0.267 rg BT 327.150 174.858 Td /F1 9.8 Tf [( \) , as well as distrust of colon cancer screening )] TJ ET 0.267 0.267 0.267 rg BT 534.689 176.365 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 544.326 174.858 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 138.255 Td /F4 12.0 Tf [(VH in a two-dimension map.)] TJ ET BT 26.250 118.301 Td /F1 9.8 Tf [(Thus we propose to add to the risk culture/healthism axis a second axis, assessing lay peoples attitudes toward health )] TJ ET BT 26.250 106.396 Td /F1 9.8 Tf [(authorities and mainstream medicine \(see Figure 1\).)] TJ ET 0.965 0.965 0.965 rg 26.250 -145.735 555.000 242.250 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 96.515 m 581.250 96.515 l 581.250 95.765 l 26.250 95.765 l f q 450.000 0 0 226.500 35.250 -139.735 cm /I4 Do Q q 35.250 -145.735 537.000 0.000 re W n Q Q q 15.000 -145.735 577.500 922.735 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(which individuals are committed or indifferent to contemporary healthism.)] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(The link between healthism and VH is quite obvious in several studies. Gilkey et al. )] TJ ET 0.267 0.267 0.267 rg BT 386.610 749.579 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 396.247 748.071 Td /F1 9.8 Tf [( observed that forgoing vaccines was )] TJ ET BT 26.250 736.167 Td /F1 9.8 Tf [(more common among parents more attentive to their childrens health and nutrition, and others underline the weight of rational )] TJ ET BT 26.250 724.262 Td /F1 9.8 Tf [(assessment and the importance of perceived control among people who were reluctant to be vaccinated against the H1N1 )] TJ ET BT 26.250 712.357 Td /F1 9.8 Tf [(influenza )] TJ ET 0.267 0.267 0.267 rg BT 67.980 713.864 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 77.617 716.245 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 80.027 713.864 Td /F4 8.7 Tf [(27)] TJ ET 0.271 0.267 0.267 rg BT 89.664 712.357 Td /F1 9.8 Tf [(. Moreover, when Opel et al. )] TJ ET 0.267 0.267 0.267 rg BT 214.844 713.864 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 224.482 712.357 Td /F1 9.8 Tf [( built a questionnaire designed to identify VH, they not only used existing items )] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(but also conducted focus groups to create new items. Because parents frequently claimed that they prefer to rely on their own )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(research on vaccines to come to an informed decision, rather than deferring to their childs doctor, the authors added the )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(following item: It is my role as a parent to question shots. We believe this item captures an aspect of commitment to risk )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(culture. Conversely, and rather remarkably, parents reluctance to get their child immunised has been used as a typical example )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(to illustrate contemporary healthism )] TJ ET 0.267 0.267 0.267 rg BT 182.845 654.341 Td /F4 8.7 Tf [(36)] TJ ET 0.271 0.267 0.267 rg BT 192.482 652.833 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 633.429 Td /F4 9.8 Tf [(The trust issue.)] TJ ET BT 26.250 614.024 Td /F1 9.8 Tf [(According to Giddens, contemporary individuals are exhorted to become the entrepreneur of their own life, but they must do so )] TJ ET BT 26.250 602.119 Td /F1 9.8 Tf [(in a context characterised by trust issues, as many if not all aspects of our daily lives depend on machines or systems that )] TJ ET BT 26.250 590.214 Td /F1 9.8 Tf [(are distant from us and beyond our understanding. Giddenss analysis is based on a concept of trust borrowed from the )] TJ ET BT 26.250 578.310 Td /F1 9.8 Tf [(psychologist Erik Erikson: depending on people/things that are not under our direct scrutiny or not fully understandable to us )] TJ ET BT 26.250 566.405 Td /F1 9.8 Tf [(induces anxiety, and we must trust them, trust a whole expert system, through a leap of faith. As our societies are characterised )] TJ ET BT 26.250 554.500 Td /F1 9.8 Tf [(by overspecialisation and the disembedding of social relationships, trust issues become essential )] TJ ET 0.267 0.267 0.267 rg BT 447.304 556.007 Td /F4 8.7 Tf [(32)] TJ ET 0.271 0.267 0.267 rg BT 456.941 554.500 Td /F1 9.8 Tf [(. Moreover, in Giddenss )] TJ ET BT 26.250 542.595 Td /F1 9.8 Tf [(perspective, the contemporary controversies regarding vaccination or other health-related issues are not the causes of distrust, )] TJ ET BT 26.250 530.691 Td /F1 9.8 Tf [(but only consequences of a wider structural phenomenon.)] TJ ET BT 26.250 511.286 Td /F1 9.8 Tf [(Trust issues are also crucial in Becks analyses of contemporary risk societies, especially regarding science and knowledge. )] TJ ET BT 26.250 499.381 Td /F1 9.8 Tf [(According to him, our societies are characterised by reflexive scientisation: scientific scepticism has been extended to science )] TJ ET BT 26.250 487.476 Td /F1 9.8 Tf [(itself and fuelled the disenchantment of science. As a result, there is a process of demonopolisation/feudalisation of scientific )] TJ ET BT 26.250 475.572 Td /F1 9.8 Tf [(knowledge, with conflictual equalisation tendencies in the gradient of rationality between experts and lay people. Sciences, )] TJ ET BT 26.250 463.667 Td /F1 9.8 Tf [(quasi-sciences and pseudo-sciences are competing sources that produce a flood of overspecialised, hyper-complex and )] TJ ET BT 26.250 451.762 Td /F1 9.8 Tf [(contradictory findings. Consequently, distrust toward science is no longer a sign of ignorance or even obscurantism, but is )] TJ ET BT 26.250 439.857 Td /F1 9.8 Tf [(endorsed by highly educated individuals )] TJ ET 0.267 0.267 0.267 rg BT 201.838 441.365 Td /F4 8.7 Tf [(37)] TJ ET 0.271 0.267 0.267 rg BT 211.475 439.857 Td /F1 9.8 Tf [(. Beck also pointed out the increasingly important issue of conflicts of interest, i.e., )] TJ ET BT 26.250 427.953 Td /F1 9.8 Tf [(situations in which scientists or experts are perceived as untrustworthy because of their financial links to industries. In this )] TJ ET BT 26.250 416.048 Td /F1 9.8 Tf [(context, people who endorse risk culture and decide to take their health in hand are confronted with discordant sources of )] TJ ET BT 26.250 404.143 Td /F1 9.8 Tf [(knowledge: they may distrust official sciences and experts, and put their faith in alternative sources of information or medical )] TJ ET BT 26.250 392.238 Td /F1 9.8 Tf [(practice \(such as homeopathy or acupuncture\).)] TJ ET BT 26.250 372.834 Td /F1 9.8 Tf [(Vaccination-related issues have not escaped from these structural features of contemporary societies, especially the crisis of )] TJ ET BT 26.250 360.929 Td /F1 9.8 Tf [(legitimacy faced by science, expertise and medical authorities. Vaccination may involve trust as a leap of faith, experienced )] TJ ET BT 26.250 349.024 Td /F1 9.8 Tf [(through relationality and familiarity with a physician [5,38]. An annual survey conducted by the IRSN \(Institute of Radiation )] TJ ET BT 26.250 337.119 Td /F1 9.8 Tf [(Protection and Nuclear Safety\) illustrates this crisis of legitimacy; it found that, generally speaking, the French people do not )] TJ ET BT 26.250 325.215 Td /F1 9.8 Tf [(trust the way authorities manage various kinds of risks, nor do they trust the information given to them. For example, only 38% )] TJ ET BT 26.250 313.310 Td /F1 9.8 Tf [(of the French had confidence that what authorities did about the H1N1 episode in 2009 was for their safety, and only 34% )] TJ ET BT 26.250 301.405 Td /F1 9.8 Tf [(believed that the information released was true. )] TJ ET 0.267 0.267 0.267 rg BT 233.808 302.912 Td /F4 8.7 Tf [(39)] TJ ET 0.271 0.267 0.267 rg BT 26.250 282.000 Td /F1 9.8 Tf [(Trust is generally considered as a crucial component of peoples attitudes toward vaccination, including VH )] TJ ET 0.267 0.267 0.267 rg BT 489.570 283.508 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 494.389 285.889 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 496.798 283.508 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 501.617 285.889 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 504.026 283.508 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 508.845 285.889 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 511.254 283.508 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 520.891 285.889 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 523.301 283.508 Td /F4 8.7 Tf [(40)] TJ ET 0.271 0.267 0.267 rg BT 532.938 282.000 Td /F1 9.8 Tf [(. For )] TJ ET BT 26.250 270.096 Td /F1 9.8 Tf [(example, trust is a key dimension in the questionnaire developed by Opel et al to assess VH )] TJ ET 0.267 0.267 0.267 rg BT 426.185 271.603 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 435.823 270.096 Td /F1 9.8 Tf [(. More precisely, lay people may )] TJ ET BT 26.250 258.191 Td /F1 9.8 Tf [(not distrust vaccines per se, but rather distrust the health authorities who are believed to be strongly influenced by vaccines )] TJ ET BT 26.250 246.286 Td /F1 9.8 Tf [(producers )] TJ ET 0.267 0.267 0.267 rg BT 72.309 247.793 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 77.128 250.174 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 79.537 247.793 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 89.174 246.286 Td /F1 9.8 Tf [(. This feature of contemporary societies is closely related to healthism, and some authors have even combined )] TJ ET BT 26.250 234.381 Td /F1 9.8 Tf [(these concepts: in such cases, healthism refers to individuals who seek to control their \(childrens\) health, who want to become )] TJ ET BT 26.250 222.477 Td /F1 9.8 Tf [(its informed and rational entrepreneur, but who also express strong doubts about medical authorities and mainstream medicine )] TJ ET BT 26.250 210.572 Td /F1 9.8 Tf [(and are more prone to turn to alternative experts, including on vaccination issues )] TJ ET 0.267 0.267 0.267 rg BT 377.416 212.079 Td /F4 8.7 Tf [(36)] TJ ET 0.271 0.267 0.267 rg BT 387.053 210.572 Td /F1 9.8 Tf [(. This relation between empowerment and )] TJ ET BT 26.250 198.667 Td /F1 9.8 Tf [(distrust is also explicitly promoted by some groups critical of vaccines, which claim that trusting blindly can be the biggest risk )] TJ ET BT 26.250 186.762 Td /F1 9.8 Tf [(of all )] TJ ET 0.267 0.267 0.267 rg BT 52.799 188.270 Td /F4 8.7 Tf [(41)] TJ ET 0.271 0.267 0.267 rg BT 62.437 186.762 Td /F1 9.8 Tf [(. Moreover, several previous studies have already found a positive correlation between VH and use of alternative )] TJ ET BT 26.250 174.858 Td /F1 9.8 Tf [(medicines \(such as acupuncture, homeopathy or naturopathy )] TJ ET 0.267 0.267 0.267 rg BT 293.420 176.365 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 303.057 178.746 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 305.466 176.365 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 315.104 178.746 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 317.513 176.365 Td /F4 8.7 Tf [(40)] TJ ET 0.271 0.267 0.267 rg BT 327.150 174.858 Td /F1 9.8 Tf [( \) , as well as distrust of colon cancer screening )] TJ ET 0.267 0.267 0.267 rg BT 534.689 176.365 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 544.326 174.858 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 138.255 Td /F4 12.0 Tf [(VH in a two-dimension map.)] TJ ET BT 26.250 118.301 Td /F1 9.8 Tf [(Thus we propose to add to the risk culture/healthism axis a second axis, assessing lay peoples attitudes toward health )] TJ ET BT 26.250 106.396 Td /F1 9.8 Tf [(authorities and mainstream medicine \(see Figure 1\).)] TJ ET 0.965 0.965 0.965 rg 26.250 -145.735 555.000 242.250 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 96.515 m 581.250 96.515 l 581.250 95.765 l 26.250 95.765 l f q 450.000 0 0 226.500 35.250 -139.735 cm /I6 Do Q q 35.250 -145.735 537.000 0.000 re W n Q Q q 15.000 -145.735 577.500 922.735 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(which individuals are committed or indifferent to contemporary healthism.)] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(The link between healthism and VH is quite obvious in several studies. Gilkey et al. )] TJ ET 0.267 0.267 0.267 rg BT 386.610 749.579 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 396.247 748.071 Td /F1 9.8 Tf [( observed that forgoing vaccines was )] TJ ET BT 26.250 736.167 Td /F1 9.8 Tf [(more common among parents more attentive to their childrens health and nutrition, and others underline the weight of rational )] TJ ET BT 26.250 724.262 Td /F1 9.8 Tf [(assessment and the importance of perceived control among people who were reluctant to be vaccinated against the H1N1 )] TJ ET BT 26.250 712.357 Td /F1 9.8 Tf [(influenza )] TJ ET 0.267 0.267 0.267 rg BT 67.980 713.864 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 77.617 716.245 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 80.027 713.864 Td /F4 8.7 Tf [(27)] TJ ET 0.271 0.267 0.267 rg BT 89.664 712.357 Td /F1 9.8 Tf [(. Moreover, when Opel et al. )] TJ ET 0.267 0.267 0.267 rg BT 214.844 713.864 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 224.482 712.357 Td /F1 9.8 Tf [( built a questionnaire designed to identify VH, they not only used existing items )] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(but also conducted focus groups to create new items. Because parents frequently claimed that they prefer to rely on their own )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(research on vaccines to come to an informed decision, rather than deferring to their childs doctor, the authors added the )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(following item: It is my role as a parent to question shots. We believe this item captures an aspect of commitment to risk )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(culture. Conversely, and rather remarkably, parents reluctance to get their child immunised has been used as a typical example )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(to illustrate contemporary healthism )] TJ ET 0.267 0.267 0.267 rg BT 182.845 654.341 Td /F4 8.7 Tf [(36)] TJ ET 0.271 0.267 0.267 rg BT 192.482 652.833 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 633.429 Td /F4 9.8 Tf [(The trust issue.)] TJ ET BT 26.250 614.024 Td /F1 9.8 Tf [(According to Giddens, contemporary individuals are exhorted to become the entrepreneur of their own life, but they must do so )] TJ ET BT 26.250 602.119 Td /F1 9.8 Tf [(in a context characterised by trust issues, as many if not all aspects of our daily lives depend on machines or systems that )] TJ ET BT 26.250 590.214 Td /F1 9.8 Tf [(are distant from us and beyond our understanding. Giddenss analysis is based on a concept of trust borrowed from the )] TJ ET BT 26.250 578.310 Td /F1 9.8 Tf [(psychologist Erik Erikson: depending on people/things that are not under our direct scrutiny or not fully understandable to us )] TJ ET BT 26.250 566.405 Td /F1 9.8 Tf [(induces anxiety, and we must trust them, trust a whole expert system, through a leap of faith. As our societies are characterised )] TJ ET BT 26.250 554.500 Td /F1 9.8 Tf [(by overspecialisation and the disembedding of social relationships, trust issues become essential )] TJ ET 0.267 0.267 0.267 rg BT 447.304 556.007 Td /F4 8.7 Tf [(32)] TJ ET 0.271 0.267 0.267 rg BT 456.941 554.500 Td /F1 9.8 Tf [(. Moreover, in Giddenss )] TJ ET BT 26.250 542.595 Td /F1 9.8 Tf [(perspective, the contemporary controversies regarding vaccination or other health-related issues are not the causes of distrust, )] TJ ET BT 26.250 530.691 Td /F1 9.8 Tf [(but only consequences of a wider structural phenomenon.)] TJ ET BT 26.250 511.286 Td /F1 9.8 Tf [(Trust issues are also crucial in Becks analyses of contemporary risk societies, especially regarding science and knowledge. )] TJ ET BT 26.250 499.381 Td /F1 9.8 Tf [(According to him, our societies are characterised by reflexive scientisation: scientific scepticism has been extended to science )] TJ ET BT 26.250 487.476 Td /F1 9.8 Tf [(itself and fuelled the disenchantment of science. As a result, there is a process of demonopolisation/feudalisation of scientific )] TJ ET BT 26.250 475.572 Td /F1 9.8 Tf [(knowledge, with conflictual equalisation tendencies in the gradient of rationality between experts and lay people. Sciences, )] TJ ET BT 26.250 463.667 Td /F1 9.8 Tf [(quasi-sciences and pseudo-sciences are competing sources that produce a flood of overspecialised, hyper-complex and )] TJ ET BT 26.250 451.762 Td /F1 9.8 Tf [(contradictory findings. Consequently, distrust toward science is no longer a sign of ignorance or even obscurantism, but is )] TJ ET BT 26.250 439.857 Td /F1 9.8 Tf [(endorsed by highly educated individuals )] TJ ET 0.267 0.267 0.267 rg BT 201.838 441.365 Td /F4 8.7 Tf [(37)] TJ ET 0.271 0.267 0.267 rg BT 211.475 439.857 Td /F1 9.8 Tf [(. Beck also pointed out the increasingly important issue of conflicts of interest, i.e., )] TJ ET BT 26.250 427.953 Td /F1 9.8 Tf [(situations in which scientists or experts are perceived as untrustworthy because of their financial links to industries. In this )] TJ ET BT 26.250 416.048 Td /F1 9.8 Tf [(context, people who endorse risk culture and decide to take their health in hand are confronted with discordant sources of )] TJ ET BT 26.250 404.143 Td /F1 9.8 Tf [(knowledge: they may distrust official sciences and experts, and put their faith in alternative sources of information or medical )] TJ ET BT 26.250 392.238 Td /F1 9.8 Tf [(practice \(such as homeopathy or acupuncture\).)] TJ ET BT 26.250 372.834 Td /F1 9.8 Tf [(Vaccination-related issues have not escaped from these structural features of contemporary societies, especially the crisis of )] TJ ET BT 26.250 360.929 Td /F1 9.8 Tf [(legitimacy faced by science, expertise and medical authorities. Vaccination may involve trust as a leap of faith, experienced )] TJ ET BT 26.250 349.024 Td /F1 9.8 Tf [(through relationality and familiarity with a physician [5,38]. An annual survey conducted by the IRSN \(Institute of Radiation )] TJ ET BT 26.250 337.119 Td /F1 9.8 Tf [(Protection and Nuclear Safety\) illustrates this crisis of legitimacy; it found that, generally speaking, the French people do not )] TJ ET BT 26.250 325.215 Td /F1 9.8 Tf [(trust the way authorities manage various kinds of risks, nor do they trust the information given to them. For example, only 38% )] TJ ET BT 26.250 313.310 Td /F1 9.8 Tf [(of the French had confidence that what authorities did about the H1N1 episode in 2009 was for their safety, and only 34% )] TJ ET BT 26.250 301.405 Td /F1 9.8 Tf [(believed that the information released was true. )] TJ ET 0.267 0.267 0.267 rg BT 233.808 302.912 Td /F4 8.7 Tf [(39)] TJ ET 0.271 0.267 0.267 rg BT 26.250 282.000 Td /F1 9.8 Tf [(Trust is generally considered as a crucial component of peoples attitudes toward vaccination, including VH )] TJ ET 0.267 0.267 0.267 rg BT 489.570 283.508 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 494.389 285.889 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 496.798 283.508 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 501.617 285.889 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 504.026 283.508 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 508.845 285.889 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 511.254 283.508 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 520.891 285.889 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 523.301 283.508 Td /F4 8.7 Tf [(40)] TJ ET 0.271 0.267 0.267 rg BT 532.938 282.000 Td /F1 9.8 Tf [(. For )] TJ ET BT 26.250 270.096 Td /F1 9.8 Tf [(example, trust is a key dimension in the questionnaire developed by Opel et al to assess VH )] TJ ET 0.267 0.267 0.267 rg BT 426.185 271.603 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 435.823 270.096 Td /F1 9.8 Tf [(. More precisely, lay people may )] TJ ET BT 26.250 258.191 Td /F1 9.8 Tf [(not distrust vaccines per se, but rather distrust the health authorities who are believed to be strongly influenced by vaccines )] TJ ET BT 26.250 246.286 Td /F1 9.8 Tf [(producers )] TJ ET 0.267 0.267 0.267 rg BT 72.309 247.793 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 77.128 250.174 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 79.537 247.793 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 89.174 246.286 Td /F1 9.8 Tf [(. This feature of contemporary societies is closely related to healthism, and some authors have even combined )] TJ ET BT 26.250 234.381 Td /F1 9.8 Tf [(these concepts: in such cases, healthism refers to individuals who seek to control their \(childrens\) health, who want to become )] TJ ET BT 26.250 222.477 Td /F1 9.8 Tf [(its informed and rational entrepreneur, but who also express strong doubts about medical authorities and mainstream medicine )] TJ ET BT 26.250 210.572 Td /F1 9.8 Tf [(and are more prone to turn to alternative experts, including on vaccination issues )] TJ ET 0.267 0.267 0.267 rg BT 377.416 212.079 Td /F4 8.7 Tf [(36)] TJ ET 0.271 0.267 0.267 rg BT 387.053 210.572 Td /F1 9.8 Tf [(. This relation between empowerment and )] TJ ET BT 26.250 198.667 Td /F1 9.8 Tf [(distrust is also explicitly promoted by some groups critical of vaccines, which claim that trusting blindly can be the biggest risk )] TJ ET BT 26.250 186.762 Td /F1 9.8 Tf [(of all )] TJ ET 0.267 0.267 0.267 rg BT 52.799 188.270 Td /F4 8.7 Tf [(41)] TJ ET 0.271 0.267 0.267 rg BT 62.437 186.762 Td /F1 9.8 Tf [(. Moreover, several previous studies have already found a positive correlation between VH and use of alternative )] TJ ET BT 26.250 174.858 Td /F1 9.8 Tf [(medicines \(such as acupuncture, homeopathy or naturopathy )] TJ ET 0.267 0.267 0.267 rg BT 293.420 176.365 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 303.057 178.746 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 305.466 176.365 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 315.104 178.746 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 317.513 176.365 Td /F4 8.7 Tf [(40)] TJ ET 0.271 0.267 0.267 rg BT 327.150 174.858 Td /F1 9.8 Tf [( \) , as well as distrust of colon cancer screening )] TJ ET 0.267 0.267 0.267 rg BT 534.689 176.365 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 544.326 174.858 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 138.255 Td /F4 12.0 Tf [(VH in a two-dimension map.)] TJ ET BT 26.250 118.301 Td /F1 9.8 Tf [(Thus we propose to add to the risk culture/healthism axis a second axis, assessing lay 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F!Ǽ$76.{䭼G%נĦ堏|JZNԇţX@^"VP!2UJ! 0V4A5ͭCS9Y:5BpE5*@eyY*C@zd2a 9BC%q2teMubY 5VT,A>a\*8ltR vU @Óu HK S$, D(dXΉ~Դq^v}'`KC"r0q3*R$Aծ%I jY%;w96l bUF<™W2Jं4STP쨥jq\F 0uX *H^.|wB'AO-I  Gj)ֆO }$cM5ϑʖՉKj& sU=!AeWLe(T<$bBA,QEW  Pٖ< /$sBD;Q}E _H$SG`%Ad|̀j,\ed%!ԄHEhL{ 5cT-,[ׇMƉ&B6xUh^C$UU'G0Fn4Ȣm0 Liw$R DO@0}zzUB>%5kJUi.TCC"ݱ~*2&9W*_I> 2`TH@s-' KS zʚ}fF?4cτy〦 3O^R5I543|`px~5*WaFrUSXde)+ X.Yqf{acB 0Z@@?TЪ j ɤ ܲP(sNpi;`"\uCIRxOI 2zsA4Fd'Ux_@ j &cSY ʞ4<[US&y^?!¸p]Y[1ak֬ B> 06dJ_ B0˃%,O3eDĊ< FhBBpה7iQ-[|(YԆbA Io`sQ˲ $΀c=x+\*W42^4(NւT:dp%z/vQd/iX&Lя X+ 'Xl,D)BpH؞|B!GyL!']4V\,/`[ cWjZ)`!KU˱B3e+*%xL.-.#F*䌯 YBpiflNE0`q+sku7pe\˼ ̀蝹/z*AfTzT˪ bbiceEii,_B- K@=`Jfݯ Ea[`w4# /,΃v p3'lìoFNX,I*XdWU\Z@!8A@g-6S{0H>86(!T.HhU܃$F"u!XJ A L8?iM6y@[TL=hIP}G4En YdA)<#["k[6'hYr\nUh5KH1`.σ󑬡IYm]7Pq VORyٜ/ 2,cФ*"y> r) Is521`OUCnz&*VЌrx%VB6f͹dQT 8Y*Ac/*  RT4jF5Р!)`a`GϜ: endstream endobj 654 0 obj << /Type /Page /Parent 3 0 R /Annots [ 656 0 R 658 0 R 660 0 R 662 0 R 664 0 R 666 0 R 668 0 R 670 0 R 672 0 R 674 0 R 676 0 R 678 0 R 680 0 R 682 0 R 684 0 R 686 0 R 688 0 R 690 0 R 692 0 R 694 0 R 696 0 R 698 0 R 700 0 R 702 0 R 704 0 R 706 0 R 708 0 R 710 0 R 712 0 R 714 0 R 716 0 R 718 0 R 720 0 R ] /Contents 655 0 R >> endobj 655 0 obj << /Length 28831 >> stream q 15.000 13.377 577.500 763.623 re W n 0.965 0.965 0.965 rg 26.250 726.609 555.000 50.391 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 726.609 m 581.250 726.609 l 581.250 727.359 l 26.250 727.359 l f q 35.250 737.859 537.000 39.141 re W n 0.271 0.267 0.267 rg BT 35.250 767.476 Td /F4 9.8 Tf [(Fig. 1: VH along two axes)] TJ ET BT 35.250 748.106 Td /F1 9.8 Tf [(Commitment to risk culture / healthism \(horizontal axis\) and distrust/trust toward health authorities \(vertical axis\).)] TJ ET Q BT 26.250 709.585 Td /F1 9.8 Tf [(These two axes can be used to represent different types of VH. For example, in their study of major motives for non-acceptance )] TJ ET BT 26.250 697.680 Td /F1 9.8 Tf [(of the A/H1N1 flu vaccine, Velan et al. )] TJ ET 0.267 0.267 0.267 rg BT 193.170 699.188 Td /F4 8.7 Tf [(27)] TJ ET 0.271 0.267 0.267 rg BT 202.807 697.680 Td /F1 9.8 Tf [( found several contrasting profiles, including people whose motives suggested )] TJ ET BT 26.250 685.776 Td /F1 9.8 Tf [(passiveness, inaction and dependence \(I did not think about it, I somehow did not manage to do it\), corresponding here to )] TJ ET BT 26.250 673.871 Td /F1 9.8 Tf [(the lower-left quadrant \(erratic VH\), and people who made their decision after a process of reflection \(after some deliberation I )] TJ ET BT 26.250 661.966 Td /F1 9.8 Tf [(have decided not to do it, I realised that the disease is not serious, that it is not spreading\), corresponding here to the lower-)] TJ ET BT 26.250 650.061 Td /F1 9.8 Tf [(right quadrant. Specific views regarding VH could also be positioned here: for example, in Marshalls view )] TJ ET 0.267 0.267 0.267 rg BT 483.593 651.569 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 493.231 650.061 Td /F1 9.8 Tf [(, VH is due to a )] TJ ET BT 26.250 638.157 Td /F1 9.8 Tf [(lack of faith in authorities, combined with misperceptions, emotion-driven reactions, and gullibility toward rumours spread by anti-)] TJ ET BT 26.250 626.252 Td /F1 9.8 Tf [(champions and celebrities, corresponding to the lower-left quadrant.)] TJ ET BT 26.250 606.847 Td /F1 9.8 Tf [(This map also underlines that although health promotion policies aiming at encouraging people to take their health in their own )] TJ ET BT 26.250 594.942 Td /F1 9.8 Tf [(hands may move people further along the horizontal axis, health promotion may nonetheless fuel VH, at least among some )] TJ ET BT 26.250 583.038 Td /F1 9.8 Tf [(populations, unless they are positioned high on the trust axis.)] TJ ET BT 26.250 563.633 Td /F1 9.8 Tf [(Nevertheless, talking about vaccine hesitant people may be a misuse of language, as VH also strongly depends on vaccine-)] TJ ET BT 26.250 551.728 Td /F1 9.8 Tf [(specific factors; thus specific vaccines, rather than individual profiles, could be also positioned along our two axes. In other )] TJ ET BT 26.250 539.823 Td /F1 9.8 Tf [(words, instead of considering whether or not people are vaccine-hesitant, we should consider whether a specific )] TJ ET BT 26.250 527.919 Td /F1 9.8 Tf [(context/vaccine fuels their propensity to VH. For example, people are probably more likely to endorse an active attitude, seeking )] TJ ET BT 26.250 516.014 Td /F1 9.8 Tf [(information and assessing risk and benefits, when they are confronted with new vaccine, such as the H1N1 or the HPV )] TJ ET BT 26.250 504.109 Td /F1 9.8 Tf [(vaccines, while they may be more prone to follow their physicians advice routinely and passively for some childhood vaccines )] TJ ET BT 26.250 492.204 Td /F1 9.8 Tf [(or that against seasonal influenza. Moreover, the level of confidence in health authorities about any specific vaccine obviously )] TJ ET BT 26.250 480.300 Td /F1 9.8 Tf [(depends on the extent of media coverage of existing controversies regarding its potential side effects. In the UK, for example, )] TJ ET BT 26.250 468.395 Td /F1 9.8 Tf [(the MMR vaccine would have been positioned in the upper-left quadrant before the MMR/autism controversy began, along with )] TJ ET BT 26.250 456.490 Td /F1 9.8 Tf [(the vaccine against seasonal flu. On the contrary, the HPV vaccine could be considered as relatively new and less controversial )] TJ ET BT 26.250 444.585 Td /F1 9.8 Tf [(\(upper-right quadrant\), while the H1N1 vaccine was both new and controversial \(lower-right quadrant\) )] TJ ET 0.267 0.267 0.267 rg BT 466.248 446.093 Td /F4 8.7 Tf [(15)] TJ ET 0.271 0.267 0.267 rg BT 475.885 444.585 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 407.983 Td /F4 12.0 Tf [(Conclusion)] TJ ET BT 26.250 388.029 Td /F1 9.8 Tf [(In this paper, we have discussed some of the ambiguities and contradictions of the notion of vaccine hesitancy. We have )] TJ ET BT 26.250 376.124 Td /F1 9.8 Tf [(argued that it is currently more a catchall category than a real concept. This lack of consistence is likely to hamper both )] TJ ET BT 26.250 364.219 Td /F1 9.8 Tf [(research and interventions. Therefore, as a supplement to the previous work carried out by the SAGE working group, we )] TJ ET BT 26.250 352.314 Td /F1 9.8 Tf [(propose grounding the notion of vaccine hesitancy in an explicit theoretical framework that takes some major structural features )] TJ ET BT 26.250 340.410 Td /F1 9.8 Tf [(of contemporary societies into account. We consider VH to be a kind of decision-making process that depends on peoples level )] TJ ET BT 26.250 328.505 Td /F1 9.8 Tf [(of commitment to healthism/risk culture and on their level of confidence toward health authorities and mainstream medicine.)] TJ ET BT 26.250 309.100 Td /F1 9.8 Tf [(This framework abandons the anti/pro vaccination continuum. We do not claim here that the vaccine-hesitant do not have )] TJ ET BT 26.250 297.195 Td /F1 9.8 Tf [(opinions about vaccination in general, nor that such opinions do not influence their behaviours toward a specific vaccine. )] TJ ET BT 26.250 285.291 Td /F1 9.8 Tf [(Nevertheless, we believe that these general opinions are not a key determinant of their vaccination behaviours, especially in )] TJ ET BT 26.250 273.386 Td /F1 9.8 Tf [(comparison with the two other dimensions discussed here.)] TJ ET BT 26.250 253.981 Td /F1 9.8 Tf [(We also believe our approach opens new avenues for research on VH. For example, it would be useful to consider various )] TJ ET BT 26.250 242.076 Td /F1 9.8 Tf [(kinds of VH that may be correlated to individuals socioeconomic status \(SES\), as the social differentiation of health behaviors )] TJ ET BT 26.250 230.172 Td /F1 9.8 Tf [(may reflect the social differentiation of health-related cognition, including knowledge, attitudes and beliefs )] TJ ET 0.267 0.267 0.267 rg BT 482.014 231.679 Td /F4 8.7 Tf [(42)] TJ ET 0.271 0.267 0.267 rg BT 491.651 230.172 Td /F1 9.8 Tf [(. Erratic VH is more )] TJ ET BT 26.250 218.267 Td /F1 9.8 Tf [(likely to be displayed by people with low SES, while rationalised VH may be more frequent among the educated middle classes )] TJ ET 0.267 0.267 0.267 rg BT 26.250 207.869 Td /F4 8.7 Tf [(43)] TJ ET 0.271 0.267 0.267 rg BT 35.887 206.362 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 186.957 Td /F1 9.8 Tf [(Finally, as even highly educated people may show VH, we should not focus only on lay people. We should also study )] TJ ET BT 26.250 175.053 Td /F1 9.8 Tf [(extensively VH among health professionals, and especially among general practitioners, who still play a key role in promoting )] TJ ET BT 26.250 163.148 Td /F1 9.8 Tf [(vaccination, and who also display some kinds of VH )] TJ ET 0.267 0.267 0.267 rg BT 252.762 164.655 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 257.581 167.036 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 259.990 164.655 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 264.809 167.036 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 267.218 164.655 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 276.855 163.148 Td /F1 9.8 Tf [(. We should also study their interactions with their patients. In some )] TJ ET BT 26.250 151.243 Td /F1 9.8 Tf [(cases, health professionals may fuel patients VH \(directly, when homeopaths and naturopaths express convincingly their doubt )] TJ ET BT 26.250 139.338 Td /F1 9.8 Tf [(regarding vaccination to their patients )] TJ ET 0.267 0.267 0.267 rg BT 190.996 140.846 Td /F4 8.7 Tf [(40)] TJ ET 0.271 0.267 0.267 rg BT 200.633 139.338 Td /F1 9.8 Tf [(, or indirectly, when pro-vaccine physicians refuse to accept into their practices families )] TJ ET BT 26.250 127.434 Td /F1 9.8 Tf [(who are reluctant to vaccinate their children )] TJ ET 0.267 0.267 0.267 rg BT 216.999 128.941 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 226.636 127.434 Td /F1 9.8 Tf [(\), but sometimes vaccine-hesitant patients may raise doubts in their physicians )] TJ ET BT 26.250 115.529 Td /F1 9.8 Tf [(mind )] TJ ET 0.267 0.267 0.267 rg BT 50.089 117.036 Td /F4 8.7 Tf [(38)] TJ ET 0.271 0.267 0.267 rg BT 59.726 115.529 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 96.124 Td /F1 9.8 Tf [(More generally, we should study the interactions between the various participants involved in immunisation policies, from public )] TJ ET BT 26.250 84.219 Td /F1 9.8 Tf [(health experts to lay people: is there a hesitancy cascade, with waves of influences from political hesitancy to provider )] TJ ET BT 26.250 72.315 Td /F1 9.8 Tf [(hesitancy to public hesitancy, and is there a feedback effect in some cases \(patients VH reinforcing physicians VH, which in )] TJ ET BT 26.250 60.410 Td /F1 9.8 Tf [(turn fuels VH among other patients\)?)] TJ ET Q q 15.000 13.377 577.500 763.623 re W n 0.965 0.965 0.965 rg 26.250 726.609 555.000 50.391 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 726.609 m 581.250 726.609 l 581.250 727.359 l 26.250 727.359 l f q 35.250 737.859 537.000 39.141 re W n 0.271 0.267 0.267 rg BT 35.250 767.476 Td /F4 9.8 Tf [(Fig. 1: VH along two axes)] TJ ET BT 35.250 748.106 Td /F1 9.8 Tf [(Commitment to risk culture / healthism \(horizontal axis\) and distrust/trust toward health authorities \(vertical axis\).)] TJ ET Q BT 26.250 709.585 Td /F1 9.8 Tf [(These two axes can be used to represent different types of VH. For example, in their study of major motives for non-acceptance )] TJ ET BT 26.250 697.680 Td /F1 9.8 Tf [(of the A/H1N1 flu vaccine, Velan et al. )] TJ ET 0.267 0.267 0.267 rg BT 193.170 699.188 Td /F4 8.7 Tf [(27)] TJ ET 0.271 0.267 0.267 rg BT 202.807 697.680 Td /F1 9.8 Tf [( found several contrasting profiles, including people whose motives suggested )] TJ ET BT 26.250 685.776 Td /F1 9.8 Tf [(passiveness, inaction and dependence \(I did not think about it, I somehow did not manage to do it\), corresponding here to )] TJ ET BT 26.250 673.871 Td /F1 9.8 Tf [(the lower-left quadrant \(erratic VH\), and people who made their decision after a process of reflection \(after some deliberation I )] TJ ET BT 26.250 661.966 Td /F1 9.8 Tf [(have decided not to do it, I realised that the disease is not serious, that it is not spreading\), corresponding here to the lower-)] TJ ET BT 26.250 650.061 Td /F1 9.8 Tf [(right quadrant. Specific views regarding VH could also be positioned here: for example, in Marshalls view )] TJ ET 0.267 0.267 0.267 rg BT 483.593 651.569 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 493.231 650.061 Td /F1 9.8 Tf [(, VH is due to a )] TJ ET BT 26.250 638.157 Td /F1 9.8 Tf [(lack of faith in authorities, combined with misperceptions, emotion-driven reactions, and gullibility toward rumours spread by anti-)] TJ ET BT 26.250 626.252 Td /F1 9.8 Tf [(champions and celebrities, corresponding to the lower-left quadrant.)] TJ ET BT 26.250 606.847 Td /F1 9.8 Tf [(This map also underlines that although health promotion policies aiming at encouraging people to take their health in their own )] TJ ET BT 26.250 594.942 Td /F1 9.8 Tf [(hands may move people further along the horizontal axis, health promotion may nonetheless fuel VH, at least among some )] TJ ET BT 26.250 583.038 Td /F1 9.8 Tf [(populations, unless they are positioned high on the trust axis.)] TJ ET BT 26.250 563.633 Td /F1 9.8 Tf [(Nevertheless, talking about vaccine hesitant people may be a misuse of language, as VH also strongly depends on vaccine-)] TJ ET BT 26.250 551.728 Td /F1 9.8 Tf [(specific factors; thus specific vaccines, rather than individual profiles, could be also positioned along our two axes. In other )] TJ ET BT 26.250 539.823 Td /F1 9.8 Tf [(words, instead of considering whether or not people are vaccine-hesitant, we should consider whether a specific )] TJ ET BT 26.250 527.919 Td /F1 9.8 Tf [(context/vaccine fuels their propensity to VH. For example, people are probably more likely to endorse an active attitude, seeking )] TJ ET BT 26.250 516.014 Td /F1 9.8 Tf [(information and assessing risk and benefits, when they are confronted with new vaccine, such as the H1N1 or the HPV )] TJ ET BT 26.250 504.109 Td /F1 9.8 Tf [(vaccines, while they may be more prone to follow their physicians advice routinely and passively for some childhood vaccines )] TJ ET BT 26.250 492.204 Td /F1 9.8 Tf [(or that against seasonal influenza. Moreover, the level of confidence in health authorities about any specific vaccine obviously )] TJ ET BT 26.250 480.300 Td /F1 9.8 Tf [(depends on the extent of media coverage of existing controversies regarding its potential side effects. In the UK, for example, )] TJ ET BT 26.250 468.395 Td /F1 9.8 Tf [(the MMR vaccine would have been positioned in the upper-left quadrant before the MMR/autism controversy began, along with )] TJ ET BT 26.250 456.490 Td /F1 9.8 Tf [(the vaccine against seasonal flu. On the contrary, the HPV vaccine could be considered as relatively new and less controversial )] TJ ET BT 26.250 444.585 Td /F1 9.8 Tf [(\(upper-right quadrant\), while the H1N1 vaccine was both new and controversial \(lower-right quadrant\) )] TJ ET 0.267 0.267 0.267 rg BT 466.248 446.093 Td /F4 8.7 Tf [(15)] TJ ET 0.271 0.267 0.267 rg BT 475.885 444.585 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 407.983 Td /F4 12.0 Tf [(Conclusion)] TJ ET BT 26.250 388.029 Td /F1 9.8 Tf [(In this paper, we have discussed some of the ambiguities and contradictions of the notion of vaccine hesitancy. We have )] TJ ET BT 26.250 376.124 Td /F1 9.8 Tf [(argued that it is currently more a catchall category than a real concept. This lack of consistence is likely to hamper both )] TJ ET BT 26.250 364.219 Td /F1 9.8 Tf [(research and interventions. Therefore, as a supplement to the previous work carried out by the SAGE working group, we )] TJ ET BT 26.250 352.314 Td /F1 9.8 Tf [(propose grounding the notion of vaccine hesitancy in an explicit theoretical framework that takes some major structural features )] TJ ET BT 26.250 340.410 Td /F1 9.8 Tf [(of contemporary societies into account. We consider VH to be a kind of decision-making process that depends on peoples level )] TJ ET BT 26.250 328.505 Td /F1 9.8 Tf [(of commitment to healthism/risk culture and on their level of confidence toward health authorities and mainstream medicine.)] TJ ET BT 26.250 309.100 Td /F1 9.8 Tf [(This framework abandons the anti/pro vaccination continuum. We do not claim here that the vaccine-hesitant do not have )] TJ ET BT 26.250 297.195 Td /F1 9.8 Tf [(opinions about vaccination in general, nor that such opinions do not influence their behaviours toward a specific vaccine. )] TJ ET BT 26.250 285.291 Td /F1 9.8 Tf [(Nevertheless, we believe that these general opinions are not a key determinant of their vaccination behaviours, especially in )] TJ ET BT 26.250 273.386 Td /F1 9.8 Tf [(comparison with the two other dimensions discussed here.)] TJ ET BT 26.250 253.981 Td /F1 9.8 Tf [(We also believe our approach opens new avenues for research on VH. For example, it would be useful to consider various )] TJ ET BT 26.250 242.076 Td /F1 9.8 Tf [(kinds of VH that may be correlated to individuals socioeconomic status \(SES\), as the social differentiation of health behaviors )] TJ ET BT 26.250 230.172 Td /F1 9.8 Tf [(may reflect the social differentiation of health-related cognition, including knowledge, attitudes and beliefs )] TJ ET 0.267 0.267 0.267 rg BT 482.014 231.679 Td /F4 8.7 Tf [(42)] TJ ET 0.271 0.267 0.267 rg BT 491.651 230.172 Td /F1 9.8 Tf [(. Erratic VH is more )] TJ ET BT 26.250 218.267 Td /F1 9.8 Tf [(likely to be displayed by people with low SES, while rationalised VH may be more frequent among the educated middle classes )] TJ ET 0.267 0.267 0.267 rg BT 26.250 207.869 Td /F4 8.7 Tf [(43)] TJ ET 0.271 0.267 0.267 rg BT 35.887 206.362 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 186.957 Td /F1 9.8 Tf [(Finally, as even highly educated people may show VH, we should not focus only on lay people. We should also study )] TJ ET BT 26.250 175.053 Td /F1 9.8 Tf [(extensively VH among health professionals, and especially among general practitioners, who still play a key role in promoting )] TJ ET BT 26.250 163.148 Td /F1 9.8 Tf [(vaccination, and who also display some kinds of VH )] TJ ET 0.267 0.267 0.267 rg BT 252.762 164.655 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 257.581 167.036 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 259.990 164.655 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 264.809 167.036 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 267.218 164.655 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 276.855 163.148 Td /F1 9.8 Tf [(. We should also study their interactions with their patients. In some )] TJ ET BT 26.250 151.243 Td /F1 9.8 Tf [(cases, health professionals may fuel patients VH \(directly, when homeopaths and naturopaths express convincingly their doubt )] TJ ET BT 26.250 139.338 Td /F1 9.8 Tf [(regarding vaccination to their patients )] TJ ET 0.267 0.267 0.267 rg BT 190.996 140.846 Td /F4 8.7 Tf [(40)] TJ ET 0.271 0.267 0.267 rg BT 200.633 139.338 Td /F1 9.8 Tf [(, or indirectly, when pro-vaccine physicians refuse to accept into their practices families )] TJ ET BT 26.250 127.434 Td /F1 9.8 Tf [(who are reluctant to vaccinate their children )] TJ ET 0.267 0.267 0.267 rg BT 216.999 128.941 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 226.636 127.434 Td /F1 9.8 Tf [(\), but sometimes vaccine-hesitant patients may raise doubts in their physicians )] TJ ET BT 26.250 115.529 Td /F1 9.8 Tf [(mind )] TJ ET 0.267 0.267 0.267 rg BT 50.089 117.036 Td /F4 8.7 Tf [(38)] TJ ET 0.271 0.267 0.267 rg BT 59.726 115.529 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 96.124 Td /F1 9.8 Tf [(More generally, we should study the interactions between the various participants involved in immunisation policies, from public )] TJ ET BT 26.250 84.219 Td /F1 9.8 Tf [(health experts to lay people: is there a hesitancy cascade, with waves of influences from political hesitancy to provider )] TJ ET BT 26.250 72.315 Td /F1 9.8 Tf [(hesitancy to public hesitancy, and is there a feedback effect in some cases \(patients VH reinforcing physicians VH, which in )] TJ ET BT 26.250 60.410 Td /F1 9.8 Tf [(turn fuels VH among other patients\)?)] TJ ET Q q 15.000 13.377 577.500 763.623 re W n 0.965 0.965 0.965 rg 26.250 726.609 555.000 50.391 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 726.609 m 581.250 726.609 l 581.250 727.359 l 26.250 727.359 l f q 35.250 737.859 537.000 39.141 re W n 0.271 0.267 0.267 rg BT 35.250 767.476 Td /F4 9.8 Tf [(Fig. 1: VH along two axes)] TJ ET BT 35.250 748.106 Td /F1 9.8 Tf [(Commitment to risk culture / healthism \(horizontal axis\) and distrust/trust toward health authorities \(vertical axis\).)] TJ ET Q BT 26.250 709.585 Td /F1 9.8 Tf [(These two axes can be used to represent different types of VH. For example, in their study of major motives for non-acceptance )] TJ ET BT 26.250 697.680 Td /F1 9.8 Tf [(of the A/H1N1 flu vaccine, Velan et al. )] TJ ET 0.267 0.267 0.267 rg BT 193.170 699.188 Td /F4 8.7 Tf [(27)] TJ ET 0.271 0.267 0.267 rg BT 202.807 697.680 Td /F1 9.8 Tf [( found several contrasting profiles, including people whose motives suggested )] TJ ET BT 26.250 685.776 Td /F1 9.8 Tf [(passiveness, inaction and dependence \(I did not think about it, I somehow did not manage to do it\), corresponding here to )] TJ ET BT 26.250 673.871 Td /F1 9.8 Tf [(the lower-left quadrant \(erratic VH\), and people who made their decision after a process of reflection \(after some deliberation I )] TJ ET BT 26.250 661.966 Td /F1 9.8 Tf [(have decided not to do it, I realised that the disease is not serious, that it is not spreading\), corresponding here to the lower-)] TJ ET BT 26.250 650.061 Td /F1 9.8 Tf [(right quadrant. Specific views regarding VH could also be positioned here: for example, in Marshalls view )] TJ ET 0.267 0.267 0.267 rg BT 483.593 651.569 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 493.231 650.061 Td /F1 9.8 Tf [(, VH is due to a )] TJ ET BT 26.250 638.157 Td /F1 9.8 Tf [(lack of faith in authorities, combined with misperceptions, emotion-driven reactions, and gullibility toward rumours spread by anti-)] TJ ET BT 26.250 626.252 Td /F1 9.8 Tf [(champions and celebrities, corresponding to the lower-left quadrant.)] TJ ET BT 26.250 606.847 Td /F1 9.8 Tf [(This map also underlines that although health promotion policies aiming at encouraging people to take their health in their own )] TJ ET BT 26.250 594.942 Td /F1 9.8 Tf [(hands may move people further along the horizontal axis, health promotion may nonetheless fuel VH, at least among some )] TJ ET BT 26.250 583.038 Td /F1 9.8 Tf [(populations, unless they are positioned high on the trust axis.)] TJ ET BT 26.250 563.633 Td /F1 9.8 Tf [(Nevertheless, talking about vaccine hesitant people may be a misuse of language, as VH also strongly depends on vaccine-)] TJ ET BT 26.250 551.728 Td /F1 9.8 Tf [(specific factors; thus specific vaccines, rather than individual profiles, could be also positioned along our two axes. In other )] TJ ET BT 26.250 539.823 Td /F1 9.8 Tf [(words, instead of considering whether or not people are vaccine-hesitant, we should consider whether a specific )] TJ ET BT 26.250 527.919 Td /F1 9.8 Tf [(context/vaccine fuels their propensity to VH. For example, people are probably more likely to endorse an active attitude, seeking )] TJ ET BT 26.250 516.014 Td /F1 9.8 Tf [(information and assessing risk and benefits, when they are confronted with new vaccine, such as the H1N1 or the HPV )] TJ ET BT 26.250 504.109 Td /F1 9.8 Tf [(vaccines, while they may be more prone to follow their physicians advice routinely and passively for some childhood vaccines )] TJ ET BT 26.250 492.204 Td /F1 9.8 Tf [(or that against seasonal influenza. Moreover, the level of confidence in health authorities about any specific vaccine obviously )] TJ ET BT 26.250 480.300 Td /F1 9.8 Tf [(depends on the extent of media coverage of existing controversies regarding its potential side effects. In the UK, for example, )] TJ ET BT 26.250 468.395 Td /F1 9.8 Tf [(the MMR vaccine would have been positioned in the upper-left quadrant before the MMR/autism controversy began, along with )] TJ ET BT 26.250 456.490 Td /F1 9.8 Tf [(the vaccine against seasonal flu. On the contrary, the HPV vaccine could be considered as relatively new and less controversial )] TJ ET BT 26.250 444.585 Td /F1 9.8 Tf [(\(upper-right quadrant\), while the H1N1 vaccine was both new and controversial \(lower-right quadrant\) )] TJ ET 0.267 0.267 0.267 rg BT 466.248 446.093 Td /F4 8.7 Tf [(15)] TJ ET 0.271 0.267 0.267 rg BT 475.885 444.585 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 407.983 Td /F4 12.0 Tf [(Conclusion)] TJ ET BT 26.250 388.029 Td /F1 9.8 Tf [(In this paper, we have discussed some of the ambiguities and contradictions of the notion of vaccine hesitancy. We have )] TJ ET BT 26.250 376.124 Td /F1 9.8 Tf [(argued that it is currently more a catchall category than a real concept. This lack of consistence is likely to hamper both )] TJ ET BT 26.250 364.219 Td /F1 9.8 Tf [(research and interventions. Therefore, as a supplement to the previous work carried out by the SAGE working group, we )] TJ ET BT 26.250 352.314 Td /F1 9.8 Tf [(propose grounding the notion of vaccine hesitancy in an explicit theoretical framework that takes some major structural features )] TJ ET BT 26.250 340.410 Td /F1 9.8 Tf [(of contemporary societies into account. We consider VH to be a kind of decision-making process that depends on peoples level )] TJ ET BT 26.250 328.505 Td /F1 9.8 Tf [(of commitment to healthism/risk culture and on their level of confidence toward health authorities and mainstream medicine.)] TJ ET BT 26.250 309.100 Td /F1 9.8 Tf [(This framework abandons the anti/pro vaccination continuum. We do not claim here that the vaccine-hesitant do not have )] TJ ET BT 26.250 297.195 Td /F1 9.8 Tf [(opinions about vaccination in general, nor that such opinions do not influence their behaviours toward a specific vaccine. )] TJ ET BT 26.250 285.291 Td /F1 9.8 Tf [(Nevertheless, we believe that these general opinions are not a key determinant of their vaccination behaviours, especially in )] TJ ET BT 26.250 273.386 Td /F1 9.8 Tf [(comparison with the two other dimensions discussed here.)] TJ ET BT 26.250 253.981 Td /F1 9.8 Tf [(We also believe our approach opens new avenues for research on VH. For example, it would be useful to consider various )] TJ ET BT 26.250 242.076 Td /F1 9.8 Tf [(kinds of VH that may be correlated to individuals socioeconomic status \(SES\), as the social differentiation of health behaviors )] TJ ET BT 26.250 230.172 Td /F1 9.8 Tf [(may reflect the social differentiation of health-related cognition, including knowledge, attitudes and beliefs )] TJ ET 0.267 0.267 0.267 rg BT 482.014 231.679 Td /F4 8.7 Tf [(42)] TJ ET 0.271 0.267 0.267 rg BT 491.651 230.172 Td /F1 9.8 Tf [(. Erratic VH is more )] TJ ET BT 26.250 218.267 Td /F1 9.8 Tf [(likely to be displayed by people with low SES, while rationalised VH may be more frequent among the educated middle classes )] TJ ET 0.267 0.267 0.267 rg BT 26.250 207.869 Td /F4 8.7 Tf [(43)] TJ ET 0.271 0.267 0.267 rg BT 35.887 206.362 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 186.957 Td /F1 9.8 Tf [(Finally, as even highly educated people may show VH, we should not focus only on lay people. We should also study )] TJ ET BT 26.250 175.053 Td /F1 9.8 Tf [(extensively VH among health professionals, and especially among general practitioners, who still play a key role in promoting )] TJ ET BT 26.250 163.148 Td /F1 9.8 Tf [(vaccination, and who also display some kinds of VH )] TJ ET 0.267 0.267 0.267 rg BT 252.762 164.655 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 257.581 167.036 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 259.990 164.655 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 264.809 167.036 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 267.218 164.655 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 276.855 163.148 Td /F1 9.8 Tf [(. We should also study their interactions with their patients. In some )] TJ ET BT 26.250 151.243 Td /F1 9.8 Tf [(cases, health professionals may fuel patients VH \(directly, when homeopaths and naturopaths express convincingly their doubt )] TJ ET BT 26.250 139.338 Td /F1 9.8 Tf [(regarding vaccination to their patients )] TJ ET 0.267 0.267 0.267 rg BT 190.996 140.846 Td /F4 8.7 Tf [(40)] TJ ET 0.271 0.267 0.267 rg BT 200.633 139.338 Td /F1 9.8 Tf [(, or indirectly, when pro-vaccine physicians refuse to accept into their practices families )] TJ ET BT 26.250 127.434 Td /F1 9.8 Tf [(who are reluctant to vaccinate their children )] TJ ET 0.267 0.267 0.267 rg BT 216.999 128.941 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 226.636 127.434 Td /F1 9.8 Tf [(\), but sometimes vaccine-hesitant patients may raise doubts in their physicians )] TJ ET BT 26.250 115.529 Td /F1 9.8 Tf [(mind )] TJ ET 0.267 0.267 0.267 rg BT 50.089 117.036 Td /F4 8.7 Tf [(38)] TJ ET 0.271 0.267 0.267 rg BT 59.726 115.529 Td /F1 9.8 Tf [(.)] TJ ET BT 26.250 96.124 Td /F1 9.8 Tf [(More generally, we should study the interactions between the various participants involved in immunisation policies, from public )] TJ ET BT 26.250 84.219 Td /F1 9.8 Tf [(health experts to lay people: is there a hesitancy cascade, with waves of influences from political hesitancy to provider )] TJ ET BT 26.250 72.315 Td /F1 9.8 Tf [(hesitancy to public hesitancy, and is there a feedback effect in some cases \(patients VH reinforcing physicians VH, which in )] TJ ET BT 26.250 60.410 Td /F1 9.8 Tf [(turn fuels VH among other patients\)?)] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(5)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Outbreaks)] TJ ET Q endstream endobj 656 0 obj << /Type /Annot /Subtype /Link /A 657 0 R /Border [0 0 0] /H /I /Rect [ 193.1700 698.3859 202.8073 707.2042 ] >> endobj 657 0 obj << /Type /Action >> endobj 658 0 obj << /Type /Annot /Subtype /Link /A 659 0 R /Border [0 0 0] /H /I /Rect [ 483.5933 650.7669 493.2306 659.5852 ] 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>> endobj 719 0 obj << /Type /Action >> endobj 720 0 obj << /Type /Annot /Subtype /Link /A 721 0 R /Border [0 0 0] /H /I /Rect [ 50.0888 116.2344 59.7261 125.0527 ] >> endobj 721 0 obj << /Type /Action >> endobj 722 0 obj << /Type /Page /Parent 3 0 R /Contents 723 0 R >> endobj 723 0 obj << /Length 20338 >> stream 0.271 0.267 0.267 rg q 15.000 47.815 577.500 729.185 re W n 0.271 0.267 0.267 rg BT 26.250 750.278 Td /F4 12.0 Tf [(Competing Interests)] TJ ET BT 26.250 730.324 Td /F1 9.8 Tf [(The authors have declared that no competing interests exist.)] TJ ET BT 26.250 693.722 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 666.267 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 666.267 Td /F1 9.8 Tf [(Black S, Rapuolin R. \(2010\) A crisis of public confidence in vaccines. Science 61: 61mr1.)] TJ ET BT 26.250 646.863 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 646.863 Td /F1 9.8 Tf [(Shetty P. \(2010\) Experts concerned about vaccination backlash. Lancet 375: 970-971.)] TJ ET BT 26.250 627.458 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 627.458 Td /F1 9.8 Tf [(Larson HJ, Cooper LZ, Eskolan J, Katz SL, Ratzan S. \(2011\) Addressing the vaccine confidence gap. Lancet 378: 526-535.)] TJ ET BT 26.250 608.053 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 608.053 Td /F1 9.8 Tf [(http://www.who.int/immunization/sage/sage_wg_vaccine_hesitancy_apr12/en/)] TJ ET BT 26.250 588.648 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 588.648 Td /F1 9.8 Tf [(Dub E, Laberge C, Guay M, Bramadat P, Roy R, Bettinger J. \(2013\) Vaccine hesitancy: an overview. Hum Vaccin )] TJ ET BT 26.250 576.744 Td /F1 9.8 Tf [(Immunother 9\(8\): 1763?1773.)] TJ ET BT 26.250 557.339 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 557.339 Td /F1 9.8 Tf [(Gowda C, Dempsey AF. \(2013\) The rise \(and fall?\) of parental vaccine hesitancy. Hum Vaccin Immunother 9\(8\): 1755-1762.)] TJ ET BT 26.250 537.934 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 537.934 Td /F1 9.8 Tf [(Larson HJ, Jarrett C, Eckersberger E, Smith DMD, Paterson P. \(2014\) Understanding vaccine hesitancy around vaccines )] TJ ET BT 26.250 526.029 Td /F1 9.8 Tf [(and vaccination from a global perspective: a systematic review of published literature, 2007-2012. Vaccine 32\(19\): 2150?2159.)] TJ ET BT 26.250 506.625 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 506.625 Td /F1 9.8 Tf [(Yaqub O, Castle-Clarke S, Sevdalis N, Chataway J. \(2014\) Attitudes to vaccination: A critical review. Soc Sci Med 112: 1-11.)] TJ ET BT 26.250 487.220 Td /F1 9.8 Tf [(9.)] TJ ET BT 38.132 487.220 Td /F1 9.8 Tf [(Limb M. \(2011\) "Vaccine hesitancy" means scientists need to be more honest about risks. BMJ 15;342: d2479.)] TJ ET BT 26.250 467.815 Td /F1 9.8 Tf [(10.)] TJ ET BT 43.553 467.815 Td /F1 9.8 Tf [(Bloom BR, Marcuse E, Mnookin S. \(2014\) Addressing vaccine hesitancy. Science 344\(6182\): 339.)] TJ ET BT 26.250 448.410 Td /F1 9.8 Tf [(11.)] TJ ET BT 43.553 448.410 Td /F1 9.8 Tf [(Opel DJ, Mangione-Smith R, Taylor JA, Korfiatis C, Wiese C, Catz S, Martin DP. \(2011\) Development of a survey to identify )] TJ ET BT 26.250 436.506 Td /F1 9.8 Tf [(vaccine-hesitant parents. The Parent Attitudes about Childhood Vaccines survey. Hum Vaccin 7\(4\): 419-425.)] TJ ET BT 26.250 417.101 Td /F1 9.8 Tf [(12.)] TJ ET BT 43.553 417.101 Td /F1 9.8 Tf [(Patel PR, Berenson AB. \(2013\) Sources of HPV vaccine hesitancy in parents. Hum Vaccin Immunother 9\(12\): 2649-2653.)] TJ ET BT 26.250 397.696 Td /F1 9.8 Tf [(13.)] TJ ET BT 43.553 397.696 Td /F1 9.8 Tf [(Gust D, Brown C, Sheedy K, Hibbs B, Weaver D, Nowak G. \(2005\) Immunization attitudes and beliefs among parents: )] TJ ET BT 26.250 385.791 Td /F1 9.8 Tf [(beyond a dichotomous perspective. Am J Health Behav 29\(1\): 81-92.)] TJ ET BT 26.250 366.387 Td /F1 9.8 Tf [(14.)] TJ ET BT 43.553 366.387 Td /F1 9.8 Tf [(Velan B, Boyko V, Lerner-Geva L, Ziv A, Yagar Y, Kaplan G. \(2012\) Individualism, acceptance and differentiation as attitude )] TJ ET BT 26.250 354.482 Td /F1 9.8 Tf [(traits in the publics response to vaccination. Hum Vaccin Immunother 8\(9\): 1272-1282.)] TJ ET BT 26.250 335.077 Td /F1 9.8 Tf [(15.)] TJ ET BT 43.553 335.077 Td /F1 9.8 Tf [(Velan B \(2011\). Acceptance on the move: public reaction to shifting vaccination realities. Human Vaccin 7\(12\): 1261-1270.)] TJ ET BT 26.250 315.672 Td /F1 9.8 Tf [(16.)] TJ ET BT 43.553 315.672 Td /F1 9.8 Tf [(Henrich N, Holmes B. \(2009\) The publics acceptance of novel vaccines during a pandemic: a focus group study and its )] TJ ET BT 26.250 303.768 Td /F1 9.8 Tf [(application to influenza H1N1. Emerging Health Threats Journal 2:e8. doi: 10.3134/ehtj.09.008.)] TJ ET BT 26.250 284.363 Td /F1 9.8 Tf [(17.)] TJ ET BT 43.553 284.363 Td /F1 9.8 Tf [(Siddiqui M, Salmon DA, Omer SB. \(2013\) Epidemiology of vaccine hesitancy in the United States. Hum Vaccin Immunother )] TJ ET BT 26.250 272.458 Td /F1 9.8 Tf [(9\(12\): 2643-2648.)] TJ ET BT 26.250 253.053 Td /F1 9.8 Tf [(18.)] TJ ET BT 43.553 253.053 Td /F1 9.8 Tf [(Healy CM, Pickering LK. \(2011\) How to communicate with vaccine-hesitant parents. Pediatrics 127: S127.)] TJ ET BT 26.250 233.649 Td /F1 9.8 Tf [(19.)] TJ ET BT 43.553 233.649 Td /F1 9.8 Tf [(Gowda C, Schaffer SE, Kopec K, Markel A, Dempsey AF. \(2013\). Does the relative importance of MMR vaccine concerns )] TJ ET BT 26.250 221.744 Td /F1 9.8 Tf [(differ by degree of parental vaccine hesitancy? An exploratory study. Hum Vaccin Immunother 9\(2\): 430-436.)] TJ ET BT 26.250 202.339 Td /F1 9.8 Tf [(20.)] TJ ET BT 43.553 202.339 Td /F1 9.8 Tf [(Marshall GS. \(2013\) Roots of Vaccine Hesitancy. S D Med Spec no: 52-57.)] TJ ET BT 26.250 182.934 Td /F1 9.8 Tf [(21.)] TJ ET BT 43.553 182.934 Td /F1 9.8 Tf [(MacDonald NE, Smith J, Appleton M. \(2012\) Risk perception, risk management and safety management: What can )] TJ ET BT 26.250 171.030 Td /F1 9.8 Tf [(governments do to increase public confidence in their vaccine system? Biologicals 40: 384-388.)] TJ ET BT 26.250 151.625 Td /F1 9.8 Tf [(22.)] TJ ET BT 43.553 151.625 Td /F1 9.8 Tf [(Glanz JM, Wagner NM, Narwaney KJ, Shoup JA, McClure DL, McCormick EV et al. \(2013\) A mixed method study of )] TJ ET BT 26.250 139.720 Td /F1 9.8 Tf [(parental vaccine decision making and parent-provider trust. Acad Pediatr 13\(5\): 481-488.)] TJ ET BT 26.250 120.315 Td /F1 9.8 Tf [(23.)] TJ ET BT 43.553 120.315 Td /F1 9.8 Tf [(Caplan A \(2013\). Liberty has its responsabilities. Hum Vaccin Immunother 9\(12\): 2666-2667.)] TJ ET BT 26.250 100.911 Td /F1 9.8 Tf [(24.)] TJ ET BT 43.553 100.911 Td /F1 9.8 Tf [(Opel DJ, Marcuse EK. \(2013\). Rethinking vaccine policy making in an era of vaccine hesitancy: time to rebuild, not )] TJ ET BT 26.250 89.006 Td /F1 9.8 Tf [(remodel? Hum Vaccin Immunother 9\(12\): 2672-2673.)] TJ ET BT 26.250 69.601 Td /F1 9.8 Tf [(25.)] TJ ET BT 43.553 69.601 Td /F1 9.8 Tf [(Diekema DS. \(2013\) Provider dismissal of vaccine-hesitant families: misguided policy that fails to benefit children. Hum )] TJ ET BT 26.250 57.696 Td /F1 9.8 Tf [(Vaccin Immunother 9\(12\): 2661-2662.)] TJ ET Q q 15.000 47.815 577.500 729.185 re W n 0.271 0.267 0.267 rg BT 26.250 750.278 Td /F4 12.0 Tf [(Competing Interests)] TJ ET BT 26.250 730.324 Td /F1 9.8 Tf [(The authors have declared that no competing interests exist.)] TJ ET BT 26.250 693.722 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 666.267 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 666.267 Td /F1 9.8 Tf [(Black S, Rapuolin R. \(2010\) A crisis of public confidence in vaccines. Science 61: 61mr1.)] TJ ET BT 26.250 646.863 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 646.863 Td /F1 9.8 Tf [(Shetty P. \(2010\) Experts concerned about vaccination backlash. Lancet 375: 970-971.)] TJ ET BT 26.250 627.458 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 627.458 Td /F1 9.8 Tf [(Larson HJ, Cooper LZ, Eskolan J, Katz SL, Ratzan S. \(2011\) Addressing the vaccine confidence gap. Lancet 378: 526-535.)] TJ ET BT 26.250 608.053 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 608.053 Td /F1 9.8 Tf [(http://www.who.int/immunization/sage/sage_wg_vaccine_hesitancy_apr12/en/)] TJ ET BT 26.250 588.648 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 588.648 Td /F1 9.8 Tf [(Dub E, Laberge C, Guay M, Bramadat P, Roy R, Bettinger J. \(2013\) Vaccine hesitancy: an overview. Hum Vaccin )] TJ ET BT 26.250 576.744 Td /F1 9.8 Tf [(Immunother 9\(8\): 1763?1773.)] TJ ET BT 26.250 557.339 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 557.339 Td /F1 9.8 Tf [(Gowda C, Dempsey AF. \(2013\) The rise \(and fall?\) of parental vaccine hesitancy. Hum Vaccin Immunother 9\(8\): 1755-1762.)] TJ ET BT 26.250 537.934 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 537.934 Td /F1 9.8 Tf [(Larson HJ, Jarrett C, Eckersberger E, Smith DMD, Paterson P. \(2014\) Understanding vaccine hesitancy around vaccines )] TJ ET BT 26.250 526.029 Td /F1 9.8 Tf [(and vaccination from a global perspective: a systematic review of published literature, 2007-2012. Vaccine 32\(19\): 2150?2159.)] TJ ET BT 26.250 506.625 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 506.625 Td /F1 9.8 Tf [(Yaqub O, Castle-Clarke S, Sevdalis N, Chataway J. \(2014\) Attitudes to vaccination: A critical review. Soc Sci Med 112: 1-11.)] TJ ET BT 26.250 487.220 Td /F1 9.8 Tf [(9.)] TJ ET BT 38.132 487.220 Td /F1 9.8 Tf [(Limb M. \(2011\) "Vaccine hesitancy" means scientists need to be more honest about risks. BMJ 15;342: d2479.)] TJ ET BT 26.250 467.815 Td /F1 9.8 Tf [(10.)] TJ ET BT 43.553 467.815 Td /F1 9.8 Tf [(Bloom BR, Marcuse E, Mnookin S. \(2014\) Addressing vaccine hesitancy. Science 344\(6182\): 339.)] TJ ET BT 26.250 448.410 Td /F1 9.8 Tf [(11.)] TJ ET BT 43.553 448.410 Td /F1 9.8 Tf [(Opel DJ, Mangione-Smith R, Taylor JA, Korfiatis C, Wiese C, Catz S, Martin DP. \(2011\) Development of a survey to identify )] TJ ET BT 26.250 436.506 Td /F1 9.8 Tf [(vaccine-hesitant parents. The Parent Attitudes about Childhood Vaccines survey. Hum Vaccin 7\(4\): 419-425.)] TJ ET BT 26.250 417.101 Td /F1 9.8 Tf [(12.)] TJ ET BT 43.553 417.101 Td /F1 9.8 Tf [(Patel PR, Berenson AB. \(2013\) Sources of HPV vaccine hesitancy in parents. Hum Vaccin Immunother 9\(12\): 2649-2653.)] TJ ET BT 26.250 397.696 Td /F1 9.8 Tf [(13.)] TJ ET BT 43.553 397.696 Td /F1 9.8 Tf [(Gust D, Brown C, Sheedy K, Hibbs B, Weaver D, Nowak G. \(2005\) Immunization attitudes and beliefs among parents: )] TJ ET BT 26.250 385.791 Td /F1 9.8 Tf [(beyond a dichotomous perspective. Am J Health Behav 29\(1\): 81-92.)] TJ ET BT 26.250 366.387 Td /F1 9.8 Tf [(14.)] TJ ET BT 43.553 366.387 Td /F1 9.8 Tf [(Velan B, Boyko V, Lerner-Geva L, Ziv A, Yagar Y, Kaplan G. \(2012\) Individualism, acceptance and differentiation as attitude )] TJ ET BT 26.250 354.482 Td /F1 9.8 Tf [(traits in the publics response to vaccination. Hum Vaccin Immunother 8\(9\): 1272-1282.)] TJ ET BT 26.250 335.077 Td /F1 9.8 Tf [(15.)] TJ ET BT 43.553 335.077 Td /F1 9.8 Tf [(Velan B \(2011\). Acceptance on the move: public reaction to shifting vaccination realities. Human Vaccin 7\(12\): 1261-1270.)] TJ ET BT 26.250 315.672 Td /F1 9.8 Tf [(16.)] TJ ET BT 43.553 315.672 Td /F1 9.8 Tf [(Henrich N, Holmes B. \(2009\) The publics acceptance of novel vaccines during a pandemic: a focus group study and its )] TJ ET BT 26.250 303.768 Td /F1 9.8 Tf [(application to influenza H1N1. Emerging Health Threats Journal 2:e8. doi: 10.3134/ehtj.09.008.)] TJ ET BT 26.250 284.363 Td /F1 9.8 Tf [(17.)] TJ ET BT 43.553 284.363 Td /F1 9.8 Tf [(Siddiqui M, Salmon DA, Omer SB. \(2013\) Epidemiology of vaccine hesitancy in the United States. Hum Vaccin Immunother )] TJ ET BT 26.250 272.458 Td /F1 9.8 Tf [(9\(12\): 2643-2648.)] TJ ET BT 26.250 253.053 Td /F1 9.8 Tf [(18.)] TJ ET BT 43.553 253.053 Td /F1 9.8 Tf [(Healy CM, Pickering LK. \(2011\) How to communicate with vaccine-hesitant parents. Pediatrics 127: S127.)] TJ ET BT 26.250 233.649 Td /F1 9.8 Tf [(19.)] TJ ET BT 43.553 233.649 Td /F1 9.8 Tf [(Gowda C, Schaffer SE, Kopec K, Markel A, Dempsey AF. \(2013\). Does the relative importance of MMR vaccine concerns )] TJ ET BT 26.250 221.744 Td /F1 9.8 Tf [(differ by degree of parental vaccine hesitancy? An exploratory study. Hum Vaccin Immunother 9\(2\): 430-436.)] TJ ET BT 26.250 202.339 Td /F1 9.8 Tf [(20.)] TJ ET BT 43.553 202.339 Td /F1 9.8 Tf [(Marshall GS. \(2013\) Roots of Vaccine Hesitancy. S D Med Spec no: 52-57.)] TJ ET BT 26.250 182.934 Td /F1 9.8 Tf [(21.)] TJ ET BT 43.553 182.934 Td /F1 9.8 Tf [(MacDonald NE, Smith J, Appleton M. \(2012\) Risk perception, risk management and safety management: What can )] TJ ET BT 26.250 171.030 Td /F1 9.8 Tf [(governments do to increase public confidence in their vaccine system? Biologicals 40: 384-388.)] TJ ET BT 26.250 151.625 Td /F1 9.8 Tf [(22.)] TJ ET BT 43.553 151.625 Td /F1 9.8 Tf [(Glanz JM, Wagner NM, Narwaney KJ, Shoup JA, McClure DL, McCormick EV et al. \(2013\) A mixed method study of )] TJ ET BT 26.250 139.720 Td /F1 9.8 Tf [(parental vaccine decision making and parent-provider trust. Acad Pediatr 13\(5\): 481-488.)] TJ ET BT 26.250 120.315 Td /F1 9.8 Tf [(23.)] TJ ET BT 43.553 120.315 Td /F1 9.8 Tf [(Caplan A \(2013\). Liberty has its responsabilities. Hum Vaccin Immunother 9\(12\): 2666-2667.)] TJ ET BT 26.250 100.911 Td /F1 9.8 Tf [(24.)] TJ ET BT 43.553 100.911 Td /F1 9.8 Tf [(Opel DJ, Marcuse EK. \(2013\). Rethinking vaccine policy making in an era of vaccine hesitancy: time to rebuild, not )] TJ ET BT 26.250 89.006 Td /F1 9.8 Tf [(remodel? Hum Vaccin Immunother 9\(12\): 2672-2673.)] TJ ET BT 26.250 69.601 Td /F1 9.8 Tf [(25.)] TJ ET BT 43.553 69.601 Td /F1 9.8 Tf [(Diekema DS. \(2013\) Provider dismissal of vaccine-hesitant families: misguided policy that fails to benefit children. Hum )] TJ ET BT 26.250 57.696 Td /F1 9.8 Tf [(Vaccin Immunother 9\(12\): 2661-2662.)] TJ ET Q q 15.000 47.815 577.500 729.185 re W n 0.271 0.267 0.267 rg BT 26.250 750.278 Td /F4 12.0 Tf [(Competing Interests)] TJ ET BT 26.250 730.324 Td /F1 9.8 Tf [(The authors have declared that no competing interests exist.)] TJ ET BT 26.250 693.722 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 666.267 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 666.267 Td /F1 9.8 Tf [(Black S, Rapuolin R. \(2010\) A crisis of public confidence in vaccines. Science 61: 61mr1.)] TJ ET BT 26.250 646.863 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 646.863 Td /F1 9.8 Tf [(Shetty P. \(2010\) Experts concerned about vaccination backlash. Lancet 375: 970-971.)] TJ ET BT 26.250 627.458 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 627.458 Td /F1 9.8 Tf [(Larson HJ, Cooper LZ, Eskolan J, Katz SL, Ratzan S. \(2011\) Addressing the vaccine confidence gap. Lancet 378: 526-535.)] TJ ET BT 26.250 608.053 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 608.053 Td /F1 9.8 Tf [(http://www.who.int/immunization/sage/sage_wg_vaccine_hesitancy_apr12/en/)] TJ ET BT 26.250 588.648 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 588.648 Td /F1 9.8 Tf [(Dub E, Laberge C, Guay M, Bramadat P, Roy R, Bettinger J. \(2013\) Vaccine hesitancy: an overview. Hum Vaccin )] TJ ET BT 26.250 576.744 Td /F1 9.8 Tf [(Immunother 9\(8\): 1763?1773.)] TJ ET BT 26.250 557.339 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 557.339 Td /F1 9.8 Tf [(Gowda C, Dempsey AF. \(2013\) The rise \(and fall?\) of parental vaccine hesitancy. Hum Vaccin Immunother 9\(8\): 1755-1762.)] TJ ET BT 26.250 537.934 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 537.934 Td /F1 9.8 Tf [(Larson HJ, Jarrett C, Eckersberger E, Smith DMD, Paterson P. \(2014\) Understanding vaccine hesitancy around vaccines )] TJ ET BT 26.250 526.029 Td /F1 9.8 Tf [(and vaccination from a global perspective: a systematic review of published literature, 2007-2012. Vaccine 32\(19\): 2150?2159.)] TJ ET BT 26.250 506.625 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 506.625 Td /F1 9.8 Tf [(Yaqub O, Castle-Clarke S, Sevdalis N, Chataway J. \(2014\) Attitudes to vaccination: A critical review. Soc Sci Med 112: 1-11.)] TJ ET BT 26.250 487.220 Td /F1 9.8 Tf [(9.)] TJ ET BT 38.132 487.220 Td /F1 9.8 Tf [(Limb M. \(2011\) "Vaccine hesitancy" means scientists need to be more honest about risks. BMJ 15;342: d2479.)] TJ ET BT 26.250 467.815 Td /F1 9.8 Tf [(10.)] TJ ET BT 43.553 467.815 Td /F1 9.8 Tf [(Bloom BR, Marcuse E, Mnookin S. \(2014\) Addressing vaccine hesitancy. Science 344\(6182\): 339.)] TJ ET BT 26.250 448.410 Td /F1 9.8 Tf [(11.)] TJ ET BT 43.553 448.410 Td /F1 9.8 Tf [(Opel DJ, Mangione-Smith R, Taylor JA, Korfiatis C, Wiese C, Catz S, Martin DP. \(2011\) Development of a survey to identify )] TJ ET BT 26.250 436.506 Td /F1 9.8 Tf [(vaccine-hesitant parents. The Parent Attitudes about Childhood Vaccines survey. Hum Vaccin 7\(4\): 419-425.)] TJ ET BT 26.250 417.101 Td /F1 9.8 Tf [(12.)] TJ ET BT 43.553 417.101 Td /F1 9.8 Tf [(Patel PR, Berenson AB. \(2013\) Sources of HPV vaccine hesitancy in parents. Hum Vaccin Immunother 9\(12\): 2649-2653.)] TJ ET BT 26.250 397.696 Td /F1 9.8 Tf [(13.)] TJ ET BT 43.553 397.696 Td /F1 9.8 Tf [(Gust D, Brown C, Sheedy K, Hibbs B, Weaver D, Nowak G. \(2005\) Immunization attitudes and beliefs among parents: )] TJ ET BT 26.250 385.791 Td /F1 9.8 Tf [(beyond a dichotomous perspective. Am J Health Behav 29\(1\): 81-92.)] TJ ET BT 26.250 366.387 Td /F1 9.8 Tf [(14.)] TJ ET BT 43.553 366.387 Td /F1 9.8 Tf [(Velan B, Boyko V, Lerner-Geva L, Ziv A, Yagar Y, Kaplan G. \(2012\) Individualism, acceptance and differentiation as attitude )] TJ ET BT 26.250 354.482 Td /F1 9.8 Tf [(traits in the publics response to vaccination. Hum Vaccin Immunother 8\(9\): 1272-1282.)] TJ ET BT 26.250 335.077 Td /F1 9.8 Tf [(15.)] TJ ET BT 43.553 335.077 Td /F1 9.8 Tf [(Velan B \(2011\). Acceptance on the move: public reaction to shifting vaccination realities. Human Vaccin 7\(12\): 1261-1270.)] TJ ET BT 26.250 315.672 Td /F1 9.8 Tf [(16.)] TJ ET BT 43.553 315.672 Td /F1 9.8 Tf [(Henrich N, Holmes B. \(2009\) The publics acceptance of novel vaccines during a pandemic: a focus group study and its )] TJ ET BT 26.250 303.768 Td /F1 9.8 Tf [(application to influenza H1N1. Emerging Health Threats Journal 2:e8. doi: 10.3134/ehtj.09.008.)] TJ ET BT 26.250 284.363 Td /F1 9.8 Tf [(17.)] TJ ET BT 43.553 284.363 Td /F1 9.8 Tf [(Siddiqui M, Salmon DA, Omer SB. \(2013\) Epidemiology of vaccine hesitancy in the United States. Hum Vaccin Immunother )] TJ ET BT 26.250 272.458 Td /F1 9.8 Tf [(9\(12\): 2643-2648.)] TJ ET BT 26.250 253.053 Td /F1 9.8 Tf [(18.)] TJ ET BT 43.553 253.053 Td /F1 9.8 Tf [(Healy CM, Pickering LK. \(2011\) How to communicate with vaccine-hesitant parents. Pediatrics 127: S127.)] TJ ET BT 26.250 233.649 Td /F1 9.8 Tf [(19.)] TJ ET BT 43.553 233.649 Td /F1 9.8 Tf [(Gowda C, Schaffer SE, Kopec K, Markel A, Dempsey AF. \(2013\). Does the relative importance of MMR vaccine concerns )] TJ ET BT 26.250 221.744 Td /F1 9.8 Tf [(differ by degree of parental vaccine hesitancy? An exploratory study. Hum Vaccin Immunother 9\(2\): 430-436.)] TJ ET BT 26.250 202.339 Td /F1 9.8 Tf [(20.)] TJ ET BT 43.553 202.339 Td /F1 9.8 Tf [(Marshall GS. \(2013\) Roots of Vaccine Hesitancy. S D Med Spec no: 52-57.)] TJ ET BT 26.250 182.934 Td /F1 9.8 Tf [(21.)] TJ ET BT 43.553 182.934 Td /F1 9.8 Tf [(MacDonald NE, Smith J, Appleton M. \(2012\) Risk perception, risk management and safety management: What can )] TJ ET BT 26.250 171.030 Td /F1 9.8 Tf [(governments do to increase public confidence in their vaccine system? Biologicals 40: 384-388.)] TJ ET BT 26.250 151.625 Td /F1 9.8 Tf [(22.)] TJ ET BT 43.553 151.625 Td /F1 9.8 Tf [(Glanz JM, Wagner NM, Narwaney KJ, Shoup JA, McClure DL, McCormick EV et al. \(2013\) A mixed method study of )] TJ ET BT 26.250 139.720 Td /F1 9.8 Tf [(parental vaccine decision making and parent-provider trust. Acad Pediatr 13\(5\): 481-488.)] TJ ET BT 26.250 120.315 Td /F1 9.8 Tf [(23.)] TJ ET BT 43.553 120.315 Td /F1 9.8 Tf [(Caplan A \(2013\). Liberty has its responsabilities. Hum Vaccin Immunother 9\(12\): 2666-2667.)] TJ ET BT 26.250 100.911 Td /F1 9.8 Tf [(24.)] TJ ET BT 43.553 100.911 Td /F1 9.8 Tf [(Opel DJ, Marcuse EK. \(2013\). Rethinking vaccine policy making in an era of vaccine hesitancy: time to rebuild, not )] TJ ET BT 26.250 89.006 Td /F1 9.8 Tf [(remodel? Hum Vaccin Immunother 9\(12\): 2672-2673.)] TJ ET BT 26.250 69.601 Td /F1 9.8 Tf [(25.)] TJ ET BT 43.553 69.601 Td /F1 9.8 Tf [(Diekema DS. \(2013\) Provider dismissal of vaccine-hesitant families: misguided policy that fails to benefit children. Hum )] TJ ET BT 26.250 57.696 Td /F1 9.8 Tf [(Vaccin Immunother 9\(12\): 2661-2662.)] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(6)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Outbreaks)] TJ ET Q endstream endobj 724 0 obj << /Type /Page /Parent 3 0 R /Contents 725 0 R >> endobj 725 0 obj << /Length 15364 >> stream 0.271 0.267 0.267 rg q 15.000 257.953 577.500 519.047 re W n 0.271 0.267 0.267 rg BT 26.250 759.976 Td /F1 9.8 Tf [(26.)] TJ ET BT 43.553 759.976 Td /F1 9.8 Tf [(Gilkey MB, McRee AL, Brewer NT. \(2013\) Forgone vaccination during childhood and adolescence: Finding of a statewide )] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(survey of parents. Prev Med 56: 202-206.)] TJ ET BT 26.250 728.667 Td /F1 9.8 Tf [(27.)] TJ ET BT 43.553 728.667 Td /F1 9.8 Tf [(Velan B, Kaplan G, Ziv A, Boyko V, Lerner-Geva L. \(2011\). Major motives in non-acceptance of A/H1N1 flu vaccination: the )] TJ ET BT 26.250 716.762 Td /F1 9.8 Tf [(weight of rational assessment. 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