Géraldine Escriva-Boulley

Olena Mandrik

Marie Préau

Rolando Herrero

Dr Patricia Villain
email: villainp@iarc.fr

Cognitions and behaviours of general practitioners in France regarding HPV vaccination: A theory-based systematic review

Keywords: General Practitioners, Reasoned Action Approach, HPV vaccination, France

Human papillomavirus (HPV) vaccination is safe and efficacious to prevent persistent HPV infection, precancerous anogenital lesions and cervical cancer. However, in countries where vaccination programmes are implemented outside of schools, such as France, reaching high HPV vaccination coverage of the target population is challenging. Many studies have been performed in France to assess cognitions of general practitioners' (GPs) regarding HPV vaccination. However, the evidence is not consistent about which cognitions are key. To provide a comprehensive overview, we performed a systematic review of studies conducted in France on GPs' cognitions regarding HPV vaccination and used the reasoned action approach to extract and synthesize data. The systematic search was performed up to July 2020 in Medline via PubMed, PsycINFO, PsycARTICLES, Embase, CINAHL Plus, Web of Science, Pascal and Francis databases. Grey literature was searched for in the French Public Health Database, Cairn. Info, yahoo.fr, and Google Scholar. Twenty-five scientific publications were selected based on eligibility criteria and assessed for quality. Our qualitative synthesis highlights that although 73% of GPs report recommending HPV vaccination, up to 50% would not recommend it because of concerns, including changes in patients' health behaviours and doubts about safety and/or efficacy. GPs' injunctive norms, i.e. trust in institutional information, were shown to be associated positively with GPs' willingness to recommend HPV vaccination. Parents' fears, girls' age, and potential connection with sexuality do not seem to affect GPs' recommendations. These results will inform the development of a professional educational intervention targeting GPs in France.

Introduction

Human papillomavirus (HPV) vaccination has been shown to be highly effective to reduce the prevalence of persistent infections with targeted HPV types and the incidence of high-grade precancerous cervical lesions. Thus, it is currently being implemented in many countries, though with variable coverage rates [START_REF] Bruni | Global estimates of human papillomavirus vaccination coverage by region and income level: a pooled analysis[END_REF] . In some high-income settings, such as Canada and the United Kingdom, HPV vaccination coverage can reach more than 80%. It is generally much lower in countries where almost all vaccinations are delivered outside of schools such as the United States and France 1. In France, where general practitioners (GPs) are responsible for counselling and vaccinating adolescent girls, HPV vaccination coverage of the target population, i.e. girls aged 11-14 year since 2012, has not exceeded 30% since its implementation [START_REF]HPV vaccination coverage in France by age group[END_REF] . Barriers and facilitators to HPV vaccination have been intensely studied in France [START_REF] Verrier | Infections à papillomavirus humain : influence des perceptions de la maladie et du vaccin sur le statut vaccinal. (Influence of perceptions of disease and vaccine on immunization status)[END_REF][START_REF] Blondel | Influence des facteurs socioéconomiques sur la vaccination contre les infections à HPV chez les adolescentes en France. J o u r n a l P r e -p r o o f (Influence of socioeconomic factors on human papillomavirus vaccine uptake in adolescent girls in France)[END_REF][START_REF]Enquete-de-perception-aupres-des-medecinsgeneralistes-et-des-parents[END_REF] . For French parents and young girls, the main barriers regarding HPV vaccination are concerns about serious side effects [START_REF] Verrier | Infections à papillomavirus humain : influence des perceptions de la maladie et du vaccin sur le statut vaccinal. (Influence of perceptions of disease and vaccine on immunization status)[END_REF][START_REF] Blondel | Influence des facteurs socioéconomiques sur la vaccination contre les infections à HPV chez les adolescentes en France. J o u r n a l P r e -p r o o f (Influence of socioeconomic factors on human papillomavirus vaccine uptake in adolescent girls in France)[END_REF][START_REF]Enquete-de-perception-aupres-des-medecinsgeneralistes-et-des-parents[END_REF] . Socioeconomic determinants have been shown to influence HPV vaccination uptake with a lower uptake observed in more deprived groups [START_REF] Blondel | Influence des facteurs socioéconomiques sur la vaccination contre les infections à HPV chez les adolescentes en France. J o u r n a l P r e -p r o o f (Influence of socioeconomic factors on human papillomavirus vaccine uptake in adolescent girls in France)[END_REF] .

Similarly to others primary care professionals, the HPV vaccination decision of French parents is driven by the recommendations of their GPs [START_REF]Enquete-de-perception-aupres-des-medecinsgeneralistes-et-des-parents[END_REF][START_REF] Karafillakis | HPV vaccination in a context of public mistrust and uncertainty: a systematic literature review of determinants of HPV vaccine hesitancy in Europe[END_REF][START_REF] Newman | Parents' uptake of human papillomavirus vaccines for their children: a systematic review and meta-analysis of observational studies[END_REF] . GPs' barriers mainly concern the efficacy and safety of HPV vaccination, and also relate to the national recommendations regarding HPV vaccination age and groups [START_REF]Enquete-de-perception-aupres-des-medecinsgeneralistes-et-des-parents[END_REF][START_REF] Karafillakis | HPV vaccination in a context of public mistrust and uncertainty: a systematic literature review of determinants of HPV vaccine hesitancy in Europe[END_REF] . The French National Cancer Institute and/or other national agencies have implemented interventions to address GPs' barriers [START_REF] Campana | Interventions permettant d'augmenter la couverture vaccinale du vaccin contre les papillomavirus humains. (Interventions to increase HPV vaccination coverage)[END_REF][START_REF] Fonteneau | Évolution de la couverture vaccinale du vaccin contre le papillomavirus en France -2008-2018. (HPV vaccination coverage in France -2008-2018)[END_REF] . Changes in the national recommendations regarding the age of girls did not lead to an increase in HPV vaccination uptake and it is too early to report on the efficacy of extending HPV vaccination to boys [START_REF] Fonteneau | Évolution de la couverture vaccinale du vaccin contre le papillomavirus en France -2008-2018. (HPV vaccination coverage in France -2008-2018)[END_REF][START_REF]HPV vaccination recommandation to be extended to boys[END_REF] . The provision of information about HPV vaccination to GPs has been reinforced since 2017 11 . Although they have not been formally evaluated, these actions are speculated to contribute to the upward trend in coverage observed in France since 2015 [START_REF] Fonteneau | Évolution de la couverture vaccinale du vaccin contre le papillomavirus en France -2008-2018. (HPV vaccination coverage in France -2008-2018)[END_REF] . The gaps and the apparent contradiction in the evidence suggest that some important determinants regarding French GPs' cognitions might have been missed.

A systematic review focusing on French GPs' cognitions and going beyond only knowledge and attitude, which are usually reported, will fil this research gap [START_REF] Rosen | US Health Care Clinicians' Knowledge, Attitudes, and Practices Regarding Human Papillomavirus Vaccination: A Qualitative Systematic Review[END_REF][START_REF] Herzog | Are healthcare workers' intentions to vaccinate related to their knowledge, beliefs and attitudes? a systematic review[END_REF] . Using a behaviour theory as a framework to extract evidence can provide a more comprehensive overview of these cognitions. We chose to conduct a reasoned action approach (RAA) theory-based systematic review of studies performed in France in order to provide a comprehensive overview of French GPs' cognitions related to HPV vaccination. The RAA is the most recent derivative of the theory of planned behaviour, which has been the most used theoretical J o u r n a l P r e -p r o o f framework to explain and predict health practitioners' intentions and behaviours regarding HPV vaccination [START_REF] Ferrer | An appraisal of theoretical approaches to examining behaviours in relation to Human Papillomavirus (HPV) vaccination of young women[END_REF][START_REF] Ajzen | The theory of planned behavior[END_REF][START_REF] Fishbein | Predicting and changing behaviour: The reasoned action approach[END_REF] . In addition, the RAA provides a more detailed framework with each of the cognitions of the theory of planned behaviour represented by pairs of distinct, but related, subcomponents, which have been shown to be important in predicting and explaining behaviour [START_REF] Fishbein | Predicting and changing behaviour: The reasoned action approach[END_REF][START_REF] Mceachan | Meta-Analysis of the Reasoned Action Approach (RAA) to Understanding Health Behaviors[END_REF] . The RAA differentiates the following cognitions (Fig. 1 We used this framework to (i) report GPs' cognitions and beliefs, and (ii) examine the impacts of these cognitions on GPs' behaviours. The impact of background variables related to GPs, i.e. self-related, contextual, or sociodemographic, was also investigated, because they could be influential to French GPs' cognitions and/or behaviours regarding HPV vaccination (Fig. 1) [START_REF] Rosen | US Health Care Clinicians' Knowledge, Attitudes, and Practices Regarding Human Papillomavirus Vaccination: A Qualitative Systematic Review[END_REF] . The results of this review will inform the design of an educational intervention on HPV vaccination targeting GPs in France.

J o u r n a l P r e -p r o o f

Figure 1. Theoretical framework used in the review based on the reasoned action approach (RAA) [START_REF] Fishbein | Predicting and changing behaviour: The reasoned action approach[END_REF] . In this theory, behaviour is driven by intention, which in turn is driven by instrumental and experiential attitudes towards the behaviour, injunctive and descriptive norms, and PBC's capacity and autonomy. Intention regarding HPV vaccination was not assessed in the review, because no data were available. GP= general practitioner; PBC = perceived behavioural control J o u r n a l P r e -p r o o f

Methods

We used the PRISMA statement and the checklist to report explicitly and comprehensively all the recommended components [START_REF] Moher | Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement[END_REF] .

Study search and selection

The systematic search was performed by PV up to December 2018 in the following To be considered for inclusion, titles/abstracts and then full texts were required to meet the following criteria: (a) published in any language, (b) the study population was GPs or included GPs, (c) used quantitative (self-reported questionnaire) and/or qualitative (semistructured interview, focus group) method, (c) reported outcomes related to any information regarding GPs' cognitions and/or behaviours related to HPV vaccination, (d) based in France or included France among other countries, and (e) was an original study and either a peerreviewed article or a medical dissertation. Studies were excluded when (a) focused on psychometric validation of questionnaires, or (b) were review, conference abstract, opinion and/or a published survey that did not provide a full description of the methodology and results or (c) was a medical dissertation whose related results were published in a peerreviewed article, which was part of the review.

Data extraction

A data extraction form and coding method was developed and tested first with some of the included studies. The variables of interest were those presented in the tables in the Result section or the Appendix. The variables were descriptive and included studies characteristics, GPs' characteristics, GPs' cognitions as reported in the RAA model (Fig. 1) and background variables that have been shown to influence primary care professionals' behaviour regarding HPV vaccination [START_REF] Rosen | US Health Care Clinicians' Knowledge, Attitudes, and Practices Regarding Human Papillomavirus Vaccination: A Qualitative Systematic Review[END_REF] (Fig. 1).

We also extracted all variables to explore a possible relationship or an association between a) GPs' attitudes, norms, perceived behavioural control and either cognitions or behaviour Data from all included full-text publications were identified and extracted by two investigators (GEB and PV). Any disagreement in data extraction was resolved by consensus.

Assessment of study quality

Two of the authors independently assessed the methodological quality of the included articles using the Newcastle-Ottawa quality assessment scale (NOS) for cohort studies adapted for cross sectional studies and the Critical Appraisal Skills Programme (CASP) framework for qualitative articles [START_REF] Herzog | Are healthcare workers' intentions to vaccinate related to their knowledge, beliefs and attitudes? a systematic review[END_REF][START_REF] Stang | Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses[END_REF][START_REF] Singh | Critical appraisal skills programme[END_REF] . An additional column was added to the NOS tool to highlight articles. Any disagreement in quality grading was resolved by consensus.

Synthesis

Because of heterogeneity in data measurements and the outcomes, qualitative synthesis was applied to synthetize the data [START_REF] Seers | Qualitative systematic reviews: their importance for our understanding of research relevant to pain[END_REF] . No study was excluded based on its quality. However when synthetized the findings and when appropriate, the research outcomes were evaluated taking into account the quality of the studies involved.

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Results

We identified 2361 abstracts through our systematic search and 73 additional through a nonsystematic search (Fig. 2). We screened 1512 abstract for eligibility. We assessed 78 records based on full text evaluation. Twenty-five studies were included in the synthesis (Fig. 2).

Description of the included articles

Among the 25 studies identified for this review , 18 reported quantitative and seven qualitative designs (Table 1). The majority of the studies were conducted either before 2011 [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Erpeldinger | Vaccination contre les infections à papillomavirus en médecine générale. La décision de vacciner par le Gardasil® est-elle un choix éclairé? Enquête auprès de 518 MG du Rhône. Médecine (Vaccination against papillomavirus infections in general medicine. Is the decision to vaccinate with Gardasil® an informed choice? Survey with 518 general practitioners from Rhône)[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF][START_REF] Thierry | Human Papillomavirus vaccination in general practice in France, three years after the implementation of a targeted vaccine recommendation based on age and sexual history[END_REF] with some around 2007-2008 i.e. the period where HPV vaccination was implemented in France [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Erpeldinger | Vaccination contre les infections à papillomavirus en médecine générale. La décision de vacciner par le Gardasil® est-elle un choix éclairé? Enquête auprès de 518 MG du Rhône. Médecine (Vaccination against papillomavirus infections in general medicine. Is the decision to vaccinate with Gardasil® an informed choice? Survey with 518 general practitioners from Rhône)[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF] , or over the 2011-2015 period [START_REF] Agrinier | Discrepancies between general practitioners' vaccination recommendations for their patients and practices for their children[END_REF][START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Killian | Vaccine hesitancy among general practitioners: evaluation and comparison of their immunisation practice for themselves, their patients and their children[END_REF][START_REF] Lamirand | Vaccination anti-papillomavirus humain (HPV): influence des nouvelles recommandations et des médias sur la pratique des médecins généralistes[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Martinez | The commitment of French general practitioners to vaccination: the DIVA study (Determinants of vaccination intentions)[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] . The most recent studies were conducted in 2016 [START_REF] Chauvet | Vaccination anti-HPV : évaluation de la pertinence d'outils d'aide a l'information vaccinale enquête aupres des médecins généralistes de Côte d'Or. (HPV vaccination: evaluation of information tools used by general practitioners from Côte d'Or)[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF] or in 2019 [START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF] . The sample size ranged from ten to 31 GPs in the qualitative studies and from 96 to 1598 in the quantitative studies.

Except for five articles in which the participants represented a national panel [START_REF] Agrinier | Discrepancies between general practitioners' vaccination recommendations for their patients and practices for their children[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Thierry | Human Papillomavirus vaccination in general practice in France, three years after the implementation of a targeted vaccine recommendation based on age and sexual history[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] , the studies included participants from local panels. Only one study used random sampling to select participants [START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF] .

The quality of the included articles varied widely, with ten articles [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Killian | Vaccine hesitancy among general practitioners: evaluation and comparison of their immunisation practice for themselves, their patients and their children[END_REF][START_REF] Lamirand | Vaccination anti-papillomavirus humain (HPV): influence des nouvelles recommandations et des médias sur la pratique des médecins généralistes[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Martinez | The commitment of French general practitioners to vaccination: the DIVA study (Determinants of vaccination intentions)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] , considered at low risk (i.e., high-quality studies), six [START_REF] Agrinier | Discrepancies between general practitioners' vaccination recommendations for their patients and practices for their children[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Thierry | Human Papillomavirus vaccination in general practice in France, three years after the implementation of a targeted vaccine recommendation based on age and sexual history[END_REF] at moderate risk (i.e., moderate-quality studies), and nine at high risk of bias [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Chauvet | Vaccination anti-HPV : évaluation de la pertinence d'outils d'aide a l'information vaccinale enquête aupres des médecins généralistes de Côte d'Or. (HPV vaccination: evaluation of information tools used by general practitioners from Côte d'Or)[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Erpeldinger | Vaccination contre les infections à papillomavirus en médecine générale. La décision de vacciner par le Gardasil® est-elle un choix éclairé? Enquête auprès de 518 MG du Rhône. Médecine (Vaccination against papillomavirus infections in general medicine. Is the decision to vaccinate with Gardasil® an informed choice? Survey with 518 general practitioners from Rhône)[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF] (i.e., low-quality studies) (Appendix, Tables A.2 and A.3).

Although the characteristics of the participants were not systematically reported in the articles, those that did report the characteristics described the GP study groups as mainly men (more than 50% in 20 of the 25 articles), middle-aged (mean age range: 42.3-54 years) [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Chauvet | Vaccination anti-HPV : évaluation de la pertinence d'outils d'aide a l'information vaccinale enquête aupres des médecins généralistes de Côte d'Or. (HPV vaccination: evaluation of information tools used by general practitioners from Côte d'Or)[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lamirand | Vaccination anti-papillomavirus humain (HPV): influence des nouvelles recommandations et des médias sur la pratique des médecins généralistes[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF][START_REF] Thierry | Human Papillomavirus vaccination in general practice in France, three years after the implementation of a targeted vaccine recommendation based on age and sexual history[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF] , with more than 10 years of experience in general practice [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF] , working mainly in urban and suburban areas [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Chauvet | Vaccination anti-HPV : évaluation de la pertinence d'outils d'aide a l'information vaccinale enquête aupres des médecins généralistes de Côte d'Or. (HPV vaccination: evaluation of information tools used by general practitioners from Côte d'Or)[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Killian | Vaccine hesitancy among general practitioners: evaluation and comparison of their immunisation practice for themselves, their patients and their children[END_REF][START_REF] Lamirand | Vaccination anti-papillomavirus humain (HPV): influence des nouvelles recommandations et des médias sur la pratique des médecins généralistes[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Martinez | The commitment of French general practitioners to vaccination: the DIVA study (Determinants of vaccination intentions)[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF] , and with a workload of between 3000 and 6000 consultations per year for more than 50% of GPs [START_REF] Agrinier | Discrepancies between general practitioners' vaccination recommendations for their patients and practices for their children[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Killian | Vaccine hesitancy among general practitioners: evaluation and comparison of their immunisation practice for themselves, their patients and their children[END_REF][START_REF] Lamirand | Vaccination anti-papillomavirus humain (HPV): influence des nouvelles recommandations et des médias sur la pratique des médecins généralistes[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF] (Appendix, Table A.4). To assess the prevalence of vaccine hesitancy among GPs through the frequency of their vaccine recommendations, and the determinants of these recommendations Low GP = general practitioner; HPV = human papillomavirus a Peer-reviewed article or medical dissertation b Invited to participate in the study, where available c Appendix, Tables A.2 and A.3

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GPs' attitudes, norms, perceived behavioural control, and underlying beliefs regarding HPV vaccination

GPs' cognitions regarding HPV vaccination are summarized in table 2. Attitudes [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Erpeldinger | Vaccination contre les infections à papillomavirus en médecine générale. La décision de vacciner par le Gardasil® est-elle un choix éclairé? Enquête auprès de 518 MG du Rhône. Médecine (Vaccination against papillomavirus infections in general medicine. Is the decision to vaccinate with Gardasil® an informed choice? Survey with 518 general practitioners from Rhône)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Martinez | The commitment of French general practitioners to vaccination: the DIVA study (Determinants of vaccination intentions)[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF][START_REF] Thierry | Human Papillomavirus vaccination in general practice in France, three years after the implementation of a targeted vaccine recommendation based on age and sexual history[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] and perceived behavioural control towards HPV vaccination [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Chauvet | Vaccination anti-HPV : évaluation de la pertinence d'outils d'aide a l'information vaccinale enquête aupres des médecins généralistes de Côte d'Or. (HPV vaccination: evaluation of information tools used by general practitioners from Côte d'Or)[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lamirand | Vaccination anti-papillomavirus humain (HPV): influence des nouvelles recommandations et des médias sur la pratique des médecins généralistes[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Martinez | The commitment of French general practitioners to vaccination: the DIVA study (Determinants of vaccination intentions)[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF][START_REF] Thierry | Human Papillomavirus vaccination in general practice in France, three years after the implementation of a targeted vaccine recommendation based on age and sexual history[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] were evaluated in a total of 21 studies each, whereas norms were examined in only 11 articles 24,25,31,34,36,38,40- 43,46 . None of the articles distinguished between the subcomponents of each cognition when reporting the results.

Attitudes and underlying beliefs

Among the 21 studies reporting GPs' attitudes, we identified that one reported GPs' experiential attitudes only [START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF] , nine reported instrumental attitudes only, [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Martinez | The commitment of French general practitioners to vaccination: the DIVA study (Determinants of vaccination intentions)[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Thierry | Human Papillomavirus vaccination in general practice in France, three years after the implementation of a targeted vaccine recommendation based on age and sexual history[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] and 11 reported both [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Erpeldinger | Vaccination contre les infections à papillomavirus en médecine générale. La décision de vacciner par le Gardasil® est-elle un choix éclairé? Enquête auprès de 518 MG du Rhône. Médecine (Vaccination against papillomavirus infections in general medicine. Is the decision to vaccinate with Gardasil® an informed choice? Survey with 518 general practitioners from Rhône)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF] (Table 2). Experiential attitudes were reported mostly in terms of favourable versus unfavourable opinions towards HPV vaccination, confidence versus concern, worry or doubt, and/or enthusiasm [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Erpeldinger | Vaccination contre les infections à papillomavirus en médecine générale. La décision de vacciner par le Gardasil® est-elle un choix éclairé? Enquête auprès de 518 MG du Rhône. Médecine (Vaccination against papillomavirus infections in general medicine. Is the decision to vaccinate with Gardasil® an informed choice? Survey with 518 general practitioners from Rhône)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF] . Instrumental attitudes were reported in terms of trust regarding efficacy and security, perceptions of the efficacy of HPV vaccination, its benefits, its usefulness and/or its risks represented by fear of side effects, especially in relation to autoimmune diseases [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Erpeldinger | Vaccination contre les infections à papillomavirus en médecine générale. La décision de vacciner par le Gardasil® est-elle un choix éclairé? Enquête auprès de 518 MG du Rhône. Médecine (Vaccination against papillomavirus infections in general medicine. Is the decision to vaccinate with Gardasil® an informed choice? Survey with 518 general practitioners from Rhône)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Martinez | The commitment of French general practitioners to vaccination: the DIVA study (Determinants of vaccination intentions)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF][START_REF] Thierry | Human Papillomavirus vaccination in general practice in France, three years after the implementation of a targeted vaccine recommendation based on age and sexual history[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] . Instrumental attitudes were also reported by assessing beliefs related to the impact of HPV vaccination on other health behaviours, i.e., cervical cancer screening, condom use, and/or sexual behaviours [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF] .

The results showed that GPs found HPV vaccination to be useful and necessary [START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF][START_REF] Thierry | Human Papillomavirus vaccination in general practice in France, three years after the implementation of a targeted vaccine recommendation based on age and sexual history[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] .

When assessed, and independently of study quality, more than 74% of GPs were in favour of or approved of HPV vaccination [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF] . When study quality was taken into account, i.e. reported percentage adjusted to reflect overall quality of the studies, 21%-35% of GPs reported doubts about the clinical benefits or efficacy of HPV vaccination [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF] and about 30-50% reported worries or concerns about side effects [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Thierry | Human Papillomavirus vaccination in general practice in France, three years after the implementation of a targeted vaccine recommendation based on age and sexual history[END_REF] . More specifically, rates of GPs with worries and concerns were 19-50% in high-quality studies [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF] , 23-60% in moderate-quality studies [START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Thierry | Human Papillomavirus vaccination in general practice in France, three years after the implementation of a targeted vaccine recommendation based on age and sexual history[END_REF] , and 23-34% in low-quality studies [START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF] .

The date of study did not seem to explain these results. Three low-quality studies reported that up to 10% of GPs even considered HPV vaccination to be dangerous [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF] . In studies performed before 2015, for up to 61% of GPs these doubts about efficacy and benefits/risks J o u r n a l P r e -p r o o f were linked to the "novelty" of HPV vaccination and the relatively short period since the introduction of the vaccine [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF] . Irrespective of study quality and date, 16-29% of GPs believed that HPV vaccination would decrease patients' participation in cervical cancer screening [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF] , 16-24% of GPs reported that HPV vaccination would decrease the use of condoms [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF] and 5-10% that it would lead to taking sexual risks and/or encourage premature sexuality [START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF] . Furthermore, in five articles mostly with high [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Erpeldinger | Vaccination contre les infections à papillomavirus en médecine générale. La décision de vacciner par le Gardasil® est-elle un choix éclairé? Enquête auprès de 518 MG du Rhône. Médecine (Vaccination against papillomavirus infections in general medicine. Is the decision to vaccinate with Gardasil® an informed choice? Survey with 518 general practitioners from Rhône)[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF] to moderate [START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF] risk of bias, GPs reported that screening and/or condom use are more effective than HPV vaccination [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Erpeldinger | Vaccination contre les infections à papillomavirus en médecine générale. La décision de vacciner par le Gardasil® est-elle un choix éclairé? Enquête auprès de 518 MG du Rhône. Médecine (Vaccination against papillomavirus infections in general medicine. Is the decision to vaccinate with Gardasil® an informed choice? Survey with 518 general practitioners from Rhône)[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF] .

Norms and underlying beliefs

Regarding norms, influence of pairs was approached in two studies [START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Martinez | The commitment of French general practitioners to vaccination: the DIVA study (Determinants of vaccination intentions)[END_REF] and injunctive norms were mainly assessed [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Martinez | The commitment of French general practitioners to vaccination: the DIVA study (Determinants of vaccination intentions)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] (Table 2) These norms included GPs' perceptions of their role in public health policies, the need to follow health authorities' recommendations, and trust in institutional information. Overall, 81-94.5% of GPs trusted that institutional information (i.e., from the ministry of health, health agencies, scientific sources, and the opinions of scientists and specialist physician colleagues) about the benefits and risks of immunization was reliable [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Martinez | The commitment of French general practitioners to vaccination: the DIVA study (Determinants of vaccination intentions)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] . HPV vaccination was seen as a requirement for preventive medicine and a benefit for public health [START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Martinez | The commitment of French general practitioners to vaccination: the DIVA study (Determinants of vaccination intentions)[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF] . For instance, the beneficial effects of vaccination on primary prevention of HPV and public health were highlighted by 60% of GPs [START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF] . GPs emphasized their role in public health, which consisted of informing patients about recommended vaccines, explaining, convincing, and justifying the vaccination recommendations, addressing discussions about sexuality, and vaccinating their patients [START_REF] Martinez | The commitment of French general practitioners to vaccination: the DIVA study (Determinants of vaccination intentions)[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF] .

GPs also stated that they vaccinated their patients to be in line with recommendations [START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF] . Attitude Experiential attitudes [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Erpeldinger | Vaccination contre les infections à papillomavirus en médecine générale. La décision de vacciner par le Gardasil® est-elle un choix éclairé? Enquête auprès de 518 MG du Rhône. Médecine (Vaccination against papillomavirus infections in general medicine. Is the decision to vaccinate with Gardasil® an informed choice? Survey with 518 general practitioners from Rhône)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF]  In favour or approve HPV vaccination [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF] : > 74%  Prudent, enthusiast, doubt, worried [START_REF] Erpeldinger | Vaccination contre les infections à papillomavirus en médecine générale. La décision de vacciner par le Gardasil® est-elle un choix éclairé? Enquête auprès de 518 MG du Rhône. Médecine (Vaccination against papillomavirus infections in general medicine. Is the decision to vaccinate with Gardasil® an informed choice? Survey with 518 general practitioners from Rhône)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF] Instrumental attitudes [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Erpeldinger | Vaccination contre les infections à papillomavirus en médecine générale. La décision de vacciner par le Gardasil® est-elle un choix éclairé? Enquête auprès de 518 MG du Rhône. Médecine (Vaccination against papillomavirus infections in general medicine. Is the decision to vaccinate with Gardasil® an informed choice? Survey with 518 general practitioners from Rhône)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Martinez | The commitment of French general practitioners to vaccination: the DIVA study (Determinants of vaccination intentions)[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF][START_REF] Thierry | Human Papillomavirus vaccination in general practice in France, three years after the implementation of a targeted vaccine recommendation based on age and sexual history[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF]  Trust in efficacy and safety 45 : 81%  Useful and necessary [START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF][START_REF] Thierry | Human Papillomavirus vaccination in general practice in France, three years after the implementation of a targeted vaccine recommendation based on age and sexual history[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] : 75%  Doubt about clinical benefits or efficacy 23,24,27,37 : 21% -35%  Worried about potential side effects and risks [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Thierry | Human Papillomavirus vaccination in general practice in France, three years after the implementation of a targeted vaccine recommendation based on age and sexual history[END_REF] : 30% -50%  HPV vaccine is dangerous [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF] : < 10%  Other consequences [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF] o Decrease of cervical cancer screening [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF] : 16% -29% o Decrease of condom use [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF] : 16%-24% o Encourage riskier sexual behaviour or premature sexual relation [START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF] : 5%-10% Norms Injunctive norms [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Martinez | The commitment of French general practitioners to vaccination: the DIVA study (Determinants of vaccination intentions)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF]  GP's role regarding public health policies [START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Martinez | The commitment of French general practitioners to vaccination: the DIVA study (Determinants of vaccination intentions)[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF] : 60%

J o u r n a l P r e -p r o o f

Descriptive norms

 Rely on pairs opinion and practice to decide to vaccinate [START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Martinez | The commitment of French general practitioners to vaccination: the DIVA study (Determinants of vaccination intentions)[END_REF] Perceived Behavioural Control

Capacity [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Chauvet | Vaccination anti-HPV : évaluation de la pertinence d'outils d'aide a l'information vaccinale enquête aupres des médecins généralistes de Côte d'Or. (HPV vaccination: evaluation of information tools used by general practitioners from Côte d'Or)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Thierry | Human Papillomavirus vaccination in general practice in France, three years after the implementation of a targeted vaccine recommendation based on age and sexual history[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF]  Have enough information about HPV vaccination and related subjects [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF] : > 68%  Feel confident to inform about HPV vaccination [START_REF] Chauvet | Vaccination anti-HPV : évaluation de la pertinence d'outils d'aide a l'information vaccinale enquête aupres des médecins généralistes de Côte d'Or. (HPV vaccination: evaluation of information tools used by general practitioners from Côte d'Or)[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] : 19% to 88%  Feel able to implement recommendations 39 : 70%  Feel comfortable with adolescents care 44 : 95% Autonomy (essentially barriers) [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lamirand | Vaccination anti-papillomavirus humain (HPV): influence des nouvelles recommandations et des médias sur la pratique des médecins généralistes[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Martinez | The commitment of French general practitioners to vaccination: the DIVA study (Determinants of vaccination intentions)[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF]  Parents 28 : 56%  Parents' fear of side effects [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF]  Scarcity of pre-adolescents or adolescents' consultations [START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Lamirand | Vaccination anti-papillomavirus humain (HPV): influence des nouvelles recommandations et des médias sur la pratique des médecins généralistes[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF]  Socio-cultural characteristics of patients as barriers [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Lamirand | Vaccination anti-papillomavirus humain (HPV): influence des nouvelles recommandations et des médias sur la pratique des médecins généralistes[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF] : 17.5% to 25%  Lack of time 23,25,30,38,43,45 HPV= human papillomavirus a Percentage of general practitioners was reported when available

J o u r n a l P r e -p r o o f

Perceived Behavioural control and underlying beliefs

Capacity

Except for one study, which did not indicate rates [START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF] , more than 68% of GPs felt that they were well-informed about HPV and HPV vaccination [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF] . GPs felt confident in justifying vaccine recommendations and in explaining the utility of the vaccine (up to 88%) and its safety (up to 77%) [START_REF] Chauvet | Vaccination anti-HPV : évaluation de la pertinence d'outils d'aide a l'information vaccinale enquête aupres des médecins généralistes de Côte d'Or. (HPV vaccination: evaluation of information tools used by general practitioners from Côte d'Or)[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] . However, this rate was lower (up to 58%), when confidence in explaining the role of vaccine adjuvants was investigated [START_REF] Chauvet | Vaccination anti-HPV : évaluation de la pertinence d'outils d'aide a l'information vaccinale enquête aupres des médecins généralistes de Côte d'Or. (HPV vaccination: evaluation of information tools used by general practitioners from Côte d'Or)[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] . GPs reported being comfortable with having adolescents as patients [START_REF] Thierry | Human Papillomavirus vaccination in general practice in France, three years after the implementation of a targeted vaccine recommendation based on age and sexual history[END_REF] .

Autonomy

Parents' fear of side effects of HPV vaccination is one of the most important barriers, reported by more than 60% of GPs [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF] .

GPs explained these fears by the relatively short period since the introduction of the vaccine [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF] and controversies about vaccination in general or about specific vaccines, such as those against hepatitis B virus, H1N1 influenza virus, and HPV [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF] . Independently of their quality, studies reported high variability in the rate of GPs who considered the socio-cultural characteristics of patients and their parents (e.g., religion and personal conviction) to be important barriers (17.5-25%) [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Lamirand | Vaccination anti-papillomavirus humain (HPV): influence des nouvelles recommandations et des médias sur la pratique des médecins généralistes[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Plessis | Vaccination contre le papillomavirus et médecins généralistes. Une enquête qualitative en Pays-de-Loire (Vaccination against papillomavirus and general practitioners. A qualitative survey in Pays-de-Loire[END_REF] .

The main practice-related barriers reported were the age of girls [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lamirand | Vaccination anti-papillomavirus humain (HPV): influence des nouvelles recommandations et des médias sur la pratique des médecins généralistes[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF] and the scarcity of consultations with adolescents [START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Lamirand | Vaccination anti-papillomavirus humain (HPV): influence des nouvelles recommandations et des médias sur la pratique des médecins généralistes[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF] . Before 2012, when vaccination was recommended for girls aged 14 years, 28-72% of GPs would have preferred to vaccinate against HPV at as young an age as possible (i.e., 11-14 years) to avoid having to discuss sexually transmitted infections and sexuality [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF] . Indeed, addressing sexually transmitted infections was reported as an issue for 11-31% of GPs [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF] . After 2012, when HPV vaccination became recommended for girls aged 11-14 years, GPs no longer felt an obligation to discuss sexuality, and therefore they perceived this change as beneficial [START_REF] Lamirand | Vaccination anti-papillomavirus humain (HPV): influence des nouvelles recommandations et des médias sur la pratique des médecins généralistes[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF] .

Nevertheless, some GPs continued to address sexuality as part of the information on HPV vaccination or to satisfy parents' expectations and requests [START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lamirand | Vaccination anti-papillomavirus humain (HPV): influence des nouvelles recommandations et des médias sur la pratique des médecins généralistes[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF] . This did not seem to be a barrier anymore [START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF] . Meanwhile, new issues were reported by GPs regarding younger ages of patients: girls being too young to be concerned [START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lamirand | Vaccination anti-papillomavirus humain (HPV): influence des nouvelles recommandations et des médias sur la pratique des médecins généralistes[END_REF] , having to rely on parents negative decision as reported by 56% of GPs [START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF] , and parents being insecure to talk about sexuality at such young age and/or frightened of encouraging premature sexuality [START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lamirand | Vaccination anti-papillomavirus humain (HPV): influence des nouvelles recommandations et des médias sur la pratique des médecins généralistes[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF] . These issues J o u r n a l P r e -p r o o f affected GPs' practice as both parents and GPs had the tendency to delay HPV vaccination to older ages (i.e. 14) [START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF] .

The scarcity of consultations with adolescents was perceived as a serious obstacle [START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Lamirand | Vaccination anti-papillomavirus humain (HPV): influence des nouvelles recommandations et des médias sur la pratique des médecins généralistes[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF] . Therefore, any reason for consultation (i.e., medical consultation other than vaccination, certificate of fitness for sport) was reported to be used to propose the vaccine [START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF] .

GPs' behaviours regarding HPV vaccination

Main results are presented in Fig. 3 and in details in Appendix (Table A .5). In the more recent studies of moderate to high quality and with larger number of participants, 73% of GPs reported either always (46%) or often (27%) recommending HPV vaccination to the target population [START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] , and 72.9% of GPs reported proposing to vaccinate these girls against HPV [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF] .

J o u r n a l P r e -p r o o f

Impact of cognitions

Five articles used quantitative methods to examine the effects of specific cognitions on the behaviour of interest, essentially to recommend or propose [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Chauvet | Vaccination anti-HPV : évaluation de la pertinence d'outils d'aide a l'information vaccinale enquête aupres des médecins généralistes de Côte d'Or. (HPV vaccination: evaluation of information tools used by general practitioners from Côte d'Or)[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] . Five articles examined the links between cognitions and dependent variables, i.e., experiential attitudes [START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF] , vaccine hesitancy [START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF] , or perceived behavioural control [START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF] .

Importance of instrumental attitudes

Among attitudes tested, GPs' perceptions of risks, including change in patients' health behaviour and doubts about vaccine utility/efficacy, were shown to be negatively associated with proposing and recommending HPV vaccination [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] . GPs' concerns about side effects of HPV vaccination were shown to be negatively associated with favourable (experiential) attitudes [START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF] .

Importance of injunctive norms

Results from three studies of either moderate quality [START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF] or high quality [START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] were in favour of a positive and significant association between trust and recommending HPV vaccination.

GPs' trust in institutional information showed a positive and significant association with HPV vaccination recommendation, either directly [START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] or indirectly and mediated through a decrease in vaccine hesitancy [START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF] . Trust was also positively correlated with ability to explain the utility, safety, and adverse events of vaccination [START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF] . Beneficial effects of vaccination in public health and its role in primary prevention were positively correlated with favourable (experiential) attitudes [START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF] .

Perceived behavioural control: inconsistent results

The impact of abilities on behaviour was contradictory from two high-quality studies.

Confidence in GPs' ability to explain the utility of vaccines, the safety of vaccines, and the role of adjuvants in general (including HPV) was reported to be either associated (positively)

or not associated with recommendation of the vaccines [START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] . Ability to talk about sexuality was positively associated with favourable opinions about HPV vaccination [START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF] , but HPV vaccine knowledge, by itself, seemed not to have effect on experiential attitudes [START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF] .

When autonomy, i.e., barriers related to either patients or practice (i.e., reason for consultation, age for vaccination, questions asked by patients, parents' presence and reluctance to address sexuality, and necessity to address the issue of sexually transmitted J o u r n a l P r e -p r o o f infections) were examined, they were not associated with GPs' recommendation [START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF] and it is not clear if it is associated with GPs' attitudes [START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF] .

Impact of background variables on behaviours and experiential attitudes regarding

HPV vaccination

Ten articles reported effects of background variables on behaviours and/or experiential attitudes (i.e., favourable opinion), with age and gender being the most studied variables [START_REF] Agrinier | Discrepancies between general practitioners' vaccination recommendations for their patients and practices for their children[END_REF][START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Chauvet | Vaccination anti-HPV : évaluation de la pertinence d'outils d'aide a l'information vaccinale enquête aupres des médecins généralistes de Côte d'Or. (HPV vaccination: evaluation of information tools used by general practitioners from Côte d'Or)[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Erpeldinger | Vaccination contre les infections à papillomavirus en médecine générale. La décision de vacciner par le Gardasil® est-elle un choix éclairé? Enquête auprès de 518 MG du Rhône. Médecine (Vaccination against papillomavirus infections in general medicine. Is the decision to vaccinate with Gardasil® an informed choice? Survey with 518 general practitioners from Rhône)[END_REF][START_REF] Killian | Vaccine hesitancy among general practitioners: evaluation and comparison of their immunisation practice for themselves, their patients and their children[END_REF][START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF]40 (Appendix,Table A.6).

When study quality was taken into account, results from studies assessing age of GPs [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Chauvet | Vaccination anti-HPV : évaluation de la pertinence d'outils d'aide a l'information vaccinale enquête aupres des médecins généralistes de Côte d'Or. (HPV vaccination: evaluation of information tools used by general practitioners from Côte d'Or)[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Erpeldinger | Vaccination contre les infections à papillomavirus en médecine générale. La décision de vacciner par le Gardasil® est-elle un choix éclairé? Enquête auprès de 518 MG du Rhône. Médecine (Vaccination against papillomavirus infections in general medicine. Is the decision to vaccinate with Gardasil® an informed choice? Survey with 518 general practitioners from Rhône)[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF] showed that younger GPs were more favourable to proposing vaccination and to vaccinating against HPV [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF] . The results showed no significant association between gender and behaviours or attitudes [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Chauvet | Vaccination anti-HPV : évaluation de la pertinence d'outils d'aide a l'information vaccinale enquête aupres des médecins généralistes de Côte d'Or. (HPV vaccination: evaluation of information tools used by general practitioners from Côte d'Or)[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Erpeldinger | Vaccination contre les infections à papillomavirus en médecine générale. La décision de vacciner par le Gardasil® est-elle un choix éclairé? Enquête auprès de 518 MG du Rhône. Médecine (Vaccination against papillomavirus infections in general medicine. Is the decision to vaccinate with Gardasil® an informed choice? Survey with 518 general practitioners from Rhône)[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF] , except in one high-quality article in which men were more prone to have favourable opinions [START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF] . Practice-related variables (workload reported as consultations or visits >100/week or >3000/year, consultation duration <20 minutes, seeing more women or children/teenagers) were positively associated with favourable opinions and recommendation/vaccination [START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF] . HPV vaccination behaviour was not affected by practice of alternative medicine (e.g., homeopathy, acupuncture), practice of Pap smear or gynaecology, or recommendation of other vaccines, although these variables were shown to affect favourable opinions towards HPV vaccination [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Chauvet | Vaccination anti-HPV : évaluation de la pertinence d'outils d'aide a l'information vaccinale enquête aupres des médecins généralistes de Côte d'Or. (HPV vaccination: evaluation of information tools used by general practitioners from Côte d'Or)[END_REF][START_REF] Erpeldinger | Vaccination contre les infections à papillomavirus en médecine générale. La décision de vacciner par le Gardasil® est-elle un choix éclairé? Enquête auprès de 518 MG du Rhône. Médecine (Vaccination against papillomavirus infections in general medicine. Is the decision to vaccinate with Gardasil® an informed choice? Survey with 518 general practitioners from Rhône)[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF] . Variables that were not related to behaviours or attitudes were type of practice (i.e., solo/group), number of years of practice, cost of vaccine, and number of injections [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Chauvet | Vaccination anti-HPV : évaluation de la pertinence d'outils d'aide a l'information vaccinale enquête aupres des médecins généralistes de Côte d'Or. (HPV vaccination: evaluation of information tools used by general practitioners from Côte d'Or)[END_REF][START_REF] Killian | Vaccine hesitancy among general practitioners: evaluation and comparison of their immunisation practice for themselves, their patients and their children[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF] .

J o u r n a l P r e -p r o o f

Discussion

The use of the RAA theoretical framework to extract and analyse data offers new insights into French GPs' cognitions and behaviours regarding HPV vaccination. Our review shows that, in terms of attitude, these are fears of risks (i.e., concerns about safety and change of behaviour) and doubts about utility/efficacy regarding HPV vaccination, which drive GPs' decisions about whether to recommend HPV vaccination [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] . Taking into account that very strong ethical norms are in place in GPs as a professional group, including the precautionary principle, which is very well embedded in norms in France regarding public health [START_REF] David | Risques et principe de précaution en matière médicale[END_REF] , it is more likely that GPs with concerns and doubts, i.e., 30-50% of GPs [START_REF] Barjhoux | Vaccination contre les infections à papillomavirus humains : pratique et difficultés des médecins généralistes isérois (Vaccination against human papillomavirus infections: practice and difficulties of general practitioners from Isère)[END_REF][START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Leicht | Quels sont les freins des médecins généralistes à la vaccination contre les[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF][START_REF] Thierry | Human Papillomavirus vaccination in general practice in France, three years after the implementation of a targeted vaccine recommendation based on age and sexual history[END_REF] will neither propose nor recommend HPV vaccination to girls. This figure may even be underestimated, because GPs' responses are potentially biased due to social desirability (GPs respond what they think they should say) and/or wishful thinking (GPs respond what they would like to be true). It is worth noting that the percentage of GPs with concerns and doubts is very high and in line with the rate of unvaccinated adolescent girls in France, i.e. about 70% in 2019 [START_REF]HPV vaccination coverage in France by age group[END_REF] .

Although up to 88% of GPs report confidence in explaining the safety and efficacy of HPV vaccination [START_REF] Chauvet | Vaccination anti-HPV : évaluation de la pertinence d'outils d'aide a l'information vaccinale enquête aupres des médecins généralistes de Côte d'Or. (HPV vaccination: evaluation of information tools used by general practitioners from Côte d'Or)[END_REF][START_REF] Pelissier | HPV vaccine and cervical cancer prevention in general practice. Survey conducted among general practitioners in the French departments of Eure-et-Loir and Cher[END_REF][START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] , the percentage of GPs who will be able to answer related specific questions is probably much lower, as reported in France and in other settings [START_REF] Tutala | Evaluation de l'impact des praticiens sur la couverture vaccinale HPV en Occitanie (Evaluation of General practitioners' impact in HPV vaccination coverage in Occitanie)[END_REF][START_REF] Mcsherry | Which primary care practitioners have poor human papillomavirus (HPV) knowledge? A step towards informing the development of professional education initiatives[END_REF] . This result together with the fact that up to 50% of GPs reports doubts and concerns regarding HPV vaccination is intriguing. Indeed, reliable information related to HPV vaccination safety and efficacy is easily accessible to GPs through authoritative health websites 11 . It is possible that French GPs, who have been reported to work at least 50 hours a week, may not have time to both access HPV vaccination-related information and attend continuing education [START_REF] Chaput | Deux tiers des médecins généralistes libéraux déclarent travaillerau moins 50 heures par semaine (Two-thirds of GPs report working at least 50 hours a week)[END_REF] . Another possibility, which might be also related to their heavy workload, is that GPs use heuristics to process HPV-related information. These are mental shortcuts that enable them to make decisions and process information more rapidly and based on incomplete, uncertain, or/and peripheral information [START_REF] Stroebe | Social psychology and health[END_REF] . Heuristics have been shown to be part of health practitioners' practice and driven by constraints such as time [START_REF] Marewski | Heuristic decision making in medicine[END_REF] . Moreover, it has been shown that heuristicsbased information is less resistant to counter-argument and less predictive of behaviour than systematic processing [START_REF] Stroebe | Social psychology and health[END_REF] . It is thus possible that GPs when facing parents would not be able to address parents' arguments and even recommend HPV vaccination, which is a driver for parents to vaccinate [START_REF]Enquete-de-perception-aupres-des-medecinsgeneralistes-et-des-parents[END_REF][START_REF] Karafillakis | HPV vaccination in a context of public mistrust and uncertainty: a systematic literature review of determinants of HPV vaccine hesitancy in Europe[END_REF][START_REF] Newman | Parents' uptake of human papillomavirus vaccines for their children: a systematic review and meta-analysis of observational studies[END_REF] . This may explain the discrepancy between the GP-reported recommendation/vaccination rate (i.e. 70%) [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] and actual HPV vaccination rates (of less J o u r n a l P r e -p r o o f than 30%), which is also reported in other settings [START_REF] Rosen | US Health Care Clinicians' Knowledge, Attitudes, and Practices Regarding Human Papillomavirus Vaccination: A Qualitative Systematic Review[END_REF][START_REF] Vollrath | Meaningful Methods for Increasing Human Papillomavirus Vaccination Rates: An Integrative Literature Review[END_REF] . The positive effect of higher (>3000 consultations/year) workload on GPs behaviour 27 seems to contradict our hypothesis on time constraints stated above. This threshold may be underestimated according to the average number of consultations per GP per year i.e. 5100 -5800 [START_REF] Chaput | Deux tiers des médecins généralistes libéraux déclarent travaillerau moins 50 heures par semaine (Two-thirds of GPs report working at least 50 hours a week)[END_REF][START_REF] Jakoubovitch | Les emplois du temps des medecins generalistes[END_REF] . Thus, instead of considering a positive effect of high workload, we may assume that GPs with a workload lower than average (e.g. semi-retired, working part-time or as substitutes), recommend less HPV vaccination, what may be explained by seeing less patients including girls.

Our results suggest that the ways in which HPV vaccination-related information is currently provided to GPs in France are not adequate. Vaccination teaching in the French medical curriculum has shown some limitations [START_REF] Kernéis | Vaccine Education of Medical Students: A Nationwide Cross-sectional Survey[END_REF] . Continuing medical education is not mandatory, eventhough completing at least one training is part of the GPs' annual performance scheme.

Information tools, including continuing education, should be developed to favour less heuristic processing of information and take into account GPs' constraints.

Our review highlights the central place of injunctive norms, i.e., trust in institutional information, in positively affecting GPs' beliefs and behaviours regarding HPV vaccination [START_REF] Raude | Opening the 'Vaccine Hesitancy' black box: how trust in institutions affects French GPs' vaccination practices[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF] . This is understandable because GPs are recognized as a professional group with shared strong professional norms. Regarding descriptive norms, to the best of our knowledge, no studies have yet explored in details the role of these norms in GPs' behaviours regarding HPV vaccination, although they have been shown to be a driver in physicians' practice [START_REF] Keating | Peer Influence and Opportunities for Physician Behavior Change[END_REF] . Future work is needed in this field. Both the importance of HPV vaccination and the role of GPs in public health should be highlighted when developing information tools and education modules on HPV vaccination.

Parents' fear of side effects of HPV vaccination is reported by more than 60% of GPs as one of the most important barriers to recommend and vaccinate [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF][START_REF] Casimont | Opinion des médecins généralistes sur les nouvelles stratégies de prevention du cancer du col de l'uterus. Particularités départementales du Maines et Loire (Opinion of general practitioners on new strategies for cervical cancer prevention. Specificities of "Maines et Loire[END_REF][START_REF] Degoue | Place de la vaccination anti-HPVdans la pratique des médecins généralistes (HPV vaccination in general practionners' practice)[END_REF][START_REF] Gougenheim-Fretin | Réticences vis-à-vis du vaccin contre le Human Papillomavirus et solutions envisagées à partir d'une étude qualitative réalisée auprès de médecins traitants et de parents d'adolescentes[END_REF][START_REF] Houdjal | Approche des représentations des médecins généralistes sur la vaccination anti-HPV à l'aide d'un modèle évaluant les[END_REF][START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF][START_REF] Manolitsi | Exploration des freins des médecins généralistes des Yvelines par rapport à la vaccination anti-HPV (Exploration of the obstacles of general practitioners in Yvelines with regard to anti-HPV vaccination)[END_REF][START_REF] Sadki | Vaccination anti-papillomavirus : perception du vaccin par les médecins généralistes et attitudes adoptées face aux réticences qu'il suscite (HPV vaccination: general practitioners' perceptions and attitudes towards patients' reluctance)[END_REF] . Despite the change of the target age group from 14 years to 11-14 years, the age of girls remains an issue for GPs, raising even more concerns. The main reason is that HPV vaccination remains strongly connected to sexuality or sexual behaviour, as reported in other settings, such as the United States and Canada [START_REF] Rosen | US Health Care Clinicians' Knowledge, Attitudes, and Practices Regarding Human Papillomavirus Vaccination: A Qualitative Systematic Review[END_REF][START_REF] Vollrath | Meaningful Methods for Increasing Human Papillomavirus Vaccination Rates: An Integrative Literature Review[END_REF] . However, age/sexuality/parents fears does not seem to impact GPs' recommendation decision regarding HPV vaccination (in our review). Vaccination might be an issue due to girls' parents but GPs have a strategy in place i.e. vaccinate girls later, at around age 14 years, which is also highlighted in other reviews [START_REF] Rosen | US Health Care Clinicians' Knowledge, Attitudes, and Practices Regarding Human Papillomavirus Vaccination: A Qualitative Systematic Review[END_REF][START_REF] Vollrath | Meaningful Methods for Increasing Human Papillomavirus Vaccination Rates: An Integrative Literature Review[END_REF] . This is interesting as research has been developed in recent years focusing on patients as a barrier and J o u r n a l P r e -p r o o f developing interventions to improve the abilities of health providers to recommend HPV vaccination. Interventions using this approach have been shown to be effective [START_REF] Brewer | Announcements Versus Conversations to Improve HPV Vaccination Coverage: A Randomized Trial[END_REF][START_REF] Reno | Improving Provider Communication about HPV Vaccines for Vaccine-Hesitant Parents Through the Use of Motivational Interviewing[END_REF] ; however neither sustainability of these interventions nor their effects on GPs' cognitions have been shown so far [START_REF] Malo | Why is announcement training more effective than conversation training for introducing HPV vaccination? A theory-based investigation[END_REF] . Moreover if motivational interviewing seems to be promising, time required to do it properly and based on ethical principles render it difficult to be integrated in GPs' busy schedule [START_REF] Passmore | Motivational interviewing: reflecting on ethical decisions in MI[END_REF] .

Our results suggest that these are actually GPs themselves that could be considered as a barrier to HPV vaccination and that research should centre on how HPV vaccination information is effectively conveyed to them. While this study included only GP-related interventions, the findings will be applicable to other primary care professionals (e.g. nurses), in healthcare systems where the patient consultations are not limited to GPs [START_REF] Malo | The content and context of physicians' communication with males about human papillomavirus vaccination[END_REF] . Moreover, taking into account that HPV vaccination of girls aged 11-14 years often seems to be delayed to older ages and that sexuality always seems to be connected to this vaccination whatever the age of the girl, one option to facilitate HPV vaccination would be to increase the age of the target group to 15-18 years. This is supported by recent scientific evidence obtained by our group showing efficacy of HPV vaccination for this age group with a two-dose schedule [START_REF] Basu | Two-dose recommendation for Human Papillomavirus vaccine can be extended up to 18 years -updated evidence from Indian follow-up cohort study[END_REF] , but should be balanced against the possibility of missing opportunities to vaccinate before sexual debut among early initiators.

Our study has the usual limitations of synthesising evidence from retrospective surveys based on self-reporting, including recall bias, social desirability bias, and wishful thinking bias. It should be highlighted that taking into account the nature of the population surveyed, i.e., GPs, social desirability and wishful thinking may be particularly important. The included studies covered a twelve year period (Table 1), over which GP's cognitions regarding HPV vaccination might have changed. This was not formally assessed in our analysis.

The quality of this review can be acknowledged regarding the accuracy of the literature research and the use of recommended review guidelines and tools to assess bias. Compared with other literature reviews that explore cognitions related to HPV vaccination and focus on attitudes and knowledge, our review goes further by (a) using the RAA theoretical framework (b) addressing methodological differences between studies, (c) providing an overview of the impacts of all these cognitions on vaccination behaviour, and (d) focusing on only one type of health providers, i.e., GPs. The results of this review could easily be used and adapted in countries that have similar health policies and similar HPV vaccination issues.

J o u r n a l P r e -p r o o f

Journal Pre-proof

Conclusion

To our knowledge, no GP-level interventions have been successful in improving HPV uptake rates in France. Our results will inform the development of a professional educational intervention on HPV vaccination targeting GPs in France. HPV vaccination is one of the main pillars of the recently launched WHO initiative to eliminate cervical cancer around the world and removing barriers to vaccination in different settings and from different perspective including health professionals is of paramount importance for success.

Conflicts of interests

None to declare.

Table A.2 Risk of bias of the quantitative studies included in the review (the highest is the score (max.11), the lowest is the risk of bias). We used the Newcastle-Ottawa quality assessment scale (NOS) for cohort studies adapted for cross sectional studies to assess the quality of the studies. Inform PBC, capacity:

(+) confidence to explain usefulness, safety, si vaccinate PBC, capacity:

(+) confidence to explain usefulness, safety, si Collange (2016) [START_REF] Collange | General practitioners' attitudes and behaviors toward HPV vaccination: A French national survey[END_REF] Recommend Attitude:

(-)unfavourable opinion about risks/benefits balan utility p < .05 PBC, autonomy:

(NS) perceived barriers (Parents' presence and re sexuality issues)

Norms:

(NS) trust in information from official Lasset (2014) [START_REF] Lasset | Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010[END_REF]

Favourable

Norms:

Beneficial effects of vaccine on public health and prevention p = .04

Lutringer-Magnin (2011) [START_REF] Lutringer-Magnin | Human papillomavirus (HPV) vaccination: Perception and practice among French general practitioners in the year since licensing[END_REF] Favourable PBC, autonomy:

(NS) Perceived barriers: reason for medical consult vaccination, questions asked by patients and nece J o u r n a l P r e -p r o o f Bouvret (2016) [START_REF] Bouvret | Practices and attitudes regarding HPV vaccination among general practitioners from Besancon[END_REF] Favour able

  ):  Instrumental (i.e. perceived outcomes of behaviour adoption) or experiential (feelings associated with behaviour) attitudes;  Injunctive (i.e. perceived expectations of important referent individuals or social groups) and descriptive (i.e. perceptions of what important referent individuals or social groups do) norms;  Perceived behavioural control's capacity (i.e. individuals' confidence, beliefs about the necessary skills and abilities they have to perform the behaviour) and autonomy (i.e. individuals' beliefs that they have control over the behaviour).

  databases: Medline via PubMed, PsycINFO, PsycARTICLES, Embase, CINAHL plus, Web of Science, Pascal and Francis. The search for grey literature was performed by both GB and PV in the French Public Health Database (Banque de données en santé publique), Cairn.Info, yahoo.fr and Google Scholar. Search updates from December 2018 to July 2020 were conducted by PV. The full research query in Medline via PubMed is available in Appendix, Table A.1.

  J o u r n a l P r e -p r o o f Journal Pre-proof regarding HPV vaccination b) background variables and either GPs' attitude or behaviour regarding HPV vaccination.

Figure 2 .

 2 Figure 2. Studies included in the review based on the PRISMA flow diagramme[START_REF] Moher | Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement[END_REF]

  that aim to help GPs to deliver information about HPV vaccination High J o u r n a l P r e -p r o o f ' perceptions of HPV vaccination risks and efficacy and their recommendation behaviour; and the relative importance of factors associated with the frequency of their knowledge of GPs on infection with HPV and Gardasil®, and to determine the impact of training and information on knowledge and the attitude towards this

Figure 3 .

 3 Figure 3. Association between general practitioners' cognitions and behaviour variables assessed in the review. Sens of arrow reflects which variable was used as dependent vs independent in the studies. Association was either not significant (X) or significant and either positive (+) or negative (-). Descriptive norms were not assessed. PBC = perceived behavioural control; HPV = human papillomavirus

  r n a l P r e -p r o o f

Table 1 .

 1 Characteristics of studies included in the review

Author (publication year) Year(s) of data collection Document a Study design Measurement Participants /Invited b (Type of recruitment) Aim Risk of bias c

	Agrinier (2017) 22	Article	Quantitative	Self-reported	1038/1712	To measure discrepancies between vaccination	Moderate
						questionnaire		recommendations by GPs for their patients and
	2013-2014						(National panel)	practices for their children
	Barjhoux (2009)	23	Medical	Quantitative	Self-reported	278/1200	To evaluate the modalities and difficulties	High
				dissertation		questionnaire		encountered by GPs when offering the vaccine
	2008						(Local panel)	to patients
	Bouvret (2016)	24	Article	Quantitative	Self-reported	96/140	To assess opinions, practices, and difficulties of	Low
						questionnaire		GPs regarding HPV vaccination
	2014-2015						(Local panel)
	Casimont (2015) 25	Medical	Qualitative	Interview	10	To describe opinion of GPs about changes in	High
				dissertation				strategies to prevent cervical cancer
	2014						(Local panel)
	Chauvet (2016) 26

Table 2 .

 2 General practitioners' cognitions regarding HPV vaccinationTypeSubcomponents a

Table A . 3

 A3 Risk of bias of the qualitative studies included in this review (the highest is the score (max.10), the lowest is the risk of bias). We used the Critical Appraisal Skills Programme (CASP) framework to assess the quality of the studies.

			Selection		Comparability	Outcomes	Peer-reviewed a	Score b
	Author (year)	Representativeness	Sample	Non-	Ascertainment	Design and	Assessment	Statistical
		of the sample	size	respondents	of the exposure	analysis	of the	test
					(risk factor)		outcome
	Agrinier (2017) 22	*	*		*		*	*	*	6
	Barjoux (2009) 23	*			*		*			3
	Bouvret (2016) 24	**	*		*		**	*	*	8
	Chauvet (2016) 26	*			*		*			3
	Collange (2016) 27		*		*		*	*	*	5
	Degoue 28		*		*		*			3
	Erpeldinger (2012) 29	*			*		*			3
	Killian (2016) 32	*	*		**		**	*	*	8
	Lasset (2014) 34	*	*	*	*		**	*	*	8
	Leicht (2016) 35	*			*		*			3
	Lutringer-Magnin (2011) 36	*	*		*		*	*	*	6
	Manolitsi (2012) 37	*			*		**	*		5
	Pélissier (2008) 39	*

Table A . 4

 A4 General practitioners' characteristics

	Author (year)	% of men	With	Professional	Type of practice	Localization	Training	Practice b
			children a	experience
		Age			Solo/Group/	Urban/Suburban
					Alternative	/Rural
					medicine
	Agrinier (2017) 22 Barjhoux (2009) 23 Bouvret (2016) 24	Men=64.5% <50 years = 45.2%, 50-58 years = 40.4%, >58 years = 14.4% Men=59.9% Mean age= 48.67 years Men=43.7%	66% NA NA J o u r n a l P r e -p r o o f NA 36.8%/63.2%/11.9% NA/NA/NA NA NA/NA/6.2% 85.5%/NA/14.5% M = 18.8 years 50%/45.83%/NA 100%/NA/NA	Vaccination training = 44.7% NA gynaecological training: 4.2%	N: <3067 =21.2%; 3067-6028 =53%; >6028 =25.8% Women < 23 years = 38%; for 50.6% of GPs most of their patients are women, N<1500 = 51.8% 63.5% Pap smears
		Mean = 54 years
	Casimont (2015) 25	Men=40%	NA	NA	NA/NA/NA	40%/40%/20%	NA	NA
		60% >50 years
	Chauvet (2016) 26	Men=57.3%	NA	NA	36.43%/63.57%/NA	38.5%/40.6%/21%	NA	NA

Table A . 5

 A5 Association between general practitioners' attitudes, norms, perceived behavioural control and either cognitions or behaviour regarding HPV vaccination

	Author	Dependent variables	Independent variables a
	(year)
		Cognitions	Behaviour	Cognitions
	Bouvret		Propose	Attitude:
	(2016) 24
				(-) Risks/benefits of vaccination: lack of hindsight
				unknown duration of protection, real benefits in te
				necessity to pursue cervical cancer screen
				(-) Concerns about behavioural consequences of va
				condom p<.001, fear of stopping pap sm
				(-) Past hepatitis B vaccination controve
	Chauvet
	(2016) 26

Table A . 6

 A6 Association between background variables and either general practitioners' attitude or behaviour regarding HPV vaccination

		Dependent			Independent variables a
		variables
	Author (year)	Attitud	Behavio	Age Gende	Child	Practice	Training
		e	ur		r	ren/
						daugh
						ter
	Agrinier (2017) 22		Discrepa	NS	(+)men		(+) solo practice (p	(NS)
			ncies/div		(p <		< .05)	infectious
			ergence b		.05)			disease and
							(+) Practice of	vaccination
							alternative medicine
							(p < .05)
							(NS)Workload
							(NS)City size
	Barjoux (2009) 23		Propose	(+)	NS		(+) town <20 000
				Less			residents (p < .001)
				40
				years
				(P <
				.001)

Acknowledgements

The authors are grateful to Dr. Karen Muller who helped to stylistically edit the manuscript and to K. Pitaksaringkarn who helped in the manuscript submission. The authors are also grateful to their colleagues from IARC, especially Dr P. Basu, and GRePS, who kindly reviewed the protocol and provided constructive comments.

Where authors are identified as personnel of the International Agency for Research on Cancer / World Health Organization, the authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the International Agency for Research on Cancer / World Health

Funding information

P. Villain/IARC obtained funding from the French National Cancer Institute (INCa, grant nr. 2016-009) and Métropole de Lyon / Cancéropôle Lyon Auvergne-Rhône-Alpes (CLARA).

The sponsors had no involvement in the study design, collection, analysis and interpretation of data, the writing of the manuscript, or the decision to submit the manuscript for publication.

Highlights

Design and analysis

Assessment of the outcome

Statistical test

Piana (2009) [START_REF] Piana | Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians[END_REF] Author (year) J o u r n a l P r e -p r o o f