Dilema & Decision, Risk & Medical Gestures (DDREAM)
Team 8 of UMR D 257 Vectors – Tropical and Mediterranean Infections (VITROME)
Aix-Marseille University (AMU), Institut de Recherche pour le Développement (IRD) – French Military Health Service (SSA)
Scientific strategy and prospects
The enduring difficulties faced in crisis management during the last decades, especially concerning epidemic risks, have brought to the light the necessity to take seriously into account populations’ reactions. Indeed, populations are usually recruited in crisis management to endorse specific behaviors prescribed by health authorities . Such recruitment is consistent with the contemporary ‘risk culture’ that exhorts us to be more autonomous and responsible, to become the ‘entrepreneur’ of our own existence, especially regarding health issues, by relying on expert knowledge . Contemporary health policies urge us to conform to the ‘homo medicus’ norm, which is rational and predictable and thus easier to govern .
Nevertheless, contemporary societies have also been deeply influenced in recent decades by the ‘disenchantment of science’ : after having disenchanted the whole world, science disenchanted itself and the public no longer trust it. Now science tends to produce a lot of competing, partial, conditional and often contradictory results. This ‘balkanisation’ of scientific knowledge is magnified by the Internet and social media which fuel controversies and further weaken expert knowledge. Thus expert knowledge is supposed to play a crucial part in our daily existence, but we no longer trust it.
Such phenomenon is particularly marked for some contemporary risks, as they are invisible (they escape our senses) such as the mad cow prion, or more generally emerging infectious risks . Moreover, these specific risks also bring about some strong cultural and symbolic resonance, due to past great epidemics.
We aim at studying emerging infectious risks by adopting an interdisciplinary approach involving economics, public health and sociology, and articulating this approach with biomedical research in other VITROME teams.
Risk is a key concept of social sciences. While public health incorporated some main findings from psychology and social psychology (with risk being investigated since the 1970s in particular to identify personality’s traits and perceptive biases), economics explicitly involves risk perception in explaining behaviors (individual decision-making models under risk). In comparison, sociological approaches to risk are somehow newer . However, the focus frequently is on risk perception regardless of individual behaviors, as evidenced by the “psychometric paradigm” on the border of economics and psychology .
In this context, we aim at focusing on decisions and behaviors while considering risk perceptions as a key component of decision-making. To do so, we will focus on “medical procedures” in the broad sense, whether they are prescribed by medical authorities to the public or to the healthcare professionals themselves, in terms of guidelines for prevention and cure of infectious risks: vaccination, screening, wearing a mask, washing hands, taking prophylaxis or antibiotic treatments…
One the one hand, the public’s support and trust towards these medical injunctions have therefore to be assessed, given that these injunctions offal within a context where the individuals are urged to take charge of their own health, even though the information supposed to highlight their choices are sometimes very uncertain. To what extent do they trust the various information sources available? How do they access these information sources and how does the information circulate in society? These issues are surrounded by social differentiation that needs to be assessed and analyzed since it is likely that social differentiation could be involved in the genesis and reproduction of social inequalities in health. On the second hand, health professionals will be investigated as well. Since health professionals are both the target and relay of injunctions from the health authority bodies, they are at the same time experts and actors close to the public, by adopting even sometimes its perceptions.
In addition, analyzing individual decisions to conform or not to medical injunctions requires highlighting the dilemmas potentially faced by individuals. Medical procedures can indeed pose problems because they disrupt our daily lives, frustrate the pursuit of certain objectives, violate certain values, or simply because they are perceived as risky (as the potential side effects of vaccination). Doctors also face dilemmas in the case of trade-offs between injunctions from health authority bodies and their patients’ expectations.
A first axis will be dedicated to the “profane” individuals, whether these individuals are from the general population (in the case of mass vaccination, for example) or from a particular subset (deployed servicemen having to take preventive treatments, for example). In addition to quantitative and qualitative approaches to study these populations, investigating the genesis and circulation of the information relative to risks (in classic and more recent social media) will be of main issue.
The second axis will be devoted to health professionals. One the one hand, they have a major role in the dissemination of health norms within the general population. In a context of mistrust of expert knowledge, we nevertheless all need the reassurance provided by face-to-face relationships with representatives “in flesh and bones” of that knowledge . In the medical field, the therapeutic relationship plays this role: it is the physician’s task to represent/embody all the actors of the health system while informing and reassuring the patient. This task is all the more delicate since physicians may themselves feel unprepared as regards medical uncertainties and controversies when facing patients themselves increasingly “experts”. One the other hand, health professionals may themselves be the target of medical procedures. This is for example the case in infectious disease wards where health professionals are subject to very strict rules regarding hand hygiene.
Most of the researchers in the DDREAM team project are currently involved in other empirical topics than vaccination, such that addiction, targeted therapies in oncology, living conditions several years after cancer diagnosis… However, some of us have been working on vaccination during the past few years and their studies are mentioned here to illustrate our approach.
These studies showed that reluctance towards vaccination in general increased in France at the time of the A/H1N1 pandemics, with some delayed impact on vaccination behaviours . People reluctant towards vaccination in general and those reluctant towards the A/H1N1 vaccine in particular have contrasted socio-demographic characteristics. These reluctances were found to be mutually reinforcing . We proposed a theoretical model involving both individual commitment to vaccination decisions and confidence to health authorities to explain these complex attitudes that vary between vaccines and do not always lead to vaccine refusal .
We also brought to light the existence of vaccine hesitancy among general practitioners, as for the general population. This hesitancy was found to be thriving on mistrust towards health authorities and had a negative influence on their vaccination recommendations towards their patients and their vaccination behaviours towards themselves and their children [10,11]. Finally, we studied how critical information on vaccination disseminates on the Internet and underscored that this occurs according various models: not all sites are against vaccination. We have proposed new research avenues in this field .