Our study demonstrates that the main causes for refusal of the vaccination for A/H1N1 were the perception of the risks linked to a new vaccine compared to those linked to this specific type of flu, which seemed benign and aroused only moderate concern in most of the patients who refused. Instead, prevention measures appeared to be reliable means to prevent infection. Information sources did not help, and sometimes even hindered vaccination acceptance, because they were perceived as contradictory and unreliable.
People who were vaccinated explained their choice, first and foremost, by the importance of prevention by vaccination, particularly because of their disease. They relied on the advice of their health practitioner. Moreover, they clearly associated the preventive aspect of the vaccine with its altruistic dimension: vaccination to protect others as well as themselves.
1. Strengths and limitations of the study
Our methodological position has a three-fold interest.
(1) Our study is the first to use a qualitative approach to better analyse the motives for refusal. Such a methodology, based on in-depth interviews allowing open questions during which people can comment freely, allows access to the experiential contexts of the interviewees, in which events unfold, risk perceptions develop, and practices are guided 
. This deepens the analysis of risk-related perceptions and patient decision-making 
. Moreover, the patients were recruited and the interviews conducted one by one as patients kept regularly scheduled appointments, without any patient selection that could have led to bias. We stopped when a point of data saturation was obtained for all of the topics examined, which constitutes strong proof of qualitative rigor 
. Therefore, although this study does not have the representative power of a randomised sample as in a quantitative study, its qualitative methodology provided a very comprehensive approach.
(2) We focused on one high risk disease group in one geographic region. CF was used as a model because patients are better-informed and educated about health issues than the general population. As they manage their chronic disease, they gain a true “lay expertise” 
. Moreover, these patients, all received the same message from their CF doctors, supporting vaccination, including the fact that influenza virus infections present a major risk for them because they may exacerbate their respiratory disease 
. Most importantly, CF patients are generally very compliant with seasonal flu vaccine, with coverage rates that exceed 80% 
These specific characteristics thus serve to eliminate the heterogeneity of samples taken from the general population. Moreover, analysing the motives for refusal of the pandemic A/H1N1 vaccine in this population highly aware of the dangers of A/H1N1 infection allows us to focus in more detail on the reasons specifically linked to the novelty of the vaccine. Finally, enrolment of pediatric and adult patients allowed us to conclude that parents of sick children do not behave differently than adult patients.
(3) Our interviews were conducted a few months after vaccination ended in people who had faced the reality of a pandemic. This contrasts to other studies, where subjects were asked about their future intentions just as the pandemic began 
. While useful and scientifically legitimate, such prospective analyses involve a large degree of uncertainty, especially because their data rely primarily on statements out of context. Our data, based on real life experiences, allow us to evaluate the development of the respondents' behaviour. Moreover, patients in this study stated that their experience and the motives for their decision would determine their attitude in another H1N1 pandemic. The conclusions of this study are therefore useful to illuminate the behaviour of patients in future pandemics 
2. Perceptions about A/H1N1 vaccine risks were the main reason for refusing the new vaccine
We found a marked discrepancy in the assessment of vaccine-related risks between refusers and accepters. The fear aroused by the vaccine was the main reason for refusal. Two principal explanations account for this fear of the vaccine: distrust of a new vaccine manufactured on an emergency basis and concern about its possible adverse effects. On this point, our results agree with the conclusions of studies conducted in the general population 
The fear aroused by the A/H1N1 flu did not however result in uniform behaviours. The particular susceptibility to respiratory infections of people with CF and the importance of prevention of the A/H1N1 virus through vaccination were clear to the persons who were vaccinated, for they indicated it as the main reason for their decision. The patients who refused the vaccine described the A/H1N1 flu as rather essentially untroubling, and they trivialized, minimized, and even denied the notion of specific vulnerability in CF patients 
. On the other hand, most of them implemented important barrier measures. This apparent contradiction suggests that A/H1N1 flu induced real worry in this group, although not expressed explicitly but this was not sufficient to convince them to be vaccinated. Clearly, the refusers shaped their decision in a risk-benefit approach between a perception that new vaccine equals lack of safety on the one hand and ignorance or denial of their high-risk status on the other. Thus our findings contrast with previous studies focused on specific high risk group, namely pregnant women 
, patients with cardiovascular diseases 
or chronic respiratory diseases 
that suggest a strong correlation between the perception of high risk relative to the A/H1N1 flu and the decision to be vaccinated.
3. Vaccination outlook: the altruistic attitude predicts adherence to a new vaccine
Examining what we might call the “vaccination outlook” of the interviewees, we did not find anti-vaccination attitudes in either group, or exclusive adherence to alternative medicine, or any history of serious vaccination reactions. On the contrary, the interviewees, including those who refused the vaccine, very largely adhered to vaccination principles and overwhelmingly follow vaccination recommendations, including for seasonal flu.
Our study therefore shows that the decision about A/H1N1 vaccine does not directly correlate with the attitude toward seasonal flu vaccination or, more generally, towards other vaccinations. These results contrast with the findings of Seale and Schwarzinger 
regarding the association between a positive attitude toward vaccination for the seasonal flu vaccine and adherence to the A/H1N1 vaccine in the general population.
Our results go even farther. “Vaccination outlook” differed in one essential point between persons who refused the A/H1N1 vaccine and those who took it. The community immunity preventive function of vaccines and the altruistic act of being vaccinated to protect others as well as oneself were dominant notions in persons who took the vaccine and practically absent in those who refused it. Therefore, our results suggest that the altruistic principle of vaccination in the general population is a factor that predicts adherence to a new vaccine. Similar results were also shown in health care workers 
Thus, one of the main foundations of the refusal process for new vaccines is not only mistrust of the vaccine itself but also the disconnection of vaccination from its altruistic and moral motivations of prevention. Without this “affective driver”, adherence to new vaccines is highly compromised by the fears to which they may give rise in western societies where safety concerns dominate and lead to demands for vaccines at “zero risk” 
. This original result thus raises the question of the meaning of vaccination in our modern societies where new individual sensibilities coexist with changes in the circulation of pathogens. More specifically, these results should provoke policy debate on the role of the ethics of care in collective health 
4. Ecology of the vaccination campaign: general practitioner information and involvement is mandatory for the success of vaccine campaigns
Nearly all the persons who were vaccinated said they received clear, unequivocal and explicit information from their regular health care providers. On the other hand, those who refused the vaccine mentioned multiple sources (health professionals, media, friends and family) and very conflicting messages. They often perceived that the recommendations were dissonant, contradictory, and indecisive.
More specifically, they stated that the medical establishment was no longer the only legitimate stakeholder or speaker. The population received direct messages from various institutional players that fed a far-reaching controversy about the vaccine. This controversy and multiplicity of messages damaged the bond of trust that the interviewees said they had with their regular health care providers. Indeed, this health crisis was seized as an opportunity for the media and politicians to involve themselves in health policy. As they grabbed the centre of the stage, they delivered worrisome messages focused more on the potential risks of vaccination than on its benefits because not balanced by experience or true scientific information. Media studies and risk research confirm this finding and highlight the sensational nature of the coverage, which produced compelling news items to attract large audiences but little information useful to the public in deciding what they should do 
. This competition aroused wide public distrust and therefore sapped patients' confidence in the information delivered by their practitioners 
Nor did the medical establishment offer a consensus about the indications for the A/H1N1 vaccine, as the refusers pointed out. A previous study focused on health care practitioners indeed showed that health care providers with inadequate knowledge about pandemic influenza A/H1N1 and its vaccine recommended vaccination less often than those who reported their knowledge as adequate 
. Excluded from the action aspect of prescribing the vaccine, health care providers then in part offloaded responsibility for its advisory aspects 
. This abdication by physicians, leaving patients to their own devices, was widely cited by people who refused the vaccine.
Finally the interviews emphasized the contradiction the respondents felt between, on the one hand, the resources implemented by the health authorities (government communications and establishment of ad hoc vaccination centres), and the reality of the epidemic on the other. The alarming public health messages were not consistent with daily personal experience, which did not confirm the threat 
. This discrepancy between message and reality in the French context calls to mind the controversy over the HBV vaccine 
. National health authorities initiated universal HBV vaccination in the mid-1990s. However, the emotions generated by the claim that HBV vaccination might lead to multiple sclerosis resulted in a massive rejection of the HBV vaccine. Beyond this resemblance, the gap between the health authorities' message and reality reminds us of a larger set of health fears that have studded the recent history of Western countries, including, as some of the interviewees mentioned, the scandals about “mad cow” disease and GMO. This specific dimension of the 2009 A/H1N1 pandemic is again evidence of the national health authorities' difficulties in communicating about medical science and explaining vaccination procedures to the general population 
On the whole, the behaviours during the 2009 pandemic described above probably explain the low compliance rate for A/H1N1 vaccination throughout most industrialized countries and can be generalized to enable us to formulate recommendations to improve the likelihood of success of a future pandemic management plan.
Specifically, we have three main recommendations for improving adhesion to new vaccines:
(1) Patient education
It appears necessary to reinforce the education of patients about their disease and its specific risks to convey accurate information about the risk of the pandemic. This is in line with meta-analyses which have shown that perceptions of risk are an important predictor of uptake of vaccination against a variety of diseases 
. We recommend that health authorities improve risk/benefit communication and invest in the implementation of effective tools for communicating vaccine risk/benefit ratios for future vaccination campaigns, emphasising the risks of not being vaccinated and the benefits of vaccination, and explicitly acknowledging and tackling safety concerns. As most of the refusers advocated the efficacy of other prevention methods than vaccines, a target action would be to convince these people that immunization provides more protection than barrier measures. Because this study showed that the accepters also based their decision on the collective immunity aspect of the vaccine, explicitly intended to protect others, we advocate that the message delivered should also consider the altruistic principle of vaccination. It is important to educate and engage citizens on the benefits of community immunity.
(2) Health care provider involvement
Health care professionals are not impersonal participants in individual and family illnesses, and it is essential not simply to treat episodes of illness, but to build a relationship and provide continuity of care 
. Thus, the message about vaccines should first and foremost be conveyed by local health care providers, with whom patients have built strong relationships of trust 
. That message will be conveyed better if those professionals are involved in implementing the immunization 
, as shown by previous studies of H3N1 pandemics that demonstrated both general practitioners' unique skills in empowering patients and translating national guidelines into public health education and patients' feelings that GPs' are best at helping and understanding them 
. Primary health care providers should be the first point of contact in the health care system to provide better, comprehensive and continuing education during any emerging health crisis. We emphasize that the success of a mass vaccination campaign depends in large part on health care practitioners advising the general public to be vaccinated.
(3) The message about the vaccine: It also seems crucial to disseminate a clear and effective message about the safety of the vaccine in terms of manufacturing and validation processes, safety and efficacy 
. In our modern societies where health and the precautionary principle must be read together, governments have a real obligation to communicate with the public about the decisions to be made regarding health interventions 
. Because the media are an important source of information for the public during infectious disease outbreaks, it is important to provide it with regular and accurate information from the very beginning, thereby preventing public misconceptions and maintaining trust in the health authorities. We suggest that constant updates on infection rates and vaccine safety should be provided by health care authorities through the media to enable viewers to reach conclusions about their own level of risk hand and to develop a rational opinion on the vaccine's risks and benefits.