Shingles vaccine: Qualitative research to inform the introduction of the Herpes Zoster vaccine and communications to encourage its take-up
Summary of findings
Awareness and understanding of shingles
Shingles was familiar to most respondents, usually because they knew at least one person who had had it. But it was far from the front of their minds, and was never mentioned as something that they might face in the future.
Those who knew someone who had had shingles tended to know about the symptoms, and most knew someone who had had what they expected was a ‘nasty case’. As a result, they were very sure that they did not want to get shingles themselves. Those who were not familiar with shingles were often aware of the symptoms, but their aversion to getting shingles seemed much less extreme than those who had had personal experience of it.
Despite this high level of awareness, understanding of how shingles develops and how prevalent it is was extremely low across the sample. Most knew it is related to chickenpox and connected to a suppressed immune system. But almost all believed it is contagious and fairly rare. This meant that, despite their aversion to it, few were worried about getting shingles themselves: they thought that since they were unlikely to come into contact with someone who had it, they would not catch it.
Views on a vaccine
On the basis of this understanding, many approved of the idea of a vaccine for shingles and would take it if it were offered by a nurse because they did not want to get shingles, but few were convinced by the need for it. Two pieces of new information had a significant impact on these views. First, the fact that shingles develops internally, rather than being caught from someone else, implied that everyone is at risk and there is little that can be done to avoid it. Second, the prevalence of shingles was much higher than most had expected, especially among those over the age of 60. This information made most respondents more concerned about the risk of shingles than they had been and made the offer of a vaccine seem all the more attractive.
Information about the symptoms and possible complications had less impact on those who knew someone who had had shingles – the former was already familiar and the latter seemed unlikely. It had a greater effect on those who were unfamiliar with shingles: they were less aware of the symptoms to begin with, and shingles remained a little mysterious as they had not experienced it, so they could relate more easily to the complications and risk of hospitalisation, however unlikely these might be.
Most respondents, especially those in the older half of the sample, had considerable faith and trust in nurses and other health professionals. If the shingles vaccine were offered and recommended by the nurse, most of them would assume it is safe and worth having, and would take it without many questions. But queries about the vaccine’s safety and effectiveness did arise, especially on consideration and among those who were unfamiliar with shingles.
Concerns about safety stemmed from the fact that it is a new vaccine without a track record of public use – few were worried about it being ‘live’, so information about the safety of other live vaccines missed the point, and a clinical trial was often not reassuring. Questions about its effectiveness resulted from difficulties in grasping how a vaccine could protect against a virus that is already in the body; the results of the clinical trial were often not thought impressive. It seemed that endorsement from the nurse would be the most effective reassurance on both these points; learning that the shingles vaccine is already in use in the US was also helpful.
Receiving the vaccine
Respondents who were living independently were happy to go to their GP surgery to receive the vaccine. A number spontaneously said that it should be offered at the same time as the flu jab as this would be convenient and/or they were unlikely to go in at any other time; others agreed when this was suggested. Very few had any concerns about having the two vaccines at the same time, but some thought it might not be practical.
Many were also happy to have three vaccines at once (flu, shingles and pneumoccocal), provided the nurse recommended this, but a minority expressed concern about ‘overloading the system’ and would have preferred to come back to have one separately. Reassurance from the nurse seemed likely to overcome this concern in some cases, but others refused point blank to consider having all three together, and it seemed that little could be done to change their ‘gut feeling’ that this is not a good idea. Presenting the three vaccines as a ‘package’ seemed beneficial for those who were happy to have all three together anyway, but not to change the views of those who strongly wanted them separately.
Most did not want or need to know much about the vaccine, but almost all wanted some prior warning that they would be having it. The flu and pneumoccocal vaccines had often been offered and accepted ‘on spec’, without being expected. The shingles vaccine seemed to be different: shingles is not salient; the vaccine is not established and familiar; and without information about how it develops and its prevalence, the vaccine does not seem particularly urgent. Many respondents wanted to feel comfortable about having it, to appreciate why it is being offered, and to be eager to have it; endorsement and reassurance from the nurse could achieve some of this, but prior awareness of some basic facts was expected to be useful. Some also wanted a discussion with their partners before having a new vaccine. Targeted information, such as leaflets and posters in GP surgeries and the letters which are sent to individuals inviting them to have the flu jab, seemed sensible to many.
The nurses in this sample tended to mirror the public in terms of their understanding of shingles and initial attitudes towards a vaccine. They knew shingles is unpleasant and worth avoiding, and thought a vaccine would be attractive for this reason alone, but they also thought shingles is not life threatening and relatively rare, and that a vaccine might not offer good value for money. Information about how it develops and its prevalence was often new to them, but had less impact than among the public. Ultimately, all said they would deliver the vaccine if instructed to do so, and would endorse it to patients if that were the policy, but none considered it vital.
All nurses confirmed the trust that the public respondents said they had in health professionals, and thought that their endorsement would be enough to persuade most people of that age to have the vaccine. Most extended this trust relationship to DH, assuming that if the vaccine were made available it would be safe and reasonably effective. But most still wanted information about the vaccine for their own interest and to allow them to recommend it with a ‘clear conscience’.
As with the public respondents, most nurses felt the flu jab appointment would be a good opportunity to give the shingles vaccine as well: convenient, efficient and the only time they see many people. There were few concerns about giving the two vaccines at once, provided they were satisfied that the shingles vaccine is safe in itself. But a number of practical issues arose, generally involving the time needed to prepare and give the vaccine, and the need to keep stocks.
Their views on giving three vaccines at once mirrored those of the public respondents: most were happy to do so in principle and thought that older people would agree to this if they were to recommend it. But they questioned the practicalities, predicted that some patients would have concerns, and
did not see why all three need to be given together. In addition, a few nurses felt that if a patient were to react after having the three vaccines together, it would be hard to tell which one had caused the reaction and possibly difficult to persuade the patient to have the flu jab in the future.
A combination of three factors provides a strong motivation for people to want the shingles vaccine: awareness of what shingles is like; understanding of how it develops; and appreciation of how common it is. If one of these factors is missing, the ‘case’ for a vaccine is less urgent and less convincing because shingles is not top of mind and not considered a risk that is really worth worrying about. Those who know someone who has had shingles are well aware of what it is like, but communications will need to make shingles ‘real’ for those who have not experienced it in others, as well as providing information about development and prevalence.
There was little to suggest that offering the vaccine alongside the flu jab would result in large numbers of refusals, and many could see advantages to this arrangement (although there might be practical difficulties as well). Three vaccines together would be acceptable to many, but questions about ‘system overload’ start to be asked and there would be a need for some flexibility as some people are likely to refuse to consider this altogether.
Patients are likely to want to see some simple printed information about shingles and the vaccine (covering the points made above, and reassuring on safety and effectiveness), ideally before being offered the vaccine. However, endorsement from nurses is likely to be the most effective way to promote the vaccine. Nurses would want information for themselves as well, although this could well be the same material as that provided for the public
The research was required to explore:
- public understanding and views of shingles
- reactions to the idea of a vaccine
- how people relate it to the flu jab and other injections
- the barriers to take-up
- the benefits and motivations
- the views of nurses
The Department of Health (DH) is considering a live attenuated vaccine called Herpes Zoster, a single injection of which would give long-term protection against shingles. This vaccine may be offered to those aged 60 and above, and may be given at the same time as the autumn flu jab. Initial exploratory research was commissioned to inform the introduction of the vaccine and communications designed to encourage take-up.
Three factors influence appeal of the shingles vaccine: awareness of what shingles is like; understanding of how it develops; and appreciation of how common it is. There was little to suggest that offering the vaccine alongside the flu jab would result in large numbers of refusals and endorsement from nurses is likely to be the most effective way to promote the vaccine
Some representation from ethnic minority groups
The public sample covered ages 60-85 and a spread of social grades; some respondents had long term conditions, were from ethnic minority groups, were living in care homes or had had shingles in the past:
- 15 paired interviews with couples (60 minutes)
- 8 interviews with single respondents (60 minutes)
- 2 groups with general public respondents (8 respondents; 90 minutes)
The nurses sample involved practice, community and district nurses:
- 5 paired interviews with practice nurses
- 3 paired interviews with community and district nurses
Data collection methodology
Other data collection methodology
Public n=54; nurses n=21
London, Hertfordshire, Birmingham and Newcastle.
20 January to 11 February 2009