Mitigating Vaccine Disparities Through Faith-Based Intervention: A Pre-Post Analysis of Recombinant Zoster Vaccine Knowledge and Acceptance in Socially Vulnerable Racial and Ethnic Minoritized Communities

Abstract

Introduction

The incidence of herpes zoster (HZ) is increasing globally. Despite the availability of a highly effective recombinant zoster vaccine (RZV), vaccination rates are still low in the United States, especially among racially and ethnically minoritized (REM) and socially vulnerable groups. There is an urgent need to identify obstacles to vaccination in these communities and develop effective strategies to increase confidence in the RZV.

Methods

From August 2024 to December 2024, we conducted a community-based educational intervention in San Bernardino County, California, partnering with five churches in neighborhoods with high Centers for Disease Control and Prevention (CDC) Social Vulnerability Index scores. The intervention included a 45-min presentation on HZ, its complications, and RZV recommendations. Participants aged 18 + completed pre- and post-surveys to assess attitudes, knowledge, and behaviors. Descriptive statistics summarized outcomes, while a two-proportion Z-test and Fisher’s exact test evaluated changes in vaccine literacy.

Results

A total of 156 individuals completed the pre-intervention survey, and 134 completed the post-intervention survey. All identified as REM, with 99% in vulnerable neighborhoods. Sixty-three percent had at least one co-morbid illness, and 46% had received info about HZ or RZV before the session. At baseline, 57% believed they were at risk of HZ, but 75% found the education session “extremely effective” in reassessing their risk. Significant improvements in vaccine literacy, especially regarding disease and age-based recommendations, were observed, with correct responses increasing post-intervention (p < 0.05). Following the intervention, 82% reported a high likelihood of receiving RZV, and 90% a high likelihood of recommending it.

Conclusions

This study demonstrates the feasibility and acceptability of a faith-based, community-led educational intervention to address barriers to RZV uptake among vulnerable REM populations. Using trusted community infrastructure can support equitable expansion of adult immunization programs to reduce preventable HZ disparities.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-026-01310-x.

Key Summary Points

Why carry out this study?

Recombinant zoster vaccine (RZV) uptake is low in the US among racially and ethnically minoritized (REM) and socially vulnerable populations, despite higher rates of herpes zoster (HZ)-related complications.

There is a need to identify barriers to uptake among these groups and develop interventions to address these limitations.

What was learned from the study?

Pre-intervention survey results revealed multiple limitations to RSV uptake and acceptance. Approximately 54% of participants had not received information or recommendations about the vaccine, 57% perceived themselves as unlikely to contract HZ, and 46% were unsure about vaccine affordability. Significant knowledge gaps also existed regarding vaccine literacy and age recommendations.

Faith-based community educational interventions can be effective in addressing RSV vaccine acceptance among racially and ethnically minoritized (REM) and socially vulnerable groups. Post-intervention, 82% indicated a high likelihood of receiving the RZV, and 90% would recommend it to others.

Introduction

Herpes zoster (HZ) is an infection caused by reactivation of the varicella zoster virus (VZV), which remains latent in the neural ganglia after the initial infection [1–3]. HZ infection is characterized by a painful, blistering dermatomal rash that can lead to long-lasting complications, including post-herpetic neuralgia (PHN) [4]. It is estimated that over 1 million people are infected each year, and about 1 in 3 individuals will experience infection at some point in their lifetime [1, 5]. Due to the effects of chronic illnesses on the immune system, individuals diagnosed with certain comorbidities, including type 2 diabetes mellitus (T2DM), asthma, chronic obstructive pulmonary disease (COPD), autoimmune diseases, and other immunocompromising conditions, are at high risk for HZ infection [1, 6–8]. Furthermore, due to immunosenescence or age-related immune decline, adults aged 50 and older are also highly vulnerable to HZ and its complications, including hospitalization and death [1, 9].

Antiviral therapy is available for treating HZ after infection; however, it must be started within 72 h of the HZ rash appearing to achieve the best outcomes [4]. Nevertheless, the timely initiation of antiviral treatment is often challenging due to nonspecific HZ symptoms and delays in accessing healthcare [4, 10]. Thus, vaccination has been identified as the most effective way to reduce the burden of HZ and its complications [1, 11]. The live zoster vaccine (ZVL) was approved by the Food and Drug Administration (FDA) in 2006 for adults aged 60 and older, and in 2011, approval was extended to adults aged 50 to 59 [12]. In 2017, the recombinant zoster vaccine (RZV) was approved by the FDA for use in individuals aged 50 and older [13]. The RZV is administered as a two-dose series and is over 70% effective in adults 50 years or older [13–15]. Since 2018, the Advisory Committee on Immunization Practices, along with other scientific organizations, has recommended the RZV for age-eligible individuals, including those who previously received ZVL [16]. The ZVL was discontinued in 2020, and in 2022, the FDA expanded the approval of the RZV to include use in individuals 19 and older who are immunodeficient or immunocompromised [17]. The RZV can be safely given alongside routine vaccines, such as the annual influenza vaccine, and is covered by most private insurance plans and Medicare Part D for eligible individuals [18, 19]. Despite the vaccine’s effectiveness against HZ and its broad availability, reports from the 2020 National Health Interview Survey show that fewer than 30% of adults aged 50 and older have received at least one dose of any HZ vaccine (RZV or ZVL), with only 14.1% having received at least one dose of the RZV [20, 21].

Despite efforts to boost RZV uptake, disparities persist, with lower coverage among individuals who identify as racially and ethnically minoritized (REM) and those with low socioeconomic status (SES) [20, 21]. It has been noted that only 6.3% and 6.8% of Hispanic/Latino and non-Hispanic Black individuals, respectively, have received at least one dose of the RZV [20, 21]. This is concerning, as one study found that the odds of PHN and HZ-related hospitalization are higher among non-Hispanic Black individuals compared to non-Hispanic White individuals [22]. Researchers also observed a 10% difference in RZV uptake by household income, with only 8.8% of individuals in households earning less than $35,000 vaccinated [20]. The authors further report lower RZV coverage among individuals unvaccinated against influenza [20]. Among marginalized populations, those unvaccinated against HZ often face barriers such as limited vaccine literacy due to lower education levels, lack of healthcare insurance affecting vaccine access, and longer gaps between primary care visits, which hinder receiving strong recommendations for RZV [20, 23–25]. Consequently, there is a lack of literature on effective interventions to address these obstacles and improve RZV uptake among these marginalized groups.

In San Bernardino County (SBC), California, non-Hispanic Black individuals are more likely to be diagnosed with a chronic illness compared to other racial or ethnic groups [26]. This is alarming because the high burden of chronic disease can significantly increase these individuals’ vulnerability to preventable infections [27]. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic highlighted this issue, as non-Hispanic Black residents in SBC were disproportionately represented among those infected with the virus and diagnosed with coronavirus disease 2019 (COVID-19) but were less likely to be vaccinated against it [28]. Recognizing this disparity, a community-academic partnership was formed between a faith-based organization (FBO) and a local academician (a pharmacist by training) to improve vaccine literacy and acceptance [29]. The intervention involved the expert delivering a 45-min lecture on SARS-CoV-2, COVID-19, and available COVID-19 vaccines at various churches across vulnerable REM SBC communities [29, 30]. Research assessing changes in baseline vaccine literacy and acceptance following the presentations showed increased knowledge about COVID-19 and the COVID-19 vaccines [28, 30]. An observed rise in vaccine acceptance among participants was also noted [28–30]. Building on this success, the intervention was expanded to address influenza vaccine literacy [31]. Similar to the COVID-19 educational efforts, significant improvements in literacy were indicated by an over 20% increase in correct responses to knowledge-based questions from baseline to post-intervention [31]. Participants also reported being more likely to receive the influenza vaccine in the post-intervention survey than in the baseline survey [31]. These successes demonstrated the value of the collaboration and presented an opportunity to apply the intervention to address immunization barriers for other preventable illnesses, such as HZ.

Current RZV uptake rates are unknown in SBC; however, given the reported low national rates, we hypothesize significant disparities in RZV uptake among REM individuals living in the county. Therefore, understanding the perspectives of vulnerable REM individuals regarding HZ infection and the RZV is urgently needed. Additionally, with the evolving landscape of vaccine misinformation and rapidly changing behaviors surrounding vaccine acceptance, it is critical to provide vulnerable communities with scientifically valid information to help reduce RZV uptake hesitancy.

To address these gaps, we expanded the community-based educational intervention and provided tailored education on HZ and RZ to improve understanding of the disease and vaccine. Here, we present the results of our pre- and post-interventional study, which aimed to assess the effects of the vaccine education sessions on the attitudes, literacy, and acceptance of the RZV among vulnerable REM individuals living in SBC. Specifically, we provide insights into participants’ initial perceptions of HZ and the RZV, as well as changes after education. We also report differences in RZV knowledge and acceptance at baseline and following the intervention.

Methods

Study Design and Setting

The intervention, a 45-min PowerPoint presentation on preventable diseases (delivered in English), was conducted from August 2024 to December 2024, once per month on a weekend, at five church locations in SBC. Together, the FBO and the academic used the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI) to identify highly vulnerable areas for prioritizing the educational intervention [32, 33]. The CDC SVI uses census tracts and ZIP codes to measure neighborhood-level social, material, and economic deprivation [33]. The index scores deprivation based on data from the American Community Survey, grouped into four categories: socioeconomic status, household characteristics, racial and ethnic minority status, and housing type and transportation [32, 33]. The vulnerability score is divided into four quartiles (low, low-medium, medium–high, and high) and reported for each theme and as a combined score. The combined score, which considers each theme, guided the intervention [32].

After identifying each church, a project manager appointed by the FBO contacted the faith leader for each church. Once the church expressed interest in participating, the academician provided information about the intervention and a memorandum of understanding (MOU) for all services to be delivered during the activity. Each faith leader was asked to designate a representative to serve as the “point of contact” for the activity. The faith leaders were also asked to promote the event to their parishioners and the surrounding community, using promotional materials developed by the FBO project manager and the academician. The churches received a $1000 USD incentive following the successful recruitment of at least 20 community members aged 18 or older to participate in the 45-min education session and the pre- and post-intervention survey to evaluate the intervention’s outcomes.

The 45-min educational session, led by the academician, focused on factors influencing vaccine literacy and acceptance for preventable viruses among REM individuals. The session covered HZ, influenza, and COVID-19, along with their respective vaccines. Notably, we provided information on influenza, COVID-19, and HZ to highlight opportunities to co-administer RZV with annual respiratory vaccines. The presentation began by explaining the risks associated with HZ and its complications. Following this, it addressed the nationwide burden of these diseases and the uptake of RZV, with a specific focus on the disproportionate disease burden and low RZV uptake among marginalized populations. It then explained the mechanism of action for RZV, including the use of an adjuvant in its formulation, along with age- and disease-specific guidelines for RZV use and the benefits of vaccination. The presentation also included detailed information on vaccine access, including coverage under Medicare Part D. Similar content on influenza and COVID-19 was delivered immediately after the sections on HZ and RZV. All educational materials were developed using peer-reviewed research articles and evidence-based recommendations from the CDC website. The content was presented in plain language for participants, using “shingles” instead of HZ and “flu” instead of influenza.

Community members aged 18 and older were offered a $20 USD gift card to the local grocery store as an incentive to participate in a pre- and post-intervention survey study assessing the outcomes of the education session. Participation required completing a baseline survey before the presentation began and another immediately after the 45-min education session finished (both on the same day). All participants were informed that survey participation was voluntary, and verbal consent was obtained before handing out paper surveys. The pre- and post-intervention surveys were reviewed and approved by the University of California, San Diego Institutional Review Board.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration. The University of California, San Diego Institutional Review Board approved this study (#807857) and the waiver of informed consent, given the minimal risk and an anonymous collection of the data. Since the data were collected anonymously, the study was exempt from full board review.

Pre-Intervention and Post-Intervention Surveys

We previously acknowledged our limitations in identifying survey tools that effectively measure the attitudes, knowledge, and behaviors of REM individuals regarding vaccine literacy and acceptance [31]. To address this, we developed a survey informed by the existing literature to gather information on these topics. This survey was validated and peer-reviewed. We adapted this tool, initially used in our influenza educational intervention, to also include questions about HZ and RZV [31]. Since we continued providing information on influenza, we retained some influenza-related questions in the survey. However, in this study, we discuss only our questions and findings related to HZ and RZV. The survey was piloted among a representative population of REM SBC residents 2 months before the intervention (June 2024). These individuals are not included in the final analysis, and the Cronbach’s Alpha value obtained from the pilot was 0.72.

The pre-intervention survey consisted of three sections and, like the education presentation, used terms such as “shingles” and “shingles vaccine” throughout to keep language simple for participant understanding. The health belief model guided the first section, a framework previously used to gain insights into attitudes and behaviors related to vaccine uptake [34]. The first section aimed to gather information on participants’ perceptions of the risk of HZ infection, obstacles to receiving the vaccine (such as accessibility or potential side effects), perceived benefits of receiving the RZV, and their views on RZV uptake within their communities and nationally. The second section included four true-or-false questions testing baseline knowledge of HZ, the RZV, and guideline-based recommendations for RZV use (including co-administration with the influenza vaccine). The final section contained a single vaccine acceptance question that assessed their intent to receive the RZV before receiving education on the topic. Responses in the first and third sections of the survey were recorded using five-point Likert scales with response options adjusted for clarity. The pre-intervention survey questions are shown in the Supplementary Document. Only individuals who completed the pre-intervention survey were allowed to complete the post-intervention survey.

The post-intervention survey was also divided into three sections. The first section evaluated attitudes and behaviors related to HZ and RZV after education, using a five-point Likert scale with clear response options. It also included a question about vaccine acceptance that measured how much importance individuals placed on receiving the RZV after learning about the disease. The second section repeated the four true-or-false statements from the pre-intervention survey to assess changes in vaccine literacy following the education session. The third section included two vaccine-acceptance questions: the first reassessed participants’ intent to receive the RZV after the education session, and the second measured their willingness to recommend the vaccine to a family member or friend after participating in the intervention. The post-intervention survey questions are in the Supplementary Document.

Analysis and Presentation of Results

Paper-based surveys were used for participant convenience, and after each event, the academician entered all surveys into Qualtrics for future analysis.

A power analysis was conducted to determine the minimum sample size required to detect a statistically significant difference in the proportion of correct responses to the four true-or-false knowledge-based statements between pre- and post-intervention surveys (as a metric of vaccine literacy change). We hypothesized a baseline correct response rate of 50% across all participants in the pre-intervention study based on the binary nature of the questions (true/false), with a meaningful improvement of 20% points following the intervention, corresponding to a post-intervention survey correct response rate of 70%. This difference corresponds to a Cohen’s h effect size of 0.41, representing a medium effect. The power analysis was performed using a two-proportion z-test framework with a two-tailed significance level of α = 0.05 and statistical power of 80% (1 − β = 0.80). Anticipating approximately 15% attrition between the pre- and post-intervention surveys, unequal group sizes were expected. Under these assumptions, a minimum of approximately 110 participants at baseline and 95 participants at post-intervention were required to achieve adequate statistical power. The final sample included 156 participants at baseline (pre-intervention survey) and 134 participants in the post-intervention study, exceeding the minimum requirements and yielding an estimated statistical power of approximately 94%.

Analysis and Presentation of Pre-Intervention Survey Results

To present our pre-intervention survey results, we used percentages and counts to summarize the demographic data collected from each participant, including race, ethnicity, age, gender, and SVI. We also use counts and percentages to present information on pre-existing comorbidities and whether participants had received information on HZ or RZV before the education session, based on responses to the pre-intervention survey. Additionally, we report the counts and percentages of participants’ responses to questions about their perceptions of the following topics: risks of contracting HZ, challenges in receiving the RZV, benefits of receiving the RZV, and community and national-level RZV uptake, all collected from the pre-intervention survey. We also report the counts and percentages of participants’ responses to the vaccine-acceptance-related question assessing their baseline intent to receive the RZV.

Analysis and Presentation of Post-Intervention Survey Results

For the post-intervention survey data, we present the average Likert scoring for questions assessing participants’ attitudes toward HZ, the RZV, and the delivery of content during the education session. We also include the percentages of individuals who responded with a “5,” as it was the highest score available. Because we only allowed individuals who completed the pre-intervention survey to complete the post-intervention survey, we do not present the demographic data collected from respondents to the post-intervention survey.

Analysis and Presentation of Post-Intervention Vaccine-Acceptance Results

To measure the intervention’s impact on vaccine acceptance, we report the average score of the Likert responses for the three vaccine-acceptance-related questions in the post-intervention survey. Specifically, for the question assessing participants’ perspective on the importance of receiving the RZV following the education, we also report the number of individuals who selected “5,” as it was the highest-scoring available option. For the question that reassessed participants’ intent to receive the RZV after receiving education, we also report the number of individuals who responded with a “4” or “5,” indicating a “high likelihood” of receiving the vaccine, and those who responded with a “5,” indicating the highest likelihood (recorded as “extremely likely”). Similarly, for the question that assessed participants’ willingness to recommend the RZV to a family member or friend, we report the number of individuals who responded with a “4” or “5” and those who responded with a “5”, indicating the highest likelihood (recorded as “extremely likely”).

Statistical Analysis and Presentation of Vaccine Literacy Results

The two-proportion z-test was the primary analysis, testing whether the proportions differed between groups and providing a confidence interval for the difference in percentage points. Fisher’s exact test was conducted as a supplementary analysis to provide odds ratios with confidence intervals and to validate the results.

Descriptive statistics included the number of correct responses, the total number of respondents, and the proportion correct for the four true-or-false statements in the pre- and post-intervention surveys. The improvement was calculated as the absolute difference in proportions between post-intervention and pre-intervention groups. Statistical significance was evaluated at α = 0.05 for all analyses. All statistical analyses were performed using R statistical software (version 4.5.1) [35].

Additionally, we report the counts and percentages of correct responses to the four true-or-false knowledge-based statements included in the pre- and post-intervention surveys. We also present the percent improvement between the baseline and post-intervention responses, calculated using the two-proportion Z-test. We further provide the odds ratio for changes in correct responses from baseline to post-intervention.

Results

Demographics of Pre-Intervention and Post-Intervention Survey Study Participants

A total of 156 participants completed the pre-intervention survey, while 134 completed the post-intervention survey. Among those who completed the pre-survey, most identified as non-Hispanic Black or African American (89%), followed by smaller groups identifying as Hispanic/Latino(a) (6%) and Two or More Races (5%). The largest age group was those aged 65 or older (47%), followed by participants aged 55–64 (26%). Women accounted for 71% of participants, whereas men accounted for 29%. Nearly all participants (99%) were classified as having a high level of social vulnerability based on their ZIP codes, as indicated by the CDC SVI. Most participants reported having a comorbidity (63%), with hypertension being the most common condition (51%). Before the educational session, slightly more than half of the participants (54%) reported never having received information or a recommendation for the RZV. The demographics for the pre-intervention survey participants are shown in Table 1.

Table 1.

Demographics of pre-intervention survey participants

Variable	Pre-intervention survey participants (n = 156) (%)
Race/ethnicity
Non-Hispanic Black or African American	139 (89%)
Two or more races	8 (5%)
Hispanic/Latino(a)	9 (6%)
Age
18–24	4 (3%)
25–34	8 (5%)
35–44	8 (5%)
45–54	23 (15%)
55–64	40 (26%)
65 years or older	73 (47%)
Sex
Male	45 (29%)
Female	111 (71%)
Level of social vulnerability
High	155 (99%)
Medium–high	1 (0.9%)
Comorbid disease states
Hypertension	80 (51%)
Diabetes	22 (14%)
Immunosuppressive illness (cancer or autoimmune diseases)	12 (7.7%)
Asthma	21 (10%)
Chronic obstructive pulmonary disease (COPD)	13 (8%)
No comorbid disease state	57 (37%)
Received information or a recommendation for the shingles vaccine before the education session
Yes	72 (46%)
No	84 (54%)

Shown in Table 1 are the demographics (race/ethnicity, age, gender, and comorbid disease states) collected from individuals who completed the pre-intervention survey. All information was self-reported, and participants were allowed to select more than one comorbid illness. ZIP codes were also collected from individuals who completed the baseline survey. ZIP codes were input into the CDC SVI tool to determine the level of social vulnerability

Pre-Intervention Survey HZ and RZV-Related Attitudes and Behaviors

At baseline, many participants perceived themselves as unlikely to contract HZ, with 57% rating their likelihood as either “unlikely” or “very unlikely.” Only 39% considered infection “likely” or “very likely.” Similarly, most anticipated that if they developed HZ, symptoms would be mild (44%) or negligible (12%), while 40% believed their potential symptoms would be “significant or intense”.

Regarding perceived vaccine benefits, participants held favorable views of vaccine effectiveness. Approximately 67% of participants rated the RZV as “moderately” or “very effective” in preventing infection, 66% recognized its potential to reduce symptom severity, and 64% its potential to reduce the risk of complications. However, a substantial portion of participants expressed uncertainty about vaccine affordability, with 46% reporting they were “unsure” and only 37% perceiving the vaccine as “very affordable”. Likewise, 31% were “unsure” about the convenience of obtaining the vaccine, though 43% found the process “very convenient”. When asked about anticipated side effects, 55% of participants believed they were “unlikely” or “very unlikely” to experience adverse reactions.

Perceptions of community vaccine uptake were notably low. Most participants believed that “very few” (29%) or “only some” (37%) individuals aged 50 and older in their community received the RZV. Even fewer participants were aware that the RZV and influenza vaccine could be administered concurrently, with 40% believing that few people receive both vaccines on the same day. Before the education session, when asked about their likelihood of getting the RZV given a convenient and accessible location, 33% responded “likely,” 31% responded “very likely,” and 2% responded with “extremely likely”. In comparison, 33% indicated they were “unlikely” or “very unlikely” to seek vaccination. All counts and percentages for responses to questions about HZ- and RZV-related perspectives and behaviors, captured from the pre-intervention survey, are shown in Table 2.

Table 2.

Pre-intervention survey of herpes zoster (HZ) and the recombinant zoster vaccine (RZV) attitudes and behaviors

Area of focus	Variables	Number of respondents to each Likert ranking (%) (n = 156)
Perceived risk of shingles infection	How likely are you to get shingles?	Very unlikely	Unlikely	Likely	Very likely	No response
		23 (15%)	65 (42%)	47 (30%)	14 (9%)	7 (4%)
	How severe do you think your symptoms would be if you were to get shingles?	Negligible	Mild	Significant	Intense	No response
		18 (12%)	68 (44%)	36 (23%)	27 (17%)	7 (4%)
Perceived shingles vaccine benefits	How effective do you believe the shingles vaccine is (stem question):	Not effective	Somewhat effective	Moderately effective	Very effective	No response
	in preventing you from catching shingles?	9 (6%)	33 (21%)	35 (22%)	70 (45%)	9 (6%)
	in reducing the severity of symptoms if you get infected?	8 (5%)	33 (21%)	40 (26%)	63 (40%)	12 (8%)
	in reducing your risk of complications from shingles?	6 (4%)	35 (22%)	36 (23%)	64 (41%)	15 (10%)
Perceived barriers in receiving the shingles vaccine (including accessibility barriers)	How affordable do you find the shingles vaccine?	Not affordable	Somewhat affordable	Moderately affordable	Very affordable	Unsure	No response
		6 (4%)	6 (4%)	5 (3%)	58 (37%)	71 (46%)	10 (6%)
	How convenient do you find the process of getting the shingles vaccine?	Not convenient	Somewhat convenient	Moderately convenient	Very convenient	Unsure	No response
		6 (4%)	8 (5%)	17 (11%)	67 (43%)	48 (31%)	18 (12%)
	How likely do you think you are to experience side effects from the shingles vaccine?	Very unlikely	Unlikely	Likely	Very likely	No response
		31 (20%)	55 (35%)	40 (26%)	16 (10%)	14 (9%)
Perceived community and US shingles vaccine uptake	How many people in your community (age 50+) do you think get the shingles vaccine?	Very few	Some	Many	Nearly everyone	No response
		46 (29%)	57 (37%)	34 (22%)	6 (4%)	13 (8%)
	How many people in the US do you think get the shingles and flu vaccine on the same day?	62 (40%)	44 (26%)	31 (20%)	2 (1%)	17 (11%)
Likelihood of receiving the shingles vaccine (intent to be vaccinated; as a metric of vaccine acceptance)	How likely are you to get the shingles vaccine if there is a convenient and easily accessible location for vaccination?	Very unlikely	Unlikely	Likely	Very likely	Extremely likely	No response
		19 (13%)	29 (20%)	49 (33%)	45 (31%)	3 (2%)	11 (8%)

Shown in Table 2 are the responses (represented through counts and percentages) to the pre-intervention survey questions on the participants perceptions of the herpes zoster (HZ) virus and the recombinant zoster vaccine (RZV). “Shingles” was used instead of HZ and “shingles vaccine” was used instead of RZV to prioritize the use of plain language throughout the survey. N number of participants

Post-Intervention Survey HZ and RZV-Related Attitudes and Behaviors

The 134 post-intervention survey participants rated the educational presentation highly across all measurements. The presentation was rated most effective in raising awareness of the seriousness of HZ and its complications (average score: 4.85 out of 5) and in helping participants understand the benefits of the vaccine (average score: 4.82; 83% “extremely effective”). Participants also reported that the presentation was highly effective in increasing general knowledge about HZ (average score: 4.79), building trust in vaccine safety (average score: 4.69; 75% “extremely effective”), addressing misconceptions (average score: 4.67), and prompting a re-evaluation of personal risk (average score: 4.63). Trust in the information provided during the presentation was substantial (average: 4.86).

Following the intervention, 78% of participants rated receiving the HZ vaccine at age 50 or older as “extremely important.” Intent to recommend the vaccine to family or friends was strong, with 90% indicating a high likelihood (scores of 4 or 5) of recommending the RZV. Regarding personal vaccination intent, 82% of post-intervention participants indicated a high likelihood of receiving the shingles vaccine (scores of 4 or 5). The counts and percentages of all responses for the questions assessing the impact of the intervention on HZ and RZV-related attitudes and behaviors are shown in Table 3.

Table 3.

Post-intervention survey responses on the impact of the intervention on herpes zoster (HZ) and the recombinant zoster vaccine (RZV) attitudes and behaviors

Variable	Average score (1–5 scoring) (1 = “not effective”, 5 = “extremely effective”) (n = 134)	Number responding with “5” indicating an “extremely effective” response (%) (n = 134)
How effective was the presentation in increasing your general knowledge about shingles?	4.79	108 (81%)
How effective was the presentation in helping you trust the safety of the shingles vaccine?	4.69	101(75%)
How effective was the presentation in helping you understand the benefits of the shingles vaccine?	4.82	111 (83%)
How effective was the presentation in addressing any misconceptions or myths about the shingles vaccines that you may have had?	4.67	103 (77%)
How effective was the presentation in making you re-evaluate your own risk of getting shingles (at age 50 or older)?
	4.63	101 (75%)
How effective was the presentation in making you aware of the seriousness of shingles and its complications?	4.85	116 (87%)
How much do you trust the information provided in the presentation about the shingles vaccine?	Average score (1–5 scoring) (1 = “Not at all”, 5 = “A great deal”) (n = 134)	Number responding with “5” indicating “A great deal” response (%) (n = 134)
	4.86	114 (85%)
Vaccine acceptance-related questions
How important do you feel it is to get the shingles vaccine (at age 50 older)?	Average score (1–5 scoring) (1 = “Not important”, 5 = ” Extremely important”) (n = 134)	Number responding with “5” indicating an “Extremely important” response (n = 134)
	4.69	105 (78%)
How likely are you to recommend the shingles vaccine to a family member or friend?	Average score (1–5 scoring) (1 = “Extremely unlikely, 5 = “Extremely likely”) (n = 134)	Number responding with a “4” or “5” indicating “High likelihood” (n = 134)	Number responding with “5” indicating an “Extremely likely” response (n = 134)
	4.59	121 (90%)	94 (70%)
How likely are you to get the shingles vaccine after the presentation (at age 50 or older)? (intent to be vaccinated; as a metric of vaccine acceptance)	Average score (1–5 scoring) (1 = “Extremely unlikely, 5 = “Extremely likely”) (n = 134)	Number responding with a “4” or “5” indicating “High likelihood” (n = 134)	Number responding with “5” indicating an “Extremely likely” response (n = 134)
	4.37	110 (82%)	91 (68%)

Shown in Table 3 are the responses to the post-intervention survey questions (shown by counts and percentages) assessing the impact of the intervention on the attitudes of the participants. Scoring was done via selection of a score of 1–5 on a Likert scale, and the mean score for each selection is shown in the table. We also include the percentage of individuals responding with a “5”, the highest score awarded. For the question measuring the intent to be vaccinated and to recommend the vaccine to others we also include the counts and percentages of those who responded with a “4” or “5″ indicating a high likelihood. “Shingles” was used instead of herpes zoster and ‘shingles vaccine” was used instead of recombinant zoster vaccine to prioritize the use of plain language throughout the survey. N number of participants

Changes in Pre-Intervention and Post-Intervention Vaccine Literacy

Statistically significant improvements in vaccine literacy were observed across all four knowledge-based true-or-false statements, as measured by pre-intervention and post-intervention responses. The observed mean effect size across these four items (Cohen’s h = 0.73) exceeded the anticipated low-to-medium effect threshold (Cohen’s h = 0.41), yielding a medium-to-large effect size with an average statistical power of approximately 99%.

The proportion of participants correctly recognizing that the shingles vaccine boosts the body’s natural immune response increased from 58 to 89%, a 31percentage-point rise (p < 0.05; 95% CI 22% to 41%; OR = 6.08). Knowledge that the vaccine can reduce the severity and duration of symptoms improved from 67 to 86%, a 19 percentage-point increase (p < 0.05; 95% CI 10% to 29%; OR = 3.12). Awareness that the two-dose shingles vaccine series is recommended for all individuals aged 50 or older increased from 73 to 98%, a 24 percentage-point rise (p < 0.05; 95% CI 17% to 32%; OR = 15.97). The most significant increase in knowledge was observed regarding the concurrent administration of influenza and shingles vaccines, which rose from 50% correct responses at baseline to 89% after the intervention, a 39 percentage-point improvement (p < 0.05; 95% CI 30% to 49%; OR = 8.51). The counts and percentages, as well as the results of statistical tests comparing the proportion of correct responses to the four true-or-false knowledge-based questions before and after the intervention (as a metric of vaccine literacy), are shown in Table 4. A graphical representation of the percentages of individuals who answered the statements correctly in the pre-intervention survey, compared with those who answered correctly in the post-intervention survey, is shown in Fig. 1.

Table 4.

Correct responses to the knowledge-based true or false statements (pre-intervention survey vs. post-intervention survey, as a metric of vaccine literacy)

True-or-false statement	Correct responses in the pre-intervention survey (n = 156) (%)	Correct responses in post-intervention survey (n = 134) (%)	Proportion improvement between pre-intervention and post-intervention in the correct responses (p value; 95% confidence interval [CI]) (two-proportion Z-test)	Odds ratios for pre-intervention and post-intervention changes in the correct responses (p value; 95% confidence interval [CI]) (Fisher’s exact test)
The shingles vaccine boosts your body’s natural immune response	91 (58%)	120 (89%)	+ 31% *(p < 0.05) [CI 22%, 41%]	6.08 *(p < 0.05) [3%, 13%]
The shingles vaccine can lessen the severity and duration of symptoms and other effects of the virus	105 (67%)	116 (86%)	+ 19% (p < 0.05) [CI 10%, 29%]	3.12 *(p < 0.05) [2%, 6%]
The shingles vaccine two-dose series is recommended for all individuals 50 years or older	114 (73%)	131 (97%)	+ 24%* (p < 0.05) [CI 17%, 32%]	15.97 *(p < 0.05) [5%, 83%%]
The flu vaccine and shingles vaccines can be given on the same day	78 (50%)	120 (89%)	+ 39%* (p < 0.05) [CI 30%, 49%]	8.51 *(p < 0.05) [4%, 18%]

Shown in Table 4 is a comparison of the counts and percentages of correct responses to the four true or false knowledge-based statements included in the pre- and post-intervention surveys. We provide the percent improvement between the baseline and post-intervention survey responses derived from the two-proportion Z-test. We also provide the odds ratio of a change in the correct responses from the baseline and post-intervention response. Shingles” was used instead of herpes zoster, “shingles vaccine” was used instead of recombinant zoster vaccine, and “flu vaccine” was used instead of “influenza vaccine” to prioritize the use of plain language throughout the survey. N number of participants. *(p < 0.05) denotes a statistically significant difference

Fig. 1.

Comparison of the percentages of correct responses to the true or false herpes zoster (HZ) and recombinant zoster virus (RZV) knowledge-based statements included in the pre- and post-intervention surveys. “Shingles” was used instead of HZ, “shingles vaccine” was used instead of “RZV”, and “flu” was used instead of “influenza” to prioritize plain language throughout the survey. N number of participants. *Denotes a statistically significant difference (p < 0.05), and the values have been rounded to the nearest whole number

Discussion

With increasing reports of vaccine hesitancy, innovative strategies are necessary to boost vaccine uptake. Additionally, with new evidence highlighting the benefits of HZ vaccination in preventing neurological diseases such as Alzheimer’s and dementia, it is crucial to increase RZV acceptance among older adults [36]. Our study emphasizes the value of community-based educational programs in improving HZ vaccine literacy and acceptance among vulnerable REM populations, who are at higher risk for adverse disease outcomes.

Notably, our pre-intervention survey revealed intriguing insights into attitudes toward HZ infection and barriers to RZV uptake. More than half of the baseline study participants believed they were unlikely to contract HZ. Additionally, 56% of participants indicated that if they did get HZ, it would be minor or mild, despite 63% self-reporting at least one pre-existing condition. This is worrisome, as diabetes and cardiovascular disease were among the most commonly self-reported conditions, and are linked to worse HZ outcomes [37, 38]. These findings match those reported in other studies examining the attitudes of REM individuals toward preventable diseases [24, 39]. In a prior study, we also found that only 41% of REM participants believed they were at minimal risk of influenza or severe disease outcomes, despite contrary evidence [31]. Investigators have linked this to perceptions of “good health” and the belief that acute illnesses better reflect poor health [24, 40, 41]. Therefore, having a chronic disease may not be considered an obvious risk factor for infectious diseases such as HZ.

Furthermore, a low prevalence of chronic illness may lower the need for individuals to seek healthcare or receive related advice, potentially leading to lower awareness of HZ and less knowledge about age-related infection risks. For example, among the 57 individuals who did not report a comorbid condition, 65% (37/57) had never been informed about HZ or the RZV. However, we did not collect additional data to draw conclusions from this, which highlights an area for future research and intervention.

Despite the low perceived risk of HZ infection, most participants indicated that the vaccines would be “moderately to very effective” at preventing it. These results differ significantly from studies assessing marginalized individuals’ attitudes toward the effectiveness of vaccines for other vaccine-preventable illnesses [24, 42, 43]. Several studies with predominantly non-Hispanic Black participants report low confidence in influenza vaccine effectiveness, with one study noting that 19.8% of non-Hispanic Black individuals believed the vaccine could potentially cause the disease itself [44]. Our study suggests that these attitudes may not apply to vaccines for non-respiratory preventable diseases, such as HZ.

Additionally, unlike participants in studies assessing perceptions of vaccine adverse effects, the REM participants in this study expressed little concern about experiencing side effects from the RZV [39, 43, 44]. Fewer than 40% indicated they were likely to experience side effects from RZV. Many studies on attitudes toward vaccine side effects were conducted before the COVID-19 pandemic. Given the widespread vaccination experience since the pandemic, especially among older adults, perspectives on vaccine adverse effects may have shifted [31]. We also observed this post-pandemic change in a previous study, in which fewer than 50% of REM study participants reported being likely to experience side effects from the influenza vaccine [31].

Although concerns regarding potential adverse effects may not deter individuals from obtaining the RZV, data from the pre-intervention survey suggest that access barriers persist. Nearly 50% of respondents were uncertain about the affordability of the RZV, and 31% were unsure about the immunization procedure. This finding is important because the vaccine is covered under Medicare, which should facilitate straightforward access [19]. However, 54% of survey participants reported not having received prior information about HZ or RZV before the educational session, with this lack of information 12% higher (65%) among those without a pre-existing comorbid condition. Without adequate information about the virus or the vaccine, participants are unlikely to be aware of insurance coverage options, thereby perceiving cost as a potential obstacle to receiving the RZV [45, 46]. Costs are likely especially prohibitive for participants in this study, as 99% of them had a high SVI score, which is typically associated with economic deprivation.

The lack of a provider recommendation, indicated by the number of people who had not been previously informed about the virus or vaccine, also offers a possible explanation for responses regarding community and national acceptance of the RZV. Receiving a provider recommendation for immunization has consistently been associated with higher vaccine uptake [47]. Most participants believed that only a “very few” or “some” people in their communities had received the vaccine. Additionally, 40% of respondents thought that “very few” people in the United States received the RZV and the annual influenza vaccine on the same day. This highlights the need to educate on the benefits of co-administering RZV with the annual influenza vaccine, including reductions in immunization-related healthcare costs [18]. These findings, along with the reported lack of awareness about RZV costs and coverage, may also explain why less than 70% of participants indicated a likelihood of receiving the RZV in the baseline survey.

In addition to gathering insights into participants’ baseline attitudes, we observed positive changes in vaccine literacy, as measured by the number of correct responses to the four true-or-false statements in the pre-intervention and post-intervention assessments. We noted at least a 20% increase in the number of individuals selecting the correct responses to the post-intervention survey questions compared to the pre-intervention survey. Most notably, for questions on evidence-based recommendations for the RZV, we observed an average 32% increase in correct responses between the pre- and post-intervention survey responses. These changes are worthwhile, as increased knowledge of vaccine recommendations has been shown to enhance overall health literacy and vaccine confidence [48, 49].

Interestingly, researchers have found that vaccine literacy strongly predicts an individual’s willingness to get vaccinated [48, 50]. Our results support these findings, as nearly 80% of post-intervention survey respondents considered it “extremely important” to receive the vaccine after the educational session. Most notably, 68% of the respondents stated that they were “extremely likely” to receive the RZV. This is 66% higher than the respondents who answered “extremely likely” to the “intent to be vaccinated” question in the baseline survey. Another study also indicated that providing information about HZ, raising awareness of the illness’s burden, and emphasizing the availability of the RZV can increase the willingness of unvaccinated REM individuals to get vaccinated [45]. Since 75% of participants who completed the post-intervention survey said the presentation was “extremely effective” in helping them understand their risk of HZ infection, and 77% found it “extremely effective” in correcting misconceptions or myths about the RZV, targeted education on these topics achieved the desired impact.

Furthermore, 70% of respondents also reported that they were “extremely likely” to recommend the RZV to a family member or acquaintance after the educational session. This is meaningful because several studies have found that familial and community networks are key mediators of the adoption of health behaviors among aging populations [46, 51]. Therefore, providing these individuals with factual, credible information about HZ and the RZV can help ensure the intervention has widespread effects.

Our study has several notable strengths. It builds on existing research by emphasizing the vital role that religious leaders play in the lives of REM individuals and demonstrates how collaborating with them can enhance community access and the implementation of health programs [52]. Additionally, it supports emerging research on the pandemic, showing that community-academic partnerships can help restore trust in the US healthcare system and in immunizations among socially vulnerable marginalized groups (53–55). Eighty-five percent of post-intervention survey respondents reported having a “great deal” of trust in the information provided, underscoring this point. This study is also among the first to offer post-pandemic perspectives on the HZ infection and the RZV from marginalized populations.

Notwithstanding the study’s strengths, several limitations must be acknowledged. Firstly, most participants identified as non-Hispanic Black and female; thus, the findings may not be generalizable to other demographic groups. Furthermore, most individuals resided in highly vulnerable areas of SBC; perceptions of HZ infection and the RZV among those in less vulnerable neighborhoods might differ. While we gathered insights into participants’ perceptions of vaccine accessibility, we did not explicitly assess other systemic barriers, such as the distance to vaccine sites and other associated transportation limitations, which may also influence attitudes toward RZV accessibility. Additionally, due to the study’s anonymity and the absence of unique identifiers for survey participants, it was not possible to link the pre- and post-intervention survey results to conduct parametric analyses to assess changes in literacy and acceptance. Moreover, different scales were used to measure participants’ intent to be vaccinated in the pre- and post-intervention surveys, preventing analysis of significant changes from baseline to follow-up after the educational intervention.

Furthermore, the study was confined to evaluating only the immediate effects following the intervention; owing to anonymity restrictions, it was not feasible to measure long-term knowledge retention. Additionally, it was not possible to determine whether the individuals received the RZV after the educational session. Due to the absence of a control group, any receipt of the vaccine could not be definitively attributed to their participation in the intervention.

Also, using Likert scales may have introduced bias, as respondents might have agreed with statements they did not fully understand. The use of the Likert scale, especially in the post-intervention survey, could also have contributed to social desirability bias. Moreover, offering a $20 USD gift card as an incentive may have affected participation and responses, leading to selection and response biases. Lastly, an option to indicate whether participants had received the RZV before the educational session was not provided; as a result, participants might have selected a “likely” or “unlikely” response instead of a more suitable one.

Conclusions

Disparities in HZ infections and related complications have been documented, with individuals identifying as REM or those who are socially vulnerable facing a higher risk of adverse HZ outcomes and lower RZV uptake. Insights from our study indicate that low RZV uptake across these populations may be due to limited awareness of HZ, perceptions of minimal disease risk, and limited awareness of vaccine coverage across various insurance providers. Nonetheless, providing trustworthy education can increase vaccine literacy and acceptance. These changes in literacy and acceptance have the potential to translate to increased RZV uptake within vulnerable communities. Further research is needed in this area for the continued development and implementation of effective programs to overcome barriers to vaccination.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contributions

Jacinda Abdul-Mutakabbir contributed to conceptualization, drafting the original manuscript, and revisions to the original version. Raheem Abdul-Mutakabbir contributed to conceptualization, drafted the original manuscript, and made revisions. Samuel Casey contributed to the conceptualization and review of the original manuscript.

Funding

The incentives provided to participants of the activity and to churches for participant recruitment were funded by an educational grant from CSL Seqirus. No funding was received for the publication of this article.

Data Availability

All data generated or analyzed during this study are included in this published article/as supplementary information files.

Declarations

Conflicts of Interest

Jacinda C. Abdul-Mutakabbir is an Advisory Board member of Infectious Diseases and Therapy. Jacinda C. Abdul-Mutakabbir was not involved in the selection of peer reviewers for the manuscript nor any of the subsequent editorial decisions. Jacinda C. Abdul-Mutakabbir received an honorarium from Shionogi, GSK, and Pfizer. All other authors (Raheem Abdul-Mutakabbir and Samuel J. Casey) have no conflicts to report.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration. The University of California, San Diego Institutional Review Board approved this study (#807857) and the waiver of informed consent, given the minimal risk and an anonymous collection of the data. Since the data were collected anonymously, the study was exempt from full board review.