Herpes zoster, commonly known as shingles, remains a largely underestimated viral threat among urban residents in China, according to a qualitative study published in Global Health Research and Policy. Researchers found that only 16 of 59 adults who participated in focus-group discussions expressed a clear intention to receive herpes zoster vaccination. The findings suggest that limited knowledge, misconceptions about the disease, concerns about vaccine safety and effectiveness, and the high out-of-pocket price of vaccination are suppressing demand for protection against a painful infection that becomes increasingly common with age.
Herpes zoster is caused by reactivation of varicella-zoster virus, the same virus responsible for chickenpox. After the initial infection, the virus is not eliminated from the body. Instead, it remains dormant inside sensory nerve cells, particularly in structures known as dorsal root and cranial nerve ganglia. Years or decades later, weakening immune surveillance can allow the virus to reactivate and travel along a nerve to the skin, producing the characteristic one-sided band of fluid-filled blisters. Aging is one of the most important risk factors because the immune response that keeps latent virus under control gradually declines. People with immunosuppressive conditions or treatments may also face elevated risk.
Although the rash often resolves, the infection can cause intense neuropathic pain and long-term complications. The most common is postherpetic neuralgia, in which pain persists for months or longer after the skin lesions disappear. Some patients experience neurological complications, including paralysis, encephalitis or meningitis. The global incidence of herpes zoster is estimated at approximately three to five cases per 1,000 person-years, and people who live to age 85 may face an approximately 50 percent lifetime risk in the absence of vaccination. In China, researchers have estimated that at least 2.77 million cases occur annually, creating a growing health burden as the country’s population ages.
The Chinese study was designed to explore not simply whether people would accept vaccination, but why they would accept or reject it. Between 15 and 30 October 2022, investigators conducted 12 focus-group discussions in Beijing, Weifang and Nanning. The cities were selected to represent different economic and geographical settings: Beijing as a highly developed northern metropolis, Weifang as a medium-developed city in eastern China, and Nanning in the less-developed southwestern Guangxi region. Participants were recruited purposively through community health centres and included adults between 20 and 80 years of age. The researchers deliberately included younger adults because they may influence health decisions for older parents, even though current vaccination recommendations primarily target older people.
The discussions revealed a strikingly low level of preparedness to make an informed vaccination decision. Of the 59 participants, 28 said they did not want the vaccine, 15 gave no clear answer and only 16—27.1 percent—expressed willingness to be vaccinated. Many participants had never heard of shingles or possessed only fragmentary information acquired through friends, colleagues, media reports or personal experience. Some did not know that chickenpox and shingles are caused by the same virus. Others were uncertain whether shingles is hereditary, whether previous chickenpox infection increased later risk, or whether the disease affected only people in their eighties. Without an accurate understanding of viral persistence, immune decline and age-related susceptibility, participants often concluded that their personal risk was negligible.
Personal experience strongly shaped perceptions. Several participants who had previously suffered shingles described mild itching or a rash that resolved after inexpensive treatment. Because they recovered, they regarded the illness as curable and relatively harmless. Among participants with a history of infection, six reported mild symptoms and six described severe, prolonged pain. The contrast was pronounced: most people who had experienced severe pain expressed support for vaccination, while five of the six people who described mild illness were unwilling to receive it. Participants who had seen relatives or friends endure debilitating pain were also more likely to perceive vaccination as worthwhile. These accounts demonstrate how the clinical variability of shingles can distort risk perception. A mild episode can encourage complacency, while postherpetic neuralgia can make prevention appear urgent.
Another common misconception was that healthy living could substitute for vaccination. Some participants believed that a balanced diet, exercise, adequate sleep and reduced psychological stress would provide sufficient protection by strengthening the immune system. While these habits support general health, they cannot remove latent varicella-zoster virus from nerve tissue or guarantee that age-related decline in virus-specific immunity will not occur. Other participants viewed shingles as too uncommon to justify preventive intervention, partly because they had not personally encountered many cases. Several compared shingles with cancer or influenza, concluding that the disease was less serious because it was not usually fatal, was not perceived as highly contagious and could often be treated with antiviral medicines and pain relief.
Cost was the most frequently cited practical obstacle. In China, the recombinant vaccine available during the study period was Shingrix, a non-live vaccine containing a varicella-zoster virus glycoprotein antigen combined with an immune-stimulating adjuvant. Unlike a live attenuated vaccine, it does not contain replicating virus. Clinical trials have shown protection of more than 90 percent against shingles and substantial protection against postherpetic neuralgia, including among older adults. However, the vaccine requires a two-dose schedule and was entirely self-funded because it was not included in China’s National Immunization Program. Participants reported a total cost of approximately RMB3,200 for the course, with another section of the article citing RMB3,600, equivalent to roughly US$446 at the conversion used by the authors. This price was dramatically higher than what many participants said they could pay, with stated acceptable amounts generally ranging from about US$14 to US$70.
The price also influenced how participants judged the vaccine’s effectiveness. Some expected a costly vaccine to provide nearly complete or lifelong protection and became doubtful when told that protection might decline over time or that vaccination could not prevent every case. Concerns about adverse effects further reduced acceptance. Participants worried that chronic conditions such as hypertension, diabetes or coronary heart disease might make vaccination unsafe. Others feared injection pain, questioned the safety of an imported product, or wondered whether vaccination close to another immunization could create complications. The researchers noted that even some health workers appeared to have incomplete or incorrect information, including the mistaken belief that people who had already experienced shingles would not benefit from vaccination.
Access and convenience added another layer of resistance. Many participants did not know which facilities administered adult shingles vaccination. Some confused disease-control institutions with vaccination providers, while others encountered hospitals without available doses. Appointment systems and waiting times were viewed as inconvenient, particularly compared with the highly organized COVID-19 vaccination campaign. The study suggests that a vaccine can be scientifically effective yet remain underused when people cannot easily locate it, schedule an appointment or obtain clear advice about eligibility, timing and safety.
The strongest facilitators were perceived vulnerability and fear of pain. Older participants recognized that declining immunity could make infection more likely, while people with repeated episodes of shingles saw themselves as especially susceptible. Personal or family stories of severe nerve pain made the potential benefits of vaccination more tangible than general statistical information. Professional recommendation was another powerful influence. Some participants said they would follow advice from doctors, community health workers or government health authorities even when they lacked detailed knowledge of the disease. The researchers argue that China’s existing vaccination infrastructure could support a broader shingles campaign, provided health professionals receive accurate training and actively discuss the vaccine with eligible adults.
The authors recommend combining targeted education with financial and administrative support. Public-health messages should explain that varicella-zoster virus remains latent after chickenpox, that shingles risk rises with age and immune suppression, and that treatment does not reliably prevent prolonged nerve pain. Communication should also describe the vaccine’s real-world benefits, expected side effects, dosing schedule and eligibility in clear language, avoiding exaggerated promises of complete protection. Subsidies from government or health-insurance providers could address the largest structural barrier, while community-based appointment systems and reliable information on vaccination locations could reduce the time and effort required to obtain the vaccine.
The findings should be interpreted cautiously. The study involved only 59 urban residents from three Chinese cities and used focus groups rather than a population-wide survey. Group discussions may influence individual opinions, and participants recruited through community health centres may have had greater exposure to health information than the wider population. Younger and older participants were also placed in the same groups, which could have shaped responses. Nevertheless, the study offers a detailed view of how viral biology, personal experience, trust, affordability and healthcare access intersect in vaccine decision-making. As China’s older population expands, the researchers conclude that improving shingles vaccination will require more than making the vaccine available: residents must understand the virus, believe the risk is relevant to them and be able to afford and obtain protection.
Subject of Research: Barriers and facilitators influencing herpes zoster vaccination intentions among urban adults in China
Article Title: The barriers and facilitators of herpes zoster vaccination intentions of urban residents in China: a qualitative study
Article References: Yuan B, Long C, Wang M, et al. The barriers and facilitators of herpes zoster vaccination intentions of urban residents in China: a qualitative study. Global Health Research and Policy. 2025;10:19.
Image Credits: AI Generated
DOI: 10.1186/s41256-025-00413-1
Keywords: Herpes zoster; shingles; varicella-zoster virus; herpes zoster vaccine; vaccine hesitancy; vaccination intention; health belief model; China; older adults; public health policy
