Attitudes, barriers, and facilitators to adherent completion of the recombinant zoster vaccine regimen in Canada: Qualitative interviews with healthcare providers and patients

Figures & data

Table 1. Healthcare provider participant characteristics.

	n (N = 12)
Type of Provider
Pharmacist	6
Physician	4
Nurse practitioner	2
Experience with RZV
Have administered the vaccine	12
Have prescribed the vaccine	7
Workplace
Pharmacy	5
Physician’s office	5
Hospital	1
Other	1
Geographic Region
Atlantic Region	2
Central – Quebec	3
Central – Ontario	1
Northern Territories	1
Prairie Provinces (Saskatchewan/Alberta/Manitoba)	3
West Coast	2
Language
English	9
Canadian French	3

RZV: recombinant zoster vaccine.

Table 2. Patient participant characteristics.

	n (N = 21)
Age (years)
50–64	15
≥65	6
Sex
Female	14
Male	7
RZV Doses Received and Timing
2 doses, during recommended timeframe	11
2 doses, outside of recommended timeframe	3
1 dose only	7
Setting where RZV was Administered
Pharmacy	6
Physician’s office	10
Hospital	0
Other (clinic/travel clinic)	5
Geographic Region
Atlantic	3
Central – Quebec	7
Central – Ontario	5
Northern Territories	0
Prairie Provinces (Saskatchewan/Alberta/Manitoba)	3
West Coast	3
Highest Level of Education
No certificate, diploma, or degree	1
Secondary (high) school diploma or equivalency certificate	2
Apprenticeship or trades certificate or diploma	2
College, CEGEP or other non-university certificate or diploma	4
University certificate or diploma below bachelor level	7
University certificate, diploma, or degree at bachelor level or above	5
Health Coverage Status
Private health insurance through employer	20
Provincial or Territorial Public Health program	0
NIHB program	0
No coverage	1
Other	0

CEGEP: collège d’enseignement général et professionnel; NIHB: non-insured health benefits; RZV: recombinant zoster vaccine.

Figure 1. Self-described patient (N = 21) pathways to obtaining RZV.

Patient pathways for obtaining RZV can vary based on private or public access to the vaccine and multiple pathways may exist in a single province. HCP: healthcare provider; RZV: recombinant zoster vaccine. Created using Microsoft PowerPoint.

Figure 2. Barriers and facilitators to RZV adherence identified from HCP and patient interviews.

Non-adherent participants described the actual barriers that prevented them from completing or adhering with the recommended RZV regimen, while adherent patients described potential barriers that could have, but ultimately did not, prevent them from adhering to the RZV regimen (underlined). A: adherent; HCP: healthcare provider; HZ: herpes zoster; N: number; NA: non-adherent; RZV: recombinant zoster vaccine. Created using Microsoft PowerPoint.

Table 3. Selected quotes from HCP interviews illustrating various identified barriers and facilitators to RZV completion and adherence.

Theme	Illustrative quote(s)
Barriers
High out-of-pocket costs and/or lack of insurance coverage	“Because my demographic population [seniors] is very, very used to getting things for free … so, like, their, I guess, medical therapy, yes. [So] whenever there is a cost associated with something – and this is, I’ve spent a lot of time saying this to third party payers that don’t pay for vaccines – you’re actually doing a huge disservice. Because not only, uh, is the patient hesitant about paying, they think because the third party – or the government – isn’t paying, that it [the vaccine] doesn’t work, or … it’s not good, right? Otherwise, it would be paid for, right? So, overcoming that stigma as well is not, not always easy.” – Pharmacist
Inconvenient processes in accessing and stocking RZV	“If [my patients] live too far from my clinic, we can have it done [administered] through the pharmacy. So, that’s a bit easier for some too … [but] if we had it in our clinic and we were able to sell it and stock it, and there’s an incentive to family doctors to give it, then I could see more patients , out of convenience, would be [like], ‘Ooh, how much? Yeah, sure, I’ll get it while I’m here.’ – Physician
Patient forgetfulness and/or lack of second dose reminders	“My last location was ridiculously busy, and we didn’t do things like follow ups. We didn’t put it on our computer system. We kind of just left that to the patients to call us and say, ‘Hey I need this, I need my second dose.’ And people forgot about them. It wasn’t, you know, and it would be, you know, a year later and you’re looking like ‘Oh my God, you never got your second dose, right?’ – Pharmacist
Scheduling factors, e.g., travel, snowbirds^a	“The only thing, sometimes if we do the vaccines in October, people that get the vaccine the same time as the flu season. Last year there was not this problem, but years before, there [are] the snowbirds. The seniors always go South [for the winter]. And they need to be back in time for their second shot. Definitely, I cannot schedule for the two months because they are still away. And then it’s close to the six months. So, they really need to come when we call.” – Pharmacist
Missed or delayed second doses due to COVID-19	“So, what happened there was, now pharmacists that were really doing a lot more clinical stuff almost reverted back ten years to just really focusing on just getting patients their medication. So, when that happens, there’s lost opportunities as well. Because you’re not having the medication reviews, all these other things, where, you know, uh, the vaccine may have come up.” – Pharmacist “We are doing a lot of deliveries of medications. So, we don’t talk to the patient as much to recommend and counsel on immunizations.” – Pharmacist
Facilitators
Flexibility provided by the recommended 2-to-6-month timeframe for the second dose	“So, two months is a great place to start because it gives us four months to really, um, get it within the, the dosing schedule. And if, even if they, like if they went away — which they’re not going away these, you know, the last year or so [during the COVID-19 pandemic] — but if they were going away … it still gives us time to get in touch with them. And if it’s past that time, we still do the second dose.” – Pharmacist
COVID-19 vaccines normalizing the idea of multi-dose series vaccines	“I think it’s probably actually going to increase the compliance because I, everybody, is, is all on board now recently. ‘Okay. I want to get everything I can to make sure that I’m going to be safe and that I can travel and that I can do things and I’m not going to have any problems.’ I mean, I, I work at noon today and we actually have two Shingrix bookings for this afternoon, um … Friday I think we have another, a booster [second] dose for Shingrix. So, again, I think people are just wanting to get everything they can to make sure that they’re safe and healthy.” – Pharmacist

^aSnowbirds refer to people who travel to warmer locales for the winter. HCP: healthcare provider; RZV: recombinant zoster vaccine.

Table 4. Selected quotes from patient interviews illustrating various identified barriers and facilitators to RZV completion and adherence.

Theme	Illustrative quote(s)
Barriers^a
Lack of HCP-provided education or encouragement	“So, I figured I was okay with one [dose]. I never really questioned it. I know that the other, like my husband I think he had two, but I had one, and, uh, I guess [my physician] thought that was enough because of me having chickenpox when I was younger. I don’t know. But she didn’t push it.” – Non-adherent patient, one dose only
Receiving unreliable or confusing information about RZV	“I think that sometimes ‘they’ [drug manufacturers] overdo it. Meaning one dose is as good as two doses. Um, so, yeah. That is what caused a little bit of negligence on my side and I was like, I said, you know, among all those, um, reasons, also I was, I’m thinking down like ‘maybe one dose is good enough for me to, to cover me to some extent’ … meaning one dose is enough. In all honestly, one dose could be enough.” – Non-adherent patient, one dose only
High out-of-pocket costs and/or lack of insurance coverage	“Well, that kind of leads into why I didn’t get the second dose. And that was because my insurance company stopped covering vaccines. And so, I couldn’t afford to get the second dose … it [the cost] was high. And, for instance, my mom wanted to get it. She’s a senior and on fixed income. And she wanted to get it, but because it wasn’t covered, she didn’t get it.” – Non-adherent patient, one dose only “Well, like I said earlier, like, I would have done it anyways. But, but, you know, I’m coming from a point – a place of privilege. I can afford to pay for it. So, for me personally, it [the cost] didn’t make a difference, but I absolutely believe it makes a difference for others. Um, and, you know, having access to an extended health plan that will cover vaccines.” – Adherent patient
Unpleasant or severe side effects	“The side effects were really bad. I was supposed to go to a funeral service, and I couldn’t go. I felt horrible. I had a fever, I was aching all over, I was dizzy. I felt horrible. I couldn’t get off the sofa I felt so awful … I think I was also kind of wary after my reaction to it. That didn’t sort of, it was kind of like, ‘Oh, I’m going to spend over $200 to get really sick?’ Like, I was not looking forward to another reaction like that.” – Non-adherent patient, one dose only
Patient forgetfulness	“Given the time frame [between the first and second shots], it is something you are able to forget. Thankfully, they called me back, as it is true that it is something that I might have missed. Even if I did not want to miss my second dose, I could have missed it if they did not call. The fact that they called me made a difference. I’m not sure I would have remembered…” – Non-adherent patient, two doses outside recommended timeframe
Inconvenient processes in obtaining and accessing RZV	“I think the only thing that would’ve made the whole process easier would be, as I said previously, [if] the family doctor had it on site and I didn’t have to go take that trip to the pharmacy first. But as I said, I’m not sure if that can be changed. So that would be about the only thing that I would’ve changed, and it certainly would’ve been easier.” – Adherent patient
Facilitators
Self-motivation and/or viewing the investment for RZV as an investment in themselves/their health	“The pharmacist gave me the dose, gave me the injection. But the physician … never even asked afterward if I followed through. So, it was me making sure I showed up for the second dose injection.” – Adherent patient “Because if you think about it, you’ve had the first shot. You’ve already invested the, you know, 130 bucks or whatever it was … Then it’s a waste of your investment if you don’t follow through.” – Adherent patient
Desire to gain full protection against HZ	“So, you know, like I said, when it comes to preventative measures, I’m all over it. Like, I’m not going to – I don’t want to be that person who can’t live a normal life, per se. I want to be able to – you know, I’m at that age where you start to think about your mortality. And I still have a lot of stuff I want to do. So, I’m not going to spend it being miserable and sick if I can help it.” – Adherent patient
Knowledge of the high effectiveness rate of RZV	“I was more concerned … truly my concern was, you know, ‘how well does this work?’ Because I had discounted the previous one [Zostavax] saying ‘this isn’t worth it,’ you know? It, it doesn’t work well enough that I’m going to jump on the wagon. So, the fact that this had a higher percentage of success is ultimately – yeah, I would say that’s what pushed me toward it.” – Adherent patient
Convenient processes in obtaining RZV	“I made an appointment. And she [the nurse] went through the consent form, and I got the immunization. I waited in the office, I think, for 15 minutes, and made the second appointment at that time. And it was fine. It was easy … There was no difficulty whatsoever.” – Adherent patient
Second dose reminders	“It’s just like for anything … When you go and get the first dose, it [the reminder system] initiates a countdown, and I presume that the best way to ensure that the second dose is given is for the clinic to inform us of the time period during which we have to receive it. Then, we choose a date that fits during that period, we write it down on the piece of paper. ‘Do you want us to call you back?’… However, maybe they [the pharmacy] will feel obliged to confirm, maybe they will confirm, as maybe they will have to close down for some reason or other, or they have stock problems … there is a question of synchronization that can be done, as there are always potential unplanned events.” – Adherent patient

^aNon-adherent participants described the actual barriers that prevented them from completing or adhering with the recommended RZV regimen, while adherent patients described potential barriers that could have, but ultimately did not, prevent them from adhering to the RZV regimen. HCP: healthcare provider; HZ: herpes zoster; RZV: recombinant zoster vaccine.

Data availability statement

The datasets generated and/or analyzed during the current study are not publicly available due to maintaining participant confidentiality in qualitative interview recordings. Interview guides used are available upon request from the corresponding author.