Assessment of knowledge, attitudes, and practices of herpes zoster vaccination among the general population in Jizan, Saudi Arabia

 Corresponding author: Mansour Mishal ANaim Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution Liscense 4.0. Assessment of knowledge, attitudes, and practices of herpes zoster vaccination among the general population in Jizan, Saudi Arabia Mansour Mishal ANaim * Department of Family Medicine, National Guard Hospital, Hofuf, AlAhsa Province, Saudi Arabia. World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 202-206 Publication history: Received on 04 September 2025; revised on 12 October 2025; accepted on 14 October 2025 Article DOI: https://doi.org/10.30574/wjbphs.2025.24.1.0900 Abstract Herpes zoster, or shingles, arises from the reactivation of the varicella-zoster virus, particularly prevalent among the elderly and immunosuppressed. Despite the global trend of increasing HZ incidence, its prevalence in Saudi Arabia is not well established. This study aims to assess the knowledge, attitudes, and practices regarding HZ vaccination among individuals aged 50 and over in Jizan, Saudi Arabia, addressing a significant gap in current research. This cross-sectional study was conducted in Jizan, Saudi Arabia. The target population consisted of Saudi nationals aged 50 years and older. Data were collected using an adapted questionnaire distributed via Google Forms. The responses were analyzed using SPSS version 21. Out of 690 participants, the majority had poor knowledge about HZ and its vaccine. Only 53% had heard about the shingles vaccine, and 87% demonstrated overall poor knowledge. Most participants (83.5%) were not vaccinated against shingles, with reasons including disbelief in vaccines, perceived healthiness, and lack of awareness. Interest in learning more about the disease and willingness to vaccinate upon doctor's recommendation were also noted. The study highlights a significant gap in knowledge and low vaccine uptake among the target population in Jizan. It underscores the need for educational initiatives and awareness programs to improve understanding and acceptance of the HZ vaccine. These findings can inform healthcare providers and policymakers in developing strategies to enhance vaccination coverage and ultimately improve public health outcomes in the region. Keywords: Herpes Zoster; Vaccine; Knowledge; Attitude; Practice; Saudi Arabia 1. Introduction Herpes zoster (HZ), or shingles, arises from the reactivation of the varicella-zoster virus (VZV), particularly prevalent among the elderly and immunosuppressed. Despite the global trend of increasing HZ incidence, its prevalence in Saudi Arabia is not well established. Vaccination remains a key public health strategy, yet vaccine uptake varies widely, influenced by sociodemographic, cultural, and religious factors. This study aims to assess the knowledge, attitudes, and practices regarding HZ vaccination among individuals aged 50 and over in Jizan, Saudi Arabia, addressing a significant gap in current research. Herpes zoster (HZ), commonly referred to as shingles, results from the reactivation of the varicella-zoster virus (VZV). This is the identical pathogen responsible for varicella, also known as chickenpox. Initially, VZV infection leads to varicella. Subsequently, post-varicella, VZV enters a dormant state within the dorsal root ganglia. As individuals age or experience immunosuppression, their cell-mediated immunity to the VZV diminishes, leading to the reactivation of VZV and the onset of zoster, or shingles, which can manifest anywhere on the body. Zoster can give rise to a range of complications including chronic pain known as postherpetic neuralgia, cranial nerve palsies, zoster paresis, and various neurological conditions such as meningoencephalitis, cerebellitis, and myelopathy. It may also result in multiple ocular disorders and vasculopathy, which can present with symptoms similar to those of giant cell arteritis. Importantly, these World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 202-206 203 neurological and ocular complications can develop even in the absence of a rash (1). Its prevalence and severity underscore the importance of effective vaccination strategies. Vaccination against HZ has emerged as a crucial public health intervention. In the Kingdom of Saudi Arabia, the prophylactic HZ vaccine which has been licensed is the recombinant subunit glycoprotein E vaccine which is called SHINGRIX. The vaccine for HZ is recognized as both safe and effective in preventing shingles and its associated complications. It is advised for individuals aged 50 years and older, with a two-dose regimen recommended to achieve maximum protection. (2). In Saudi Arabia, this vaccine is provided at no cost to individuals who are 50 years of age or older. Current vaccines have demonstrated efficacy in reducing the incidence and severity of HZ and its complications, including postherpetic neuralgia (3). Acceptance of vaccines may also be influenced by cultural and religious views. A recent study in Saudi Arabia that aimed to assess the vaccination rates against HZ showed that only 4.5% of people have gotten the HZ vaccine (4). This low percentage of vaccinations and the decreased awareness of the Saudi Arabian population regarding the HZ virus and its vaccinations signify the need to educate the general population and increase their awareness. Thus, to evaluate the general public's knowledge, attitude, and practice about HZ immunization in Jiazn, Saudi Arabia, we carried out this cross-sectional survey. While the importance of vaccination is well recognized globally, limited research has been conducted on the public's KAP towards HZ vaccination in Saudi Arabia, particularly in regions like Al-Ahsa. This study aims to fill this gap by providing insights into the local population's understanding and acceptance of the HZ vaccine. The findings are expected to inform healthcare providers, policymakers, and public health practitioners, facilitating the development of strategies to increase vaccination coverage and ultimately improve public health outcomes in the region. 2. Material and Methods This research is a cross-sectional study conducted in Jiazn City, Saudi Arabia. The study period extended from September 2024 to March 2025. It aimed to assess the knowledge, attitudes, and practices regarding HZ vaccination among individuals aged 50 years and older in this region. Jizan, a city in Saudi Arabia, served as the setting for this study. This area was chosen due to its unique demographic composition and healthcare landscape, which provided a relevant context for examining the research objectives. This study targeted a specific demographic: individuals aged 50 years and older residing in Jizan, Saudi Arabia. The inclusion criteria were restricted to Saudi Arabian nationals who were 50 years of age or older and residents of Jizan. In contrast, the exclusion criteria encompassed non-Saudi citizens and individuals under the age of 50 years, to maintain a focus on the local aging population's knowledge and attitudes towards HZ vaccination. Despite concerted efforts to achieve the calculated sample size, the actual response rate culminated in 690 eligible participants. While this figure falls slightly short of the initial target, it nonetheless constitutes a significant sample size. This volume of data is deemed adequate for robust analysis and interpretation, providing valuable insights into the study's objectives. This cross-sectional study was conducted using an online survey in Jizan between September 2024 to March 2025. Participants were invited to complete the questionnaire through a survey link sent to social media platforms. 3. Results and Discussion The study was completed by 690 eligible participants, with ages ranging from 50 to over 65 years, and an average age of 57.2 ± 11.1 years. Of these, 441 (64 %) were female, and 249 were male (34 %). A significant majority, 334 (96.8%), were non-Saudi. Educational backgrounds varied: 99 (28.7%) had completed secondary education, 56 (16.2%) were university students, 69 (20%) held university degrees, and 36 (10.4%) had post-graduate qualifications. In terms of chronic health conditions, 113 (32.8%) had hypertension, 127 (36.9%) had diabetes, and 111 (32.3%) reported various other chronic diseases. HZ was prevalent in 111 (32.2%) participants. Regarding awareness of HZ, 365 participants (67.2%) had heard of the disease. Among risk factors, 132 (19.7%) identified age as a factor, 193 (28.7%) knew that a history of chickenpox increases HZ risk, and 83 (24.1%) mistakenly believed they couldn’t contract the disease from an infected person. Seventy-seven (22.3%) were aware that HZ is treatable. Awareness of HZ as a treatable disease was low, with only 22.3% acknowledging this fact. While most participants correctly identified the elderly (67%) and immunocompromised (38.3%) as susceptible groups. Knowledge about HZ complications varied, with skin rash (71.3%) and fever (49.9%) being the most recognized, but less awareness about other serious complications such as neuropathy and blindness. Overall, 301 participants (87%) demonstrated poor knowledge about HZ and its vaccine, while only 44 (13%) had a good level of knowledge. The most common sources of information were other individuals (40.1%), the Internet (35.7%), physicians (32.2%), patients (24.2%), and personal experience with the disease (9.3%). A majority of participants (83.5%) had not been vaccinated against shingles. This study in Jizan, Saudi Arabia, aimed to assess the understanding, attitudes, and behaviors regarding HZ and its vaccine among individuals aged 50 and above. Our findings reveal considerable gaps in knowledge and low vaccine uptake, a trend consistent with global observations World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 202-206 204 but accentuating specific regional challenges. Awareness of HZ in our cohort was moderate at 67.2%, but misconceptions about transmission and prevention were common. Knowledge about the shingles vaccine was limited, with only 53% awareness and an overall poor knowledge level in 87% of participants. These results align with other Saudi studies, which also report limited awareness about HZ and its vaccine, though regional variances exist. For instance, a study conducted in Saudi Arabia with citizens aged 50 and older reported mean knowledge scores of 28.6% for HZ and 37.1% for the vaccine. This indicates a general lack of awareness, which is consistent with our findings. Despite a claimed awareness rate of 51.6% regarding the HZ vaccine, only 31.6% demonstrated comprehensive understanding. This study also highlighted the influence of factors like gender, previous chickenpox infection, and educational attainment on knowledge levels and vaccine acceptance (5). Another study in Saudi Arabia showed higher awareness of the shingles vaccine at 57.2%. However, this contrasts with our findings, where a majority exhibited poor knowledge. This suggests that while national awareness may be moderately high, specific regions like Al-Ahsa lag behind in public knowledge and vaccine awareness. The vaccination rates in this study were also low, at just 7.7%, mirroring the trends observed in our study (6). A cross-sectional study in Al-Ahsa targeting diabetes patients reported approximately 56.7% HZ awareness. This rate, although somewhat aligned with broader awareness, contrasts sharply with the 87% poor knowledge rate in our study. The higher vaccination rate of 18.8% observed in the study could be attributed to the targeted population of diabetes patients, who might be more health conscious or have better access to healthcare information (7). Interestingly, in a larger study involving 500 adults over 50 in Saudi Arabia, 80% were aware of HZ, but 74% did not recognize the connection between varicella and HZ. This gap in understanding the full scope of the disease might be reflected in our study, suggesting a common area for improving public health education. The study also showed that while 55.8% were familiar with the HZ vaccine, there was a significant gap in actual vaccine uptake, with 94.6% not having received the vaccine. The Saudi Arabian study also revealed that 28.1% of participants expressed reluctance to take optional vaccines, while a substantial 77.4% indicated willingness to receive the HZ vaccine if recommended by a healthcare professional. This highlights the potential impact of healthcare provider recommendations on vaccine uptake, a factor that might also play a crucial role in our study region (8). Another Saudi Arabian study conducted among diabetes patients in the Qassim region found that 25% accepted HZ vaccination, with predictors including male gender, belief in vaccine effectiveness, and awareness of higher HZ risk in immunocompromised individuals. Additionally, 74.2% expressed willingness for HZ vaccination upon physician recommendation, highlighting the influence of healthcare provider advice on vaccine uptake (9). Our study, highlighting significant gaps in knowledge about HZ and its vaccine, presents a stark contrast to international findings. In a UAE study, 64.3% of participants were aware of HZ, though many failed to recognize the link between chickenpox and HZ, mirroring our findings. Notably, being female, an Arab expatriate, or a healthcare professional positively influenced HZ knowledge, a dynamic we did not deeply explore. The UAE study's low familiarity with the HZ vaccine (14.8%) echoes the trends observed in our research, suggesting pervasive gaps in vaccine awareness across regions (10). In South Korea, a study reported high HZ awareness (85.7%) and 43.6% knowledge of HZ vaccination. This contrasts sharply with our study findings, indicating a more pronounced challenge in elevating public awareness. The South Korean study also identified demographic factors such as gender, age, and socioeconomic status as influencers of HZ awareness. Among those aware of HZ, 85.8% were willing to be vaccinated or to vaccinate their parents. However, barriers like perceived high costs and low risk perception led to a 60.2% acceptance rate (11). In China, studies showed varied levels of vaccine awareness and willingness to vaccinate, with major barriers including cost concerns and lack of healthcare recommendations. These factors align with our findings, where similar challenges likely contribute to low vaccine uptake. A cross-sectional study by Lam AC et al involving 430 participants revealed only 37.8% familiarity with HZ vaccination, highlighting knowledge disparities. Despite interest in learning about HZ and preventive measures, 94.6% of those aware of the vaccine received no doctor recommendations. This study found HZ vaccination rates to be significantly lower than for influenza and pneumococcus, attributed to factors such as unawareness, limited promotion, cost concerns, and perceived good health. Approximately 17.2% indicated potential consideration for HZ vaccination in the future (12). Conversely, another study in China involving 2864 respondents at community health centers found that 42.67% intended to receive the HZ vaccine, 21.44% refused, and 35.89% were hesitant. Both quantitative and qualitative analyses identified influencing factors characteristics, including personal knowledge, attitudes, vaccine attributes, and considerations like pain tolerance and accessibility (13). In the USA, a cross-sectional survey involving 381 participants aged 50 and older showed considerable awareness of HZ and its vaccine. Over 68% knew someone with HZ, and 13.3% of those 60 and older had personal experience with HZ. Knowledge about HZ being a nerve/skin disease, its recurrence, and non-person-to-person transmission was high. World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 202-206 205 TV and internet ads were primary sources of vaccine information. Interestingly, perceptions of vaccine side effects varied with age: 62.7% under 60 believed in side effects, contrasting with 39.2% of those 60 and older, and about 35% were unaware of these effects (14). These international insights underscore the urgency for comprehensive public health initiatives to enhance awareness, correct misconceptions, and promote HZ vaccination. Key recommendations include targeted educational campaigns facilitated by healthcare providers, addressing specific demographic and cultural influences, and overcoming financial barriers. To bridge knowledge gaps, healthcare providers should play a pivotal role in disseminating accurate information about HZ and its vaccine. Tailoring interventions to address unique regional and demographic factors is crucial for maximizing the impact of awareness campaigns. Moreover, efforts should focus on dispelling misconceptions surrounding vaccine efficacy, addressing cost concerns, and emphasizing the importance of vaccination, particularly populations. among high-risk Our study contributes valuable insights into the knowledge, attitudes, and practices surrounding HZ and its vaccine within the studied population. The identified gaps in awareness and vaccine uptake emphasize the need for targeted educational interventions to enhance understanding and promote vaccination among at-risk individuals. Additionally, the role of healthcare professionals is highlighted as central to disseminating accurate information and addressing misconceptions. 4. Conclusion The study highlights a significant gap in knowledge and low vaccine uptake among the target population in Jizan. It underscores the need for educational initiatives and awareness programs to improve understanding and acceptance of the HZ vaccine. 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