Clinical Nudge Impact on Herpes Zoster Vaccine Series Completion in Pharmacies


      A new recombinant herpes zoster vaccine has advanced efforts to prevent shingles, but its multidose regimen introduces potential barriers to full protection that must be managed by community pharmacies. To address this potential patient management challenge, a pharmacy records clinical support tool was implemented to assist pharmacy staff in managing herpes zoster vaccine dose completion.


      Beginning in November 2018, a large community pharmacy chain (operating in 36 states) implemented a provider nudge within its clinical decision support tool across all locations that fit seamlessly into the existing workflow, alerting the pharmacy staff of the need for a patient's second dose. Initial and second doses were followed over 2 overlapping, 10-month periods before and after system launch. Differences in vaccine completion rates before and after the system was operational were assessed by chi-square tests and predictors of completion, controlling for store- and patient-level characteristics, and were analyzed by multivariable logistic regression and generalized linear models throughout 2021.


      Across 2,271 pharmacies, 71,459 and 41,982 initial doses of the herpes zoster vaccine were given in the baseline and intervention period, respectively. The proportion of patients completing both doses increased slightly after system implementation (before: 71.9%, after: 75.2%; p<0.0001). However, dramatic improvements in time to dose completion were observed (before: 109.8 days, after: 93.3 days; p<0.001), and changes were significant in stores in all but 4 states.


      Results suggest that the use of a clinical nudge improved the occurrence of and time to herpes zoster vaccine dose completion in adults across the U.S.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Katz J
        • Cooper EM
        • Walther RR
        • Sweeney EW
        • Dworkin RH.
        Acute pain in herpes zoster and its impact on health-related quality of life.
        Clin Infect Dis. 2004; 39: 342-348
        • Schmader KE
        • Sloane R
        • Pieper C
        • et al.
        The impact of acute herpes zoster pain and discomfort on functional status and quality of life in older adults.
        Clin J Pain. 2007; 23: 490-496
        • Lydick E
        • Epstein RS
        • Himmelberger D
        • White CJ.
        Herpes zoster and quality of life: a self-limited disease with severe impact.
        Neurology. 1995; 45 (12): S52-S53
        • Harpaz R
        • Ortega-Sanchez IR
        • Seward JF
        Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP).
        MMWR Recomm Rep. 2008; 57 (1–CE4. Accessed August 23, 2021)
        • Williams WW
        • Lu PJ
        • O'Halloran A
        • et al.
        Surveillance of vaccination coverage among adult populations - United States, 2015.
        MMWR Surveill Summ. 2017; 66: 1-28
      1. Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep 2018;67:103–108. doi:

        • Nelson JC
        • Bittner RC
        • Bounds L
        • et al.
        Compliance with multiple-dose vaccine schedules among older children, adolescents, and adults: results from a vaccine safety datalink study.
        Am J Public Health. 2009; 99: S389-S397
        • Wang J
        • Ford LJ
        • Wingate L
        • et al.
        Effect of pharmacist intervention on herpes zoster vaccination in community pharmacies.
        J Am Pharm Assoc (2003). 2013; 53: 46-53 12019
        • Frederick KD
        • Gatwood JD
        • Atchley DR
        • et al.
        Exploring the early phase of implementation of a vaccine-based clinical decision support system in the community pharmacy.
        J Am Pharm Assoc (2003). 2020; 60: e292-e300
        • Sunstein CR.
        Nudging: a very short guide.
        Bus Econ. 2019; 54: 127-129
        • Patel MS
        • Day SC
        • Halpern SD
        • et al.
        Generic medication prescription rates after health system-wide redesign of default options within the electronic health record.
        JAMA Intern Med. 2016; 176: 847-848
        • Adusumalli S
        • Jolly E
        • Chokshi NP
        • et al.
        Referral rates for cardiac rehabilitation among eligible inpatients after implementation of a default opt-out decision pathway in the electronic medical record.
        JAMA Netw Open. 2021; 49e2033472
        • Yoong SL
        • Hall A
        • Stacey F
        • et al.
        Nudge strategies to improve healthcare providers’ implementation of evidence-based guidelines, policies and practices: a systematic review of trials included within Cochrane systematic reviews.
        Implement Sci. 2020; 15: 50
        • Curtain C
        • Peterson GM
        • Tenni P
        • Bindoff IK
        • Williams M.
        Outcomes of a decision support prompt in community pharmacy-dispensing software to promote step-down of proton pump inhibitor therapy.
        Br J Clin Pharmacol. 2011; 71: 780-784
        • Humphries TL
        • Carroll N
        • Chester EA
        • Magid D
        • Rocho B.
        Evaluation of an electronic critical drug interaction program coupled with active pharmacist intervention.
        Ann Pharmacother. 2007; 41: 1979-1985
        • Reeve JF
        • Tenni PC
        • Peterson GM.
        An electronic prompt in dispensing software to promote clinical interventions by community pharmacists: a randomized controlled trial.
        Br J Clin Pharmacol. 2008; 65: 377-385
        • Raebel MA
        • Charles J
        • Dugan J
        • et al.
        Randomized trial to improve prescribing safety in ambulatory elderly patients.
        J Am Geriatr Soc. 2007; 55: 977-985
        • Heringa M
        • Floor-Schreudering A
        • De Smet PAGM
        • Bouvy ML.
        Clinical decision support and optional point of care testing of renal function for safe use of antibiotics in elderly patients: a retrospective study in community pharmacy practice.
        Drugs Aging. 2017; 34: 851-858
        • Chan MS
        • Jamieson KH
        • Albarracin D.
        Prospective associations of regional social media messages with attitudes and actual vaccination: a big data and survey study of the influenza vaccine in the United States.
        Vaccine. 2020; 38: 6236-6247
      2. Saint Onge JM, Krueger PM. Health lifestyle behaviors among U.S. adults. SSM Popul Health. 2017;3:89–98.

        • Gatwood J
        • Renfro C
        • Hagemann T
        • et al.
        Facilitating pneumococcal vaccination among high-risk adults: impact of an assertive communication training program for community pharmacists.
        J Am Pharm Assoc (2003). 2021; 61 (e1): 572-580
        • Hofstetter AM
        • Robinson JD
        • Lepere K
        • Cunningham M
        • Etsekson N
        • Opel DJ.
        Clinician-parent discussions about influenza vaccination of children and their association with vaccine acceptance.
        Vaccine. 2017; 35: 2709-2715 03.077
        • Conrey R
        • Valencia V
        • Cioletti A
        • Williams-Brown MY.
        Regional variation in human papillomavirus vaccination uptake and completion among adolescents 13–17 in the state of Texas.
        Vaccine. 2020; 38: 4119-4124
        • La EM
        • Trantham L
        • Kurosky SK
        • Odom D
        • Aris E
        • Hogea C.
        An analysis of factors associated with influenza, pneumoccocal, Tdap, and herpes zoster vaccine uptake in the U.S. adult population and corresponding inter-state variability.
        Hum Vaccin Immunother. 2018; 14: 430-441
        • Lau JS
        • Adams SH
        • Irwin Jr., CE
        • Ozer EM.
        Receipt of preventive health services in young adults.
        J Adolesc Health. 2013; 52: 42-49
        • Miller BL
        • Kretsinger K
        • Euler GL
        • Lu PJ
        • Ahmed F.
        Barriers to early uptake of tetanus, diphtheria and acellular pertussis vaccine (Tdap) among adults-United states, 2005–2007.
        Vaccine. 2011; 29: 3850-3856
        • Takayama M
        • Wetmore CM
        • Mokdad AH.
        Characteristics associated with the uptake of influenza vaccination among adults in the United States.
        Prev Med. 2012; 54: 358-362
        • Yeung MP
        • Lam FL
        • Coker R.
        Factors associated with the uptake of seasonal influenza vaccination in adults: a systematic review.
        J Public Health (Oxf). 2016; 38: 746-753
        • Patterson BJ
        • Chen CC
        • McGuiness CB
        • Glasser LI
        • Sun K
        • Buck PO.
        Early examination of real-world uptake and second-dose completion of recombinant zoster vaccine in the United States from October 2017 to September 2019.
        Hum Vaccin Immunother. 2021; 17: 2482-2487
        • Lu PJ
        • Hung MC
        • Srivastav A
        • Williams WW
        • Dooling KL.
        Shingles vaccination of U.S. adults aged 50–59 years and ≥60 years before recommendations for use of recombinant zoster vaccine.
        Am J Prev Med. 2020; 59: 21-31
        • Vogelsang EM
        • Polonijo AN.
        Social determinants of shingles vaccination in the United States.
        J Gerontol B Psychol Sci Soc Sci. 2022; 77: 407-412
        • Shuvo S
        • Hagemann T
        • Hohmeier KC
        • Chiu CY
        • Ramachandran S
        • Gatwood J.
        The role of social determinants in timely herpes zoster vaccination among older American adults.
        Hum Vaccin Immunother. 2021; 17: 2043-2049 2020.1856598
        • Nilsen P
        • Bernhardsson S.
        Context matters in implementation science: a scoping review of determinant frameworks that describe contextual determinants for implementation outcomes.
        BMC Health Serv Res. 2019; 19: 189
        • Shoemaker SJ
        • Curran GM
        • Swan H
        • Teeter BS
        • Thomas J.
        Application of the Consolidated Framework for Implementation Research to community pharmacy: a framework for implementation research on pharmacy services.
        Res Social Adm Pharm. 2017; 13: 905-913
        • Renfro CP
        • Robinson JM
        • Turner K
        • Gaskins T
        • Ferreri SP.
        Care coordination and follow-up practices in the community pharmacy setting: a mixed methods study.
        J Am Pharm Assoc (2003). 2020; 60 (e2): 631-638
        • Hohmeier KC
        • Spivey CA
        • Boldin S
        • Moore TB
        • Chisholm-Burns M.
        Implementation of a health information exchange into community pharmacy workflow.
        J Am Pharm Assoc (2003). 2017; 57: 608-615