Table of Contents
Abstract
Influenza in the U.S. causes over 220,000 hospitalizations with 3,000-49,000 deaths; mostly occurring in the older adult population (Arriola et al., 2015). According to the CDC, the flu vaccination reduces your risk of flu illness by 40-60% (2017). This is among the overall population during peak season when the viruses are well-matched to the flu vaccine (Arriola et al., 2015). The most important health intervention to prevent hospitalization in the elderly from influenza complications is vaccination (Nagata et al., 2013).
Annually about 90 percent influenza-related deaths occur in those aged 65 or older (Nagata et al., 2013). Hospitalization and death generally occur from complications of influenza such as pneumonia. The elderly have a decreased immune system and often present with several co-morbidities which place them at increased risk of complications. Because of their chronic medical conditions, they are often unable to “bounce back” to normal health. The goal of vaccination is to prevent these complications leading to hospitalization and possible death (Nagata et al., 2013).
The purpose of this paper is to identify determinants on vaccination uptake of influenza and list interventions to better serve the older adult population. Several determinants have been studied over the years with psychological, physical, contextual and sociodemographic barriers affecting individuals choice in receiving or refusing the influenza vaccine. In order to overcome these barriers, healthcare professionals must look into ways to target this population such as providing education at town meetings, festivals and providing vaccinations during these events. With the help of identifying ways to target this population, health care providers can hope to provide an increase in uptake of influenza vaccine and decrease the complications of influenza through proper vaccination.
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KEYWORDS: older adult population, barriers to vaccination, elderly, influenza, vaccination, vaccination uptake
Preparation
According to Healthy People 2020, influenza leads to more than 200,000 hospitalizations and 36,000 deaths each year. According to Torner, 2017, “Influenza vaccination showed significant protection against ICU admission; mechanical ventilation; secondary bacterial pneumonia and a higher degree of dependence” (Torner, et al., 2016). The older adult population is one of the most vulnerable populations and vaccination should be stressed to further decrease complications. The CDC said the influenza season of 2012-2013 rate of hospitalizations in adults over 65 showed to be three times greater than in the previous four years (2017). Adults age 65 and older have weaker immune systems and are at increased risk of serious complications should they develop the flu. According to the CDC, the flu vaccine in older people can have a lower effectiveness due to their weaker immune response to the vaccine, however, receiving protection is more beneficial than no protection at all during peak seasons (2017).
In older adults, they are more likely to develop serious complications such as pneumonia and possibly death. One study showed for every 4,000 people vaccinated against the flu one death was prevented. In several studies over the years, specific concerns about flu vaccine include that it “causes side effects/adverse outcomes, is not effective, vaccine components are harmful, and vaccination is not necessary” (Rikin et al., 2018). Some people believe that the flu shot causes the flu and reduces the odds of proper vaccination (Rikin et al., 2018).
Before discussing validation we must determine the types of barriers on why individuals may refuse the influenza vaccination. According to Schmid, Rauber, Betsch, Lidolt and Denker, (2017), there are four types of barriers and they consist of psychological, physical, contextual and sociodemographic. The psychological barriers include: utility, risk perception, social benefit, subjective norm, perceived behavioral control, attitude, past behavior, experience, and knowledge. Physical barriers include unhealthy life style such as alcohol consumption and smoking. Contextual barriers include access, cues to action and system factors. And lastly, sociodemographic barriers include higher age, gender, ethnicity, living alone and being unmarried.
Validation
In review of literature it can be noted multiple barriers exist on why individuals choose to not seek vaccination. Often times refusal is due to what they’ve heard from others, what they think they know about vaccination, side effects, past behavior, experience, etc. A study from the University of Minnesota analyzed 31 articles on the effectiveness of influenza vaccination between 1967 and 2011. Key findings showed: influenza shots prevent the flu 67 percent of the time, adults over 70 years of age showed a 57 percent effectiveness in receiving the nasal spray form of the vaccine, in adults over 65 years of age showed a vaccine effectiveness of 56-73 percent.
As individuals age the immune system is weakened and results in increased susceptibility to infection as well as reducing the efficacy of vaccinations (Lord, 2013). This is what leads to more and more infections and increases older adults mortality rates once infected with influenza (Lord, 2013). In Northern California, a recent study showed influenza vaccination decreased the mortality in those age 65 and older by 4.6 percent and reduced hospital admission for pneumonia and influenza by 8.5 percent (Osterholm et al., 2013). “Current research is indicating routes to improved vaccination regimes in older adults, such as adjuvants focused upon aspects of the immune response that remain intact, or simple interventions such as the time of day the vaccine is given or the use of booster vaccinations in old subjects” (Lord, 2013).
Comparative Evaluation
In identifying potential barriers to vaccine acceptance, many researchers over the years have looked at vaccine hesitancy. Vaccine hesitancy is said to be the acceptance of vaccines between demand and no demand in regard to accepting vaccines or refusal of vaccine. The WHO SAGE working group defined vaccine hesitancy as “a delay in acceptance or refusal of vaccination despite availability of vaccination services. Vaccine hesitancy is complex and context specific, varying across time, place and vaccines’ (Schmid et al., 2017).
Using the Theory of Planned Behavior to provide psychological insight to help better understand individuals acceptance or refusal of vaccination. This particular model helps to identify potential determinants to vaccine uptake on a concrete, measurable level and specifies the different variables (Schmid et al., 2017). The TPB method looks at the function of an individuals attitude such as “negative or positive evaluation of behavior and outcome,’ perceived behavior control (ability to perform a behavior) and the significant norm such as social pressure of others (Schmid et al., 2017). “Other extensions of TPB have shown an increase in the predictive power of the theory by integrating concepts of risk perception, past behavior, knowledge and experience into this model. Thus the TPB is able to reliably predict various health behaviors such as vaccinating” (Schmid et al., 2017).
Some of the barriers of vaccination uptake include psychological barriers (i.e.-utility, risk perception, attitude, experience, knowledge and past behavior), physical barriers (i.e.-BMI, physical activity), contextual barriers (i.e.-access, interaction with healthcare system, and cues toaction), sociodemographic barriers (i.e.-age, sex, ethnicity, and living arrangements). These barriers are very important in an individuals likelihood to act and predicts their intention of vaccination.
When discussing the psychological barriers such as risk perception, cognitive parameters were identified as significant barriers (i.e.-perceiving the likelihood of developing influenza as low and perceiving the severity of the disease as low) (Schmid et al., 2017). Higher perceived risk of vaccine adverse events were found to decrease vaccine uptake (Schmid et al., 2017). Additionally, past behavior were shown to play a role in whether or not someone received the vaccine. Higher vaccine uptake were shown in the elderly who had already been vaccinated against influenza in the previous years (Schmid et al., 2017). Lacking general knowledge about influenza and the vaccine is identified as a determinant as well through lack of education of the public.
Physical barriers such as alcohol consumption, obesity, smoking were associated with having a negative impact on vaccine uptake related to unhealthy lifestyles (Schmid et al., 2017). More consistent barriers to receiving the influenza vaccine included a lower body mass index and not having any medical conditions. These individuals in this category perceive their health status as good and feel less inclined to vaccinate (Schmid et al., 2017).
Contextual barriers include access issues such as financial expenses or simply being an inconvenience (lack of transportation to clinic and disability). Also, a lack of interaction with a healthcare system was seen as less likely to get vaccinated (i.e.-no primary care physician). Another contextual barrier considered is “cues to action” such as recommendation of vaccination by a medical personnel or relatives are less likely to get vaccinated (Schmid et al., 2017).
According to Schmid et. al., (2017), sociodemographic barriers such as sex, ethnicity, living arrangements were noted to be barriers in vaccine uptake. The specifics of exactly why were not noted, but did mention living alone and being unmarried were associated with not receiving vaccination. “People who live alone with limited assistance may have less access, irregular preventative health visits, and less support from family members” (Nagata et al., 2013).
Of all of these barriers mentioned, a negative attitude towards influenza vaccines, low perceived utility of vaccination, fewer previous influenza vaccinations, and lacking cues to actions were considered the most frequently and consistently significant barrier to influenza vaccination (Schmid et al., 2017). In the elderly, sociodemographic variables (gender, age, risk factors), physical variables (smoking status, perceived health status), past behavior and living arrangements were the most reported barriers for influenza vaccine uptake (Schmid et al., 2017).
Before discussion of decision making and implementation can take place, we must carefully take into consideration possible benefits and risks associated with implementing a project to better serve the older adult population. For example, if we as providers chose to form a team of individuals to go around rural areas and administer influenza vaccines, we must consider the benefits and risks of doing so. There would need to be an approval that takes place within the region to allow this in the first place. Next, we would need to make sure we gather adequate medical history from these individuals and could accomplish this by teaming up with local health care providers (if residents see a PCP). If the individuals do not have a health care provider then we can try and collect the data first before going around and administering vaccinations. Other considerations to think about include: obtaining consent, patient’s health conditions, allergies, prior reactions, etc.
Individuals tend to feel more comfortable in their own home and may not necessarily have transportation or access to medical care. This is where providers can take charge recognizing the importance of serving diverse neighborhoods that generally might have lower rates of influenza vaccine uptake. Benefits of choosing a method such as providing vaccinations at individuals homes could provide an opportunity for providers to collaborate, coordinate and effectively communicate to these diverse areas. The patients benefit by providing convenience, improving their access to vaccination, and targeting individuals at high risk. It can be said that both parties (providers and patients) would benefit by using this method to help make a difference and decrease preventable illnesses.
Decision Making
The plan to help provide the older adult population with better care is to develop the “Vaccination Accessible Plan” (VAP). The focus of the plan being on involving local residents and ensuring their goals are met according to values and desires. In this particular plan we can provide ideas such as holding public meetings to allow for interaction with locals and allow providers/staff to answer questions. Also, we will include activities for the public to provide more education on the vaccination process. For those who are more tech savvy we can provide online surveys and for those who prefer written, we will provide a short survey to complete on what they learned during the experience. Other ideas include displays, posters, local agencies, resources, etc. to provide with more information on influenza and proper vaccination.
As a part of the VAP, nurse practitioners can develop and implement strategies by forming a committee in the community to identify health needs and prioritize these needs according to access to care, mental health, senior health, obesity and diabetes, hispanic needs, teen pregnancy, heart disease and stroke, etc. The committee will then select a geographic service area, identify/engage community leaders, and form a community health profile among several other implementations. When reviewing local healthcare plans the focus is on many important healthcare topics, but of none are noted on vaccination importance and the statistics of residents access to proper vaccination. This plan would allow us to implement adding vaccination accessibility within this healthcare profile.
Some of the community of Gainesville expressed their input on the topic of access to care and many made comments such as “residents are not aware of resources available in the community”, “providers see patients who are not even aware of available resources in the community”, “there is a gap in looping together agencies that promote wellness and these agencies need to work together rather than in silos”, and “there is no resource directory of all agencies providing services in the community”.
Other comments included, “the community needs on-the-job site preventative care (flu shots, screenings),” “health educators need to educate in ways that are consistent and clear and educate on the most important topics rather than asking individuals what they want to know about health,” and “an education barrier is that the community must come to you rather than going out to the community”. By implementing the VAP, we can provide more education to the community and ensure those who are unable to see a provider are more aware of ways to reduce complications by proper vaccination and are better educated on the subject.
Translation/Application
In order to implement change, one should consider ways to involve the public and survey the community. One step to make this plan applicable would be to increase awareness/knowledge in the older population through education about the influenza vaccination. This can be accomplished by holding two community meetings or public hearings a month to educate on the effectiveness of the vaccine and present evidence-based strategies on proper vaccination. “Influenza vaccination programs that include a number of evidence-based strategies can achieve increased rates if they are strongly supported by leadership and are backed by an aggressive focus on vaccination as a patient safety measure” (National Vaccine Advisory Committee, 2013).
Another idea is to develop a team of staff to go out into the community door-to-door and provide education to those who have limited access to transportation, are financially unstable or are disabled. The committee could post fliers throughout the town and offer freebies from local organizations to all who participate and get vaccinated. During this time staff can administer vaccines door-to-door. This can be called something fun and catchy like “Fly Flu Bye” to get peoples attention and have fun with the vaccination process. Several studies show the door-to- door method is a feasible way of reaching hard-to-reach populations and increases vaccinations (Michaela et al., 2013).
One last intervention would be holding a fall festival in town with games, music, food trucks, etc. and have an event targeting flu season with a ticket price of $15. This could be a way people can learn more about influenza, proper vaccination, and complications of influenza. There could be several booths set up of local staff from the hospital administering vaccinations for “free” (the tickets would help cover the cost of the vaccine). It’s important for people to have fun and maybe by seeing others getting vaccinated, they will too!
Evaluation
In the end, the goal of implementing such a plan would be to see an increase in acceptance of influenza vaccination and an increase in knowledge of complications related to refusal of influenza vaccination. Some ways we could consider to measure this is by providing a pre-vaccination survey patients can complete prior to administration. One question to focus on would be asking patients have they ever received the influenza vaccination and if so when was the last time. Then we would go on to ask them if they’d be willing to get vaccinated today at the convenience of their own home. If so, we’d make note on the back of the pre-vaccination survey saying they have agreed (consented) and received the vaccine. We could then configure a chart/graph detailing the percentage increase of people who have never received the vaccine who did so through the door-to-door approach.
We can identify whether patients have an increased knowledge of complications of vaccine refusal by asking them to write two facts down on their survey that they did not know about the influenza vaccination or complications. This will provide us with evidence they learned something and are able to recall the information.
We as providers cannot force individuals to do something they do not want to do, but it is our responsibility to educate individuals and ensure everything is being done to better the care in our local community. We can be certain to make a huge impact on healthcare and individual lives when we apply the skills, tools and knowledge we have learned. With hope to improve influenza vaccination uptake and education on complications from refusal of vaccination.
