Utilizing the Health Belief Model to Assess Attitudes and Beliefs of Hemodialysis Patients Regarding the Seasonal Influenza, Pneumococcal and Hepatitis B Vaccines Angela Adams, MSN,RN,CNN,DNP(c) Melissa Hall, DNP,RN,ANP-BC,FNP-BC,GNP-BC Janis Fulghum, BSN,RN,CNN Objectives • Identify the overall impact of influenza, pneumonia, and the Hepatitis B Virus (HBV) • Recognize the importance of immunization as an effective strategy to prevent infectious disease related morbidity and mortality • Identify special immunization considerations in the Chronic Kidney Disease Stage V (CKD Stage V) population • Demonstrate the use of the Health Belief Model (HBM) to promote acceptance of immunization in the hemodialysis population • Recognize individual practice applications for implementation • Identify strategies for maintaining and sustaining change related to increasing immunization acceptance in the CKD Stage V population treated with hemodialysis • Recognize future implications of utilizing the HBM to assess attitudes and beliefs of hemodialysis patients Background and Significance Overall Impact of Influenza • Average of >200,000 influenza-related hospitalizations annually • 57% of hospitalizations and 90% death occur among persons < 65 years of age • 0.5-1 deaths per 1,000 cases; > 23,000 deaths annually • Nursing homes rates ≥ 60%, with fatality rates ≥ 30% • 2.7 times more deaths occurred during seasons when a(H3N2) viruses were prominent • Cost of a severe epidemic $12 billion Background and Significance Overall Impact of Pneumonia • Estimated 175,000 hospitalizations annually • Disease incidence rates: 36% of adult community-acquired pneumonia, 50% hospital-acquired pneumonia • Common bacterial complication of influenza and measles • Case-fatality rate 5%-7%, higher in elderly • Chronic heart, pulmonary, liver or renal disease ↑ risk of invasive disease Background and Significance Overall Impact of Hepatits B Virus (HBV) • 38,000–73,000 new HBV infections annually in the U.S • 600,000 HBV-related deaths annually worldwide • 2 billion persons worldwide have been infected with HBV • 350 million worldwide live with chronic infection • Chronic HBV ↑ risk for chronic liver disease, cirrhosis, and liver cancer • Cost $700 million annually for HBV related medical care and work loss Special Considerations in the CKD Stage V Population • Patients are “sicker”,1 often with dysfunctional immune systems2 – Greater disease burden – cardiovascular, infectious, inflammatory, uremic – Increased susceptibility for infection – Decreased response to vaccination – Decreased maintenance of protective antibodies • Implications: – Results of studies in the general population do not always apply –try geriatric studies – Vaccines need to be evaluated individually – Risks and benefits (and cost issues) need to be weighed – There is a great need to prevent infections in ESRD 1 USRDS ADR 2007 2 Pesanti EL. Infections in CRF. Infect Dis Clin North Am. 15: 1-15, 2001 Slide recreated with permission from Lascon, E. (2008). Vaccination in adult patients with ESRD (PDF document). Retrieved from https://fmc4me.fmcna.com Adjusted all-cause & causespecific hospitalization rates, by modality Figure 3.1 (Volume 2) USRDS 2011 Annual Report Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 2005. Reference United States Renal Data System (2011). 2011 Annual Report. Retrieved from http://www.usrds.org/reference.aspx 2012 Adult Immunization Schedule Based on Medical and Other Indications Retrieved from http://www.cdc.gov/vaccines/recs/images/adult-schedule-chart-2.jpg USRDS 2011 Quality indicators: percentage of patients meeting clinical & preventive care guidelines Figure 2.1 (Volume 2) Reference United States Renal Data System (2011). 2011 Annual Report. Retrieved from http://www.usrds.org/reference.aspx Concept Map: Acceptance Modifying Variables •Age •Education level •Cultural beliefs •Religious beliefs •Socioeconomic status Context: Acceptance of Influenza and Pneumococcal Vaccine in the Hemodialysis Population Antecedents •Prescribed disease preventive measure •Perceived disease susceptibility •Perceived disease severity •Perceived benefit of disease preventive measure •Lack of barriers •Access •Lack of contraindications •Creditable education •Healthcare provider advisement •Altruism •Self efficacy •Internal locus of control Theoretical Definition: Decision to act favorably toward disease preventive measures based on an individual’s perceived susceptibility, severity and threat of a disease process vs. the individual's perceived benefit minus the perceived barriers to the preventive health measure. Acceptance Related Terms •Compliance •Adherence •Concordance •Decision making Consequences Patient Related •Immunization against disease processes •Decreased morbidity •Decreased mortality Health System Related •Decease healthcare cost •Decrease health system use Operational Definition Tool utilized to measure components of theoretical definition: Champion’s Health Belief Model Scale, vaccine consent forms, interview of clients to assess recommendation of vaccines to acquaintances and significant others Defining Attributes •Alignment of patient behavior and provider advice •Ability to met mutual goals and overcome perceived barriers Empirical Referents •Consent •Initial engagement in disease preventive measure •Repeat engagement in disease preventive measure •Recommendation of disease preventive measure to acquaintances and significant others Literature Review • Search engines reviewed • Inclusion criteria • Exclusion criteria • Key terms - acceptance decision making adherence, compliance, vaccine, immunization, influenza, pneumococcal, chronic kidney disease, chronic disease, disease , elderly Individual perceptions regarding influenza, pneumococcal and hepatitis B vaccines Theory: Health Belief Model Context: Acceptance of Influenza, Pneumococcal and Hepatitis B Vaccines in the Hemodialysis Population Modifying Variables Perceived susceptibility to influenza, pneumonia, and hepatitis B Perceived severity of influenza pneumonia, and Hepatitis B Perceived benefits of influenza, pneumococcal and hepatitis B vaccines Perceived barriers to receiving influenza, pneumococcal and hepatitis B vaccines Personal Variables Age Education level Cultural beliefs Religious beliefs Socioeconomic status Cues to Action Healthcare provider Vaccine prescription Healthcare provider advisement Vaccine information Sheet Diagnosis of family or acquaintance with influence or pneumonia Media campaigns Likelihood of Action Perceived benefits of the influenza. pneumococcal and hepatitis B vaccines minus perceived barriers to receiving the vaccines Self efficacy Perceived ability to overcome the perceived barriers and receive the influenza, pneumococcal, and hepatitis B vaccines Reference: Glanz, K., Rimer, B.K. & Lewis, F.M. (2002). Health Behavior and Health Education. Theory, Research and Practice. P. 52, San Francisco: Wiley &Sons. Project Purpose • Determine if there is a significant difference between gender and beliefs based on perceived susceptibility, benefits, barriers, and severity related to vaccine acceptance in the outpatient hemodialysis population • Determine if there is a significant relationship between age and beliefs based on perceived susceptibility, benefits, barriers, and severity related to vaccine acceptance in the outpatient hemodialysis population • Determine if perceived susceptibility , benefits, barriers, and cues to action will change the odds of receiving the influenza, pneumococcal, and hepatitis B vaccines related to vaccine acceptance in the outpatient hemodialysis population • Utilize project findings to influence interdisciplinary assessment and plans of care related to vaccine acceptance in the outpatient hemodialysis population • Utilize project findings to develop vaccine improvement strategies related to vaccine acceptance in the outpatient hemodialysis population DNP Project Design and Methodology • Design: Qualitative, descriptive, comparative • Setting: 10 outpatient hemodialysis facilities in metropolitan Atlanta, Georgia and Anderson, South Carolina affiliated with a large dialysis provider (LDP) • Sample: - Influenza Survey: N= 215 - Pneumonia Survey: N= 206 - HBV Survey: N= 161 • Approach: informed consent, written survey DNP Project Design and Methodology Instrument: • 22-item questionnaire adapted from Champion’s Health Belief Model (HMB) Survey • Survey utilizes 5 point Likert scale scoring scale Perceived susceptibility towards vaccine Perceived severity towards vaccine Perceived benefits towards vaccine Perceived barriers towards vaccine Cues to Action • Demographic information: age, gender, dialysis vintage • Vaccination history: date of last vaccine DNP Project Survey Tool Health Belief Model Influenza Vaccine Survey Patient Age: Date of last influenza vaccine: Patient Gender: Dialysis Vintage: Perceived Barriers Strongly Agree 54321 Strongly Disagree 1 I do not want to get the flu shot 5 4 3 2 1 2 The flu shot will make me sick 5 4 3 2 1 3 Getting the flu shot takes too much time 5 4 3 2 1 4 Getting the flu shot takes too much effort 5 4 3 2 1 5 The flu shot is not available at a convenient time 5 4 3 2 1 6 The flu shot is not available at a convenient location 5 4 3 2 1 7 I need more information before I can make a decision about 5 4 3 2 1 3 2 1 taking the flu shot 8 Flu shots cost too much Perceived Benefits 5 Strongly 4 Agree 54321 Strongly Disagree 9 The flu shot is safe for me 5 4 3 2 1 10 Taking the flu shot will prevent the flu 5 4 3 2 1 11 Taking the flu shot may save my life. 5 4 3 2 1 12 I do not want to spread the flu to my family, 5 4 3 2 1 friends, patients and workers at the dialysis clinic Perceived Susceptibility Strongly Agree 54321 Strongly Disagree 13 I have an increased chance of getting the flu 5 4 3 2 1 14 I get sick more often than others my age 5 4 3 2 1 Perceived Severity Strongly Agree 54321 Strongly Disagree 15 Complications from the flu could be serious 5 4 3 2 1 16 Getting the flu may lead to other serious health problems 5 4 3 2 1 Cues to Action Strongly Agree 54321 Strongly Disagree 17 I will take the flu shot if my doctor said it is important 5 4 3 2 1 18 I will take the flu shot if my dialysis nurse said it is important 5 4 3 2 1 19 I will take the flu shot if my pharmacist said it is important 5 4 3 2 1 20 I will take the flu shot if a family member or significant other 5 4 3 2 1 said it is important 21 I will take the flu shot if I see a TV ad that said it is important 5 4 3 2 1 22 I will take the flu shot if the interdisciplinary team at the 5 4 3 2 1 dialysis clinic said it is important during my care plan meeting Data Analysis and Results Descriptive Statistics for HBM Scores by Influenza Vaccine Influenza Vaccine Perceived Barriers Flu Shot No Flu Vaccine Received Flu Vaccine Mean 1.8780 1.6423 Std. Deviation .96532 .75549 N Perceived Benefits Flu Shot Total No Flu Vaccine Received Flu Vaccine 1.7535 3.7868 3.9867 .86648 1.08543 .97275 178 95 113 Perceived Susceptibility Flu Shot Total No Flu Vaccine Received Flu Vaccine 3.8954 2.7696 2.8451 1.02808 1.26583 1.18034 208 102 113 Perceived Severity Flu Shot Total No Flu Vaccine Received Flu Vaccine 2.8093 3.9133 3.9911 1.21936 1.10534 1.02003 215 98 112 Cues To Action Flu Shot Total No Flu Vaccine Received Flu Vaccine 3.9548 3.5686 3.7738 1.05884 1.16001 .98178 210 102 112 Total 3.6760 1.07281 214 •Individuals who received the flu vaccine had a lower average on Perceived Barriers, a higher average on Perceived Benefits, a higher average on Perceived Susceptibility, and a higher average on Cues to Action. There was almost no difference between groups on Perceived Severity. • 84 94 Data Analysis and Results Influenza Vaccine 4.50 4.00 3.50 3.00 2.50 2.00 1.50 1.00 0.50 0.00 Perceived Barriers Flu Shot Perceived Benefits Flu Shot Perceived Susceptibility Flu Shot Perceived Severity Flu Shot Cues To Action Flu Shot No Vaccine 1.88 3.79 2.77 3.91 3.57 Received Vaccine 1.64 3.99 2.85 3.99 3.77 Data Analysis and Results Descriptive Statistics for HBM Scores by Pneumonia Vaccine Perceived Barriers Pneumonia Vaccine Pneumonia Vaccine No Pneumonia Vaccine Received Pneumonia Vaccine Perceived Benefits Pneumonia Vaccine Mean Std. Deviation N 1.8104 1.5794 1.02408 .70819 91 74 Total No Pneumonia Vaccine Received Pneumonia Vaccine 1.7068 3.5803 3.8583 .90114 1.09865 .78884 165 109 90 Total Perceived Susceptibility Pneumonia No Pneumonia Vaccine Vaccine Received Pneumonia Vaccine 3.7060 2.8333 2.8871 .97844 1.26852 1.17753 199 114 93 Total No Pneumonia Vaccine Received Pneumonia Vaccine 2.8575 3.9000 4.3424 1.22583 1.20161 .87996 207 115 92 Total Cues To Action Pneumonia Vaccine No Pneumonia Vaccine Received Pneumonia Vaccine 4.0966 3.4957 3.8407 1.09071 1.20255 .94605 207 115 91 3.6481 1.10753 206 Perceived Severity Pneumonia Vaccine Total •Individuals who received the Pneumonia vaccine were lower on Perceived Barriers, higher on Perceived Benefits, higher on Perceived Severity, and higher on Cues to Action. There was very little difference between means on Perceived Susceptibility Data Analysis and Results Pneumonia Vaccine 5.00 4.50 4.00 3.50 3.00 2.50 2.00 1.50 1.00 0.50 0.00 Perceived Barriers Flu Shot Perceived Benefits Flu Shot Perceived Susceptibility Flu Shot Perceived Severity Flu Shot Cues To Action Flu Shot No Vaccine 1.81 3.58 2.83 3.90 3.50 Received Vaccine 1.58 3.86 2.89 4.34 3.84 Data Analysis and Results Descriptive Statistics for HBM Scores by Hepatitis B Vaccine Hepatitis B Vaccine Perceived Barriers Hepatitis B No Hepatitis B Vaccine Vaccine Received Hepatitis B Vaccine Total Perceived Benefits Hepatitis B No Hepatitis B Vaccine Vaccine Received Hepatitis B Vaccine Total No Hepatitis B Vaccine Perceived Susceptibility Hepatitis B Vaccine Received Hepatitis B Vaccine Total Perceived Severity Hepatitis B No Hepatitis B Vaccine Vaccine Received Hepatitis B Vaccine Total No Hepatitis B Vaccine Cues To Action Hepatitis B Vaccine Received Hepatitis B Vaccine Total Mean 1.7917 1.7445 1.7717 3.7174 3.7809 3.7517 2.8209 2.8671 2.8459 3.9130 4.2763 4.1034 3.8478 3.8205 3.8333 Std. Deviation .94648 .79920 .88494 .94802 .67706 .81074 1.24834 1.07926 1.15604 1.08789 .84615 .98230 1.01127 .86655 .93409 N 93 68 161 69 81 150 67 79 146 69 76 145 69 78 147 •For the Hepatitis B survey, there were very slight differences between group means on Perceived Barriers, Perceived Benefits, Perceived Susceptibility, and Cues to Action. Those who received the Hepatitis B vaccine were slightly higher on Perceived Severity Data Analysis and Results Hepatitis B Vaccine 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Perceived Barriers Flu Shot Perceived Benefits Flu Shot Perceived Susceptibility Flu Shot Perceived Severity Flu Shot Cues To Action Flu Shot No Vaccine 1.7917 3.7174 2.8209 3.913 3.8478 Received Vaccine 1.7445 3.7809 2.8671 4.2763 3.8205 Data Analysis and Results Levene's Tests for HBM Scores by Gender F Perceived Barriers Flu Shot Perceived Benefits Flu Shot Perceived Susceptibility Flu Shot Perceived Severity Flu Shot Perceived Barriers Pneumonia Vaccine Perceived Benefits Pneumonia Vaccine Perceived Susceptibility Pneumonia Vaccine Perceived Severity Pneumonia Vaccine Perceived Barriers Hepatitis B Vaccine Perceived Benefits Hepatitis B Vaccine Perceived Susceptibility Hepatitis B Vaccine Perceived Severity Hepatitis B Vaccine df1 .754 .038 1.791 .008 .042 1.157 .286 .510 .068 .479 .290 .034 df2 1 1 1 1 1 1 1 1 1 1 1 1 Sig. 75 75 75 75 75 75 75 75 75 75 75 75 •All Levene’s tests were nonsignificant (sig. values were greater than .05 using that criterion). This suggests that the assumption of equal variances was not violated. .388 .846 .185 .929 .838 .286 .594 .477 .794 .491 .592 .854 Data Analysis and Results Regression Coefficients for Pneumonia Vaccine by HBM Scores B S.E. Wald df Sig. Exp(B) Pneumonia Perceived Barriers -.169 .217 .609 1 .435 .844 Pneumonia Perceived Benefits -.164 .249 .432 1 .511 .849 Pneumonia Perceived Susceptibility -.054 .152 .126 1 .722 .947 Pneumonia Perceived Severity .389 .192 4.094 1 .043 1.475 Pneumonia Cues to Action .212 .209 1.032 1 .310 1.237 •The Wald statistic for Pneumonia Perceived Severity was significant. This test must be interpreted with extreme caution, because the overall chi-square value test was nonsignificant and there is evidence for weak model fit. This could be a type 1 (false positive) error. The Exp (B) value suggests that increases in Perceived Severity resulted in an increase in the odds of getting the Pneumonia Vaccine. Data Analysis and Results Regression Coefficients for Hepatitis B Vaccine by HBM Scores B S.E. Wald df Sig. Exp(B) Hepatitis B Perceived Barriers .166 .260 .410 1 .522 1.181 Hepatitis B Perceived Benefits -.127 .328 .149 1 .699 .881 Hepatitis B Perceived Susceptibility -.096 .193 .246 1 .620 .909 .627 .251 6.236 1 .013 1.873 -.198 .290 .467 1 .494 .820 Hepatitis B Perceived Severity Hepatitis B Cues To Action •The Wald statistic for Hepatitis Perceived Severity was significant. Again, interpret this with caution since the overall chisquare value test was nonsignificant and there is evidence for weak model fit. This could be a type 1 (false positive) error. The Exp (B) value suggests that increases in Perceived Severity resulted in an increase in the odds of getting the Hepatitis B Vaccine Data Analysis and Result Summary • There was a weak negative correlation between Age and Perceived Susceptibility for the Influenza Vaccine. Older participants had a slight tendency to report lower susceptibility. • There was a weak negative correlation between Age and Perceived Susceptibility for the Pneumonia Vaccine. Older participants had a slight tendency to report lower susceptibility. • There were no significant correlations between perceived susceptibility, benefits, barriers, and dialysis vintage. • Pneumonia Perceived Severity increased the odds of getting the Pneumonia Vaccine • Hepatitis Perceived Severity increased the odds of getting the Hepatitis B Vaccine. The Wald statistic was significant. DNP Study Limitations • Survey instrument amended to fit purpose of study • Study sites limited to southeastern, metropolitan locations part of one designated region affiliated with a single LDP • Study participants limited to CKD Stage V patients treated with hemodialysis • Facility staff bias could influence survey outcomes Implementing and Sustaining Change Reference United States Renal Data System (2011). 2011 Annual Report. Retrieved from http://www.usrds.org/reference.aspx Implementing and Sustaining Change Reference United States Renal Data System (2011). 2011 Annual Report. Retrieved from http://www.usrds.org/reference.aspx Implementing and Sustaining Change Reference United States Renal Data System (2011). 2011 Annual Report. Retrieved from http://www.usrds.org/reference.aspx Implementing and Sustaining Change A Sense of Urgency •Bringing the outside in A Sense of Urgency •Behaving with urgency every day •Finding opportunity in crisis •Dealing with “NoNos” or naysayers Retrieved from http://www.amazon.com Implementing and Sustaining Change Lewin’s Change Model Retrieved from http://www.bing.com/images Driving Force Force Field Analysis Increased morbidity and mortality related to infection Vaccine Rates < Healthy People 2010 and 2020 goals for hemodialysis patients Restraining Forces Lack of interdisciplinary team knowledge regarding vaccine rates and vaccine benefits Lack of patient knowledge regarding disease severity and vaccine benefit Patient and staff perceived barriers to vaccine acceptance Missed treatments due to hospitalization Nurses lack time to research vaccine history CMS appoints ESRD networks oversight of dialysis facilities to increase vaccine rates Patients are poor historians of vaccine history CMS Quality Incentive Program proposed decrease in reimbursement if vaccine goals are not met Lack of vaccine administration documentation in medical information system and vaccine data registries Summary • The overall impact of influenza, pneumonia, and the HBV is profound • Immunization is an effective strategy to prevent infectious disease related morbidity and mortality • It is imperative to recognize special immunization considerations in the CKD Stage V population • The Health Belief Model (HBM) can be used to assess immunization acceptance and promote uptake of vaccines in the hemodialysis population • Lewin’s Change Model and A Sense of Urgency tactics are effective strategies for maintaining and sustaining change related to immunization promotion. • Clinicians must continuously evaluate evidence based practice findings, such as utilization of the HBM constructs, for incorporation into individual practice settings. Conclusions and Recommendations • The nephrology Interdisciplinary team ( IDT) must educate patients regarding disease severity and vaccine benefits • The nephrology IDT must be educated regarding disease impact and special considerations in the CKD Stage V population • The nephrology IDT must be educated regarding HBM constructs and applications to disease preventive initiatives • The nephrology IDT must examine their own perceptions related to vaccines and the HBM • The nephrology IDT must consider HBM constructs when a assessing vaccine acceptance in the CKD Stage V hemodialysis patient population • Additional research is warranted regarding assessing acceptance of vaccines in CKD Stage V patients, and healthcare providers (HCP) in all treatment modality settings Conclusions and Recommendations • Facility QAPI Programs must develop processes for insuring proper obtaining vaccine history; tracking and trending vaccine administration; MIS documentation; participation in mandated vaccine registries; and development of facility specific action plans for increasing vaccinations Retrieved from http://www.google.com Conclusions and Recommendations • Dialysis providers must implement vaccine improvement programs targeting patients and staff -Vaccine Champion/Manager -Minimize barriers for patients and staff -Promote ↑ peer and family influence -Incorporate vaccine reminders/alerts in MIS -Utilize postal and electronic patient reminders -Designate vaccine education/promotion days -Utilize available CDC, Network and related resources Implications for the Future • Disease prevention and increasing vaccine uptake in the CKD Stage V patients and Healthcare Providers has a global impact -↓ morbidity and mortality in CKD Stage V population -↓ financial burden on ESRD Medicare and private payer programs -↓ financial burden on outpatient dialysis facilities -↓ patient acuity in outpatient hemodialysis setting -↑ job satisfaction for nephrology IDT Implications for the Future • The nephrology IDT is a driving force to promote influenza, pneumococcal, and HBV immunizations into individual patient’s comprehensive assessment and plan of care • Additional nephrology focused research regarding vaccine acceptance in the CKD Stage V patient and HCP in all treatment settings • Collaborative efforts and spread of best practices are imperative in the nephrology community to increase patient and HCP acceptance of vaccines and prevent the spread of infectious diseases References Berry, K. 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