Angela Adams, MSN,RN,CNN,DNP(c) Melissa Hall, DNP,RN,ANP-BC,FNP-BC,GNP-BC

1. 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

2. 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

3. Background and SignificanceOverall 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

4. Background and SignificanceOverall 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

5. Background and SignificanceOverall 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

6. 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

7. Adjusted all-cause & cause-specific hospitalization rates, by modalityFigure 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

8. 2012 Adult Immunization Schedule Based on Medical and Other Indications Retrieved from http://www.cdc.gov/vaccines/recs/images/adult-schedule-chart-2.jpg

9. USRDS 2011 Quality indicators: percentage of patients meeting clinical & preventive care guidelinesFigure 2.1 (Volume 2) • Reference • United States Renal Data System (2011). 2011 Annual Report. Retrieved from http://www.usrds.org/reference.aspx

10. Concept Map: Acceptance Context: Acceptance of Influenza and PneumococcalVaccine in the Hemodialysis Population • Modifying Variables • Age • Education level • Cultural beliefs • Religious beliefs • Socioeconomic status 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. • 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 • Defining Attributes • Alignment of patient behavior and provider advice • Ability to met mutual goals and overcome perceived barriers Acceptance • Related Terms • Compliance • Adherence • Concordance • Decision • making • 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 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

11. 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

12. Theory: Health Belief Model Context: Acceptance of Influenza, Pneumococcal and Hepatitis BVaccines in the Hemodialysis Population Individual perceptions regarding influenza, pneumococcal and hepatitis B vaccines Likelihood of Action Modifying Variables Perceived susceptibility to influenza, pneumonia, and hepatitis B • Personal Variables • Age • Education level • Cultural beliefs • Religious beliefs • Socioeconomic status Perceived benefits of the influenza. pneumococcal and hepatitis B vaccines minus perceived barriers to receiving the vaccines Perceived severity of influenza pneumonia, and Hepatitis B Perceived benefits of influenza, pneumococcal and hepatitis B vaccines • Cues to Action • Healthcare provider Vaccine prescription • Healthcare provider advisement • Vaccine information Sheet • Diagnosis of family or acquaintance with influence or pneumonia • Media campaigns Self efficacy Perceived ability to overcome the perceived barriers and receive the influenza, pneumococcal, and hepatitis B vaccines Perceived barriers to receiving 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.

13. 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

14. DNP ProjectDesign 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

15. DNP ProjectDesign 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

16. DNP Project Survey Tool

17. Data Analysis and Results • 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.

18. Data Analysis and Results

19. Data Analysis and Results • 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

20. Data Analysis and Results

21. Data Analysis and Results • 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

22. Data Analysis and Results

23. Data Analysis and Results • 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.

24. Data Analysis and Results • 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.

25. Data Analysis and Results • The Wald statistic for Hepatitis Perceived Severity was significant. Again, interpret this with caution since 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 Hepatitis B Vaccine

26. 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.

27. 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

28. Implementing and Sustaining Change • Reference • United States Renal Data System (2011). 2011 Annual Report. Retrieved from http://www.usrds.org/reference.aspx

29. Implementing and Sustaining Change • Reference • United States Renal Data System (2011). 2011 Annual Report. Retrieved from http://www.usrds.org/reference.aspx

30. Implementing and Sustaining Change Reference United States Renal Data System (2011). 2011 Annual Report. Retrieved from http://www.usrds.org/reference.aspx

31. Implementing and Sustaining ChangeA Sense of Urgency A Sense of Urgency • Bringing the outside in • Behaving with urgency every day • Finding opportunity in crisis • Dealing with “NoNos” or naysayers Retrieved from http://www.amazon.com

32. Implementing and Sustaining ChangeLewin’s Change Model Retrieved from http://www.bing.com/images

33. Force Field Analysis

34. 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.

35. 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

36. 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

37. 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

38. 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

39. 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

40. References • Berry, K. S., & Somerville, K. A. (2010). Linking change drivers and the organizational change process: A review and synthesis. Journal of Change Management, 10(2), 175-193. Retrieved from http://content.ebscohost.com.lib-proxy.usi.edu/pdf23_24/pdf/2010 • Center for Disease Control and Prevention. (2009). Data and Statistics. Retrieved from http://www.cdc.gov/Features/dsChronicKidneyDisease • Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Hamborsky J, Wolfe S, eds. 12th ed., second printing. Washington DC: Public Health Foundation, 2012. •  Champion V.L. (1984). Instrument development for health belief model constructs. Advances in Nursing Science, 6(3), 73-85. • Cork, A. (2005). A model for successful change management. Nursing Standard, 19(25), 40-40-2. Retrieved from http://search.proquest.com/docview/219846459 • Kausz, A., & Pahari, D. (2004). The value of vaccination in chronic kidney disease. Seminars in Dialysis, 17(1), 9-11. • Kotter, J. P. (2008). A sense of urgency. Boston, MA: Harvard Business Press. • Lascon, E. (2008). Vaccination in adult patients with ESRD (PDF document). Retrieved from https://fmc4me.fmcna.com • Medina-Shepherd, R., & Kleier, J. (2010). Spanish translation and adaptation of victoria champion's health belief model scales for breast cancer screening-mammography. Cancer Nursing, 33(2), 93. Retrieved from http://search.proquest.com/docview/232000454?accountid=14752 • Miller M, Boix-Mansilla V. Thinking across perspectives and disciplines. Harvard Graduate School of Education, Interdisciplinary Studies Project; Project Zero. Retrieved from http://www.pz.harvard.edu/eBookstore • Persanti, E.L. (2001). Immunological defects and vaccination in patient with chronic renal failure. Infections Disease Clinics of North America, 813-832. doi: 10.1016/S0891-5520(05)70174 • U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC. Retrieved from http://healthypeople.gov/2020 • United States Renal Data System (2011). 2011 Annual Report. Retrieved from http://www.usrds.org