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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
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