Barriers to Immunizations Among the Elderly

1
Barriers to ImmunizationsAmong the Elderly

• The University of Alabama
• Center for Mental Health and Aging
• Scientific Seminar Series
• September 22, 2003

2
Barriers to ImmunizationsAmong the Elderly

• Melissa C. Kuhajda, Ph.D.
• Assistant Professor
• Department of Community and Rural Medicine
• Department of Psychiatry and Behavioral Medicine
• College of Community Health Sciences
• The University of Alabama

3
(No Transcript)
4
IRHR Staff

• Director John C. Higginbotham, PhD, MPH
• Assistant Director for Research
• Melissa C. Kuhajda, Ph.D.
• Assistant Director for Editorial Services
• Leslie Zganjar
• Assistant Director for Information/Technology
• Mitch Shelton, Ph.D.

5
Prediction of Vaccination AmongOlder African
Americans

• Funded by The Centers for Disease Control and
  Prevention (CDC) as a Special Interest Project
  (SIP 22-01) through the UAB Center for Health
  Promotion, School of Public Health.
• Principal Investigator John C. Higginbotham,
  Ph.D., M.P.H.
• Associate Professor and Interim Chair
• Department of Community and Rural Medicine
• College of Community Health Sciences
• The University of Alabama
• Research Assistant Lasonja Kennedy, B.A., M.A.

6
Prediction of Vaccination AmongOlder African
Americans

• Investigators
• Richard Shewchuk, Ph.D., Professor, UAB
  Department of Health Services Administration.
• Rusty Foushee, Ph.D., UAB Center for Health
  Promotions Survey Research Unit, Department of
  Health Behavior.
• Karen Wooten, M.A., Mathematical Statistician,
  Centers for Disease Control and Prevention

7
Background

• Influenza and pneumonia deaths together are the
  sixth leading cause of death in the United States
  (DHHS, 2000)
• Accounting for more than 30,000 deaths each year
• Most of which occur in elderly persons (age 65
  years and older).
• Immunizations against influenza and pneumococcal
  disease can effectively prevent serious illness
  and death (CDC, 1999).

8

• Immunizations (influenza and pneumococcal) are
  associated with substantial health benefits for
  both healthy and at-risk seniors
• Reduce outpatient visits (Ashby-Hughes et al.
  1999)
• Reduce hospitalizations (Nichol et al. 1999)
• Reduce deaths (Nichol et al. 1999)

9

• It is recommended that adults aged 65 years and
  older receive
• A yearly influenza vaccine (the flu shot)
• A one-time pneumococcal vaccine (CDC, 2000)
• 5-year boosters may be required.

10

• Vaccination rates among the elderly have steadily
  increased over the past decade.
• Influenza immunization rates were 64 percent in
  1998, which is almost double the rate of 33
  percent a decade ago.
• The rates for pneumococcal vaccine have also
  increased, from 15 percent in 1988 to 46 percent
  in 1998.

11

• However, no state in the U.S. has reached the
  pneumococcal vaccination rate recommended by
  Healthy People 2000 (CDC, 1999 The prevention
  agenda for the Nation Office of Disease
  Prevention Health Promotion US Dept of Health
  Human Services www.healthypeople.gov).
• Therefore, it is believed that a comprehensive
  national education campaign is needed to promote
  both vaccines.

12

• Factors that have been found to be positively
  correlated with vaccination include
• Older age
• Presence of lung/heart disease
• Higher socioeconomic status
• Receiving the vaccination in the previous year
  (Smith et al. 1999 Chapman et al. 1999)

13

• Under-utilization of adult vaccination has been
  related to
• Lack of knowledge of needs for immunization
• Lack of awareness of immunization (Findlay et al.
  2000)
• Misconception of vaccine safety and efficacy
  (CDC, 1998)
• Lack of recommendations from health care
  providers (Morgan, 1995)

14

• Negative perception of immunization
• Inconvenience
• Painful (Armstrong et al. 2001)
• Prior experience or perception of side effects
• Negative patient attitudes (James 1995)
• Shortage of effective programs for vaccine
  delivery (Holt 1992)

15
Influenza and Pneumococcal Vaccinations Among
Older African Americans

• Elderly African-Americans have a higher incidence
  of invasive pneumococcal infection than
  White-Americans in the same age group (Harrison
  2000).
• The influenza and pneumococcal vaccination rate
  has increased slightly for elderly
  African-Americans over the past decade, but
  remains substantially below that of the general
  population.
• For example, the influenza vaccination rates of
  White-Americans was 66 percent in 1997, while for
  African-Americans, the rate was only 45 percent.

16

• Healthy People 2010 objectives include
• Increasing the proportion of noninstitutionalized
  adults who are vaccinated against pneumococcal
  disease and vaccinated annually against influenza
• Reducing disparities among racial groups (DHHS
  2000).
• The target coverage for influenza and
  pneumococcal vaccines is 90 percent (Healthy
  People 2010 Objectives 14-29a, 14-29b).

17

• To achieve this goal, more effective
  interventions for elderly African-Americans are
  required.
• Most studies have targeted high-risk inner-city
  minority populations.
• Wright et al. (2000) studied the association of
  health system factors and health status with the
  delivery of preventive services in a sample of
  African-Americans age 70 and older from
  low-income neighborhoods in Cleveland, Ohio.

18

• Armstrong et al. (2001) studied a low-income
  urban population predominated by
  African-Americans.
• The vaccination rate for children in rural areas
  was found to be lower than in metropolitan areas
  (Luman et al. 2001), and this trend may hold for
  older populations.

19

• Few studies have examined the immunization
  patterns of older rural African-American
  populations and their implication for disease
  prevention .
• Whether previously recommended vaccination
  strategies will effectively improve the
  acceptance rate in this population needs to be
  further studied in order to determine the most
  cost-effective measures to increase vaccination
  coverage.

20
Objectives

• Identify the predictors of adult immunization
  (influenza pneumococcal)
• knowledge
• attitudes
• beliefs
• barriers
• facilitators

21

• Compare identified predictors among older
  African-Americans and older White-Americans in
  urban and rural areas.

22
Study Aims

• 1. Nominal Group Technique (NGT) Groups (Delbecq,
  Van de Ven, Gustafson, 1975 Miller et al.
  2000)
• A series of idea-generating sessions with 65-
  years-old or older African-Americans and
  White-Americans in urban and rural areas of
  Alabama.
• Summarize ideas in brief statements
• Choose the five most important ideas
• Rank these five ideas in terms of importance.

23

• 2. Rating Scale Tasks
• Use the results from the NGT group sessions to
  develop and implement a rating scale task in
  which participants will rank in order of
  importance specific barriers and facilitators to
  immunizations.

24

• 3. Vaccination Predictors Questionnaire (VPQ)
• Use the results from the rating scale tasks and
  the extant literature to develop and then pretest
  a low literate, minimally burdensome
  questionnaire (Vaccination Predictors
  Questionnaire, VPQ), which will assess the
  prevalence of the various predictors of
  vaccination.

25

• 4. National Survey
• Utilize the new and pretested VPQ to conduct a
  national survey of a representative sample of
  older African- and White-Americans from both
  rural and urban localities to determine the
  prevalence of the identified predictors and to
  determine commonalities and differences between
  ethnic, gender and/or ruralurban groups.

26
Procedure

• Separate NGT meetings were convened with
  participants stratified by
• 1. Vaccination Status
• a. Those who have regularly received the
  influenza vaccine
• b. Those who have received the influenza vaccine,
  but not regularly
• c. Those who have never received the influenza
  vaccine
• d. Those who have received the pneumococcal
  vaccine
• e. Those who have never received the pneumococcal
  vaccine

27

• 2. Race
• a. African-American
• b. White-American
• 3. Residence
• a. Urban
• b. Rural

28

• 4. Question
• a. Facilitator
• What sorts of things would make you
  decide to get a flu pneumonia shot?
• b. Barrier
• What sorts of things would make you
  decide not to get a flu pneumonia shot?

29

• 40 NGT Groups were conducted
• Urban, African-American, Facilitator Question (5)
• Urban, African-American, Barrier Question (5)
• Urban, White-American, Facilitator Question (5)
• Urban, White-American, Barrier Question (5)
• Rural, African-American, Facilitator Question (5)
• Rural, African-American, Barrier Question (5)
• Rural, White-American, Facilitator Question (5)
• Rural, White-American, Barrier Question (5)

30
Alabama Counties by Percent of Population in
Poverty, 1990
Percent Poverty
Urban Groups
31
Method

• A comprehensive cognitive mapping strategy,
  concept mapping, consisting of a blend of
  quantitative and qualitative methodology will be
  employed (Axelrod 1972, 1972, 1976 Bitonti 1993
  Young 1996 Meszaros et al. 1996 Roth et al.
  1992 Trochim 1989).
• NGT results will inform ranking scale tasks,
  which will, in turn, inform the Vaccination
  Predictors Questionnaire (VPQ).
• Analyses will involve multidimensional scaling
  (MDS Kruskal et al. 1978) and cluster analysis
  (Everitt 1974 Aldenderfer et al. 1984).

32
Results

• The NGT process was found to be wearisome for
  some seniors, especially those with low literacy
  skills.
• As a result, the NGT procedures were modified.

33
Preliminary Results...

• Most Frequently Identified Barriers to Adult
  Vaccination
• 1. Becoming ill from the vaccination
• 2. Fear of needles

34

• Most Frequently Identified Facilitators to Adult
  Vaccination
• 1. Physician recommendation
• 2. Desire to prevent getting the flu
  pneumonia

35

• Other commonly identified Barriers include
• 1. No transportation
• 2. Concern about contraindications with
• other medications
• 3. Physician never mentioned it
• (pneumonia shot only)

36

• Other commonly identified Facilitators include
• 1. Availability -- No patient fee
• 2. Old Age -- Weaker immune system
• 3. To stay healthy

37
Conclusions

• NGT Benefits
• Generates large number of ideas
• Permits measures of importance of ideas
• Allows equal opportunity to voice concerns
• Avoids quick decision making
• High degree of task completion

38

• However, for our senior citizen population in
  both rural and urban areas, many participants
  with low literacy skills became frustrated with
  this demanding process.

39

• The goal of obtaining information about the
  barriers and facilitators of adult vaccination
  appears to get lost in the complexity of the NGT
  process.
• If NGT process is implemented with participants
  with low literacy skills, modifications are
  necessary.

40
References

• Afessa B, Greaves W, Frederick W. Pneumococcal
  Bacteremia in Adults A 14-year Experience in an
  Inner-city University Hospital, Clinical
  Infectious Diseases 199521(2)345-51.
• Aldenderfer MS, Blashfield RK. Cluster Analysis.
  Beverly Hills, CA Sage Publications 1984.
• Armstrong K, Berlin M, Schwartz JS, Propert K,
  Ubel PA. Barriers to Influenza Immunization in a
  Low-income Urban Population. American Journal of
  Preventive Medicine 200120(1)21-25.
• Ashby-Hughes B, Nickerson N. Provider
  Endorsement The Strongest Cue in Prompting
  High-risk Adults to Receive Influenza and
  Pneumococcal Immunizations. Clinical Excellence
  for Nurse Practitioners The International
  Journal of NPACE 19993(2)97-104.
• Axelrod R. Framework for A General Theory of
  Cognition. Berkeley, CA Institute of
  International Studies 1972.
• Axelrod R. Psycho-Algebra A Mathematical Theory
  of Cognition and Choice with an Application to
  the British Eastern Committee in 1918. Papers of
  the Peach Research Society 197218113-31.
• Axelrod R. The Structure of Decision The
  Cognitive Maps of Political Elites. Princeton,
  NJ Princeton University Press 1976.

41
References (continued)

• Bitonti C. Cognitive Mapping A Qualitative
  Research Method for Social Work. Social Work
  Research and Abstracts 199329(1)9-15.
• Centers for Disease Control and Prevention.
  Reasons reported by Medicare beneficiaries for
  not receiving influenza and pneumococcal
  vaccinations United States, 1996. Morbidity
  Mortality Weekly Report 199948(39)886-90.
• Centers for Disease Control and Prevention.
  Race-specific Differences in Influenza
  Vaccination Levels among Medicare
  BeneficiariesUnited States, 1993. Journal of
  the American Medical Association
  1995273(6)449-51.
• Centers for Disease Control and Prevention,
  National Center for Health Statistics. Healthy
  People 2000 Review, 1998-1999 2000.
• Centers for Disease Control and Prevention.
  Influenza and Pneumococcal Vaccination Levels
  among Adults Aged gt65 Years United States,
  1997. Morbidity Mortality Weekly Report 1998
  47(38)797-802.
• Chapman GB, Coups EJ. Predictors of Influenza
  Vaccine Acceptance Among Healthy Adults.
  Preventive Medicine 199929(4)249-62.
• Delbecq AL, Van de Ven AH, Gustafson DH. Group
  Techniques for Program Planning A Guide to
  Nominal Group and Delphi Processes. Glenview, IL
  Scott, Foresman 1975.

42
References (continued)

• Everitt B. Cluster Analysis. New York John Wiley
  and Sons 1974.
• Findlay PF, Gibbons YM, Primrose WR, Ellis G,
  Downie G. Influenza and neumococcal Vaccination
  Patient Perceptions. Postgraduate Medical
  Journal 200076(894)215-17.
• Harrison LH, Dwyer DM, Billmann L, Kolczak MS,
  Schuchat A. Invasive Pneumococcal Infection in
  Baltimore, Md. Archives of Internal Medicine
  2000160(1)89-94.
• Holt D. Recommendations, Usage and Efficacy of
  Immunizations for the Elderly. Practitioner
  199217(3)51-52, 58-59.
• James A. Influenza Vaccination in the Elderly.
  Journal of Investigational Allergology and
  Clinical Immunology 19955(2)73-77.
• Luman ET, McCauley MM, Rodewald LE. A Measure of
  Success Findings from the National Immunization
  Survey. American Journal of Preventive Medicine
  200120 (Suppl.).
• Meszaros J, Asch D, Baron J, Hershey J,
  Kunreuther H, Schwartz-Buzaglo J. Cognitive
  Processes and the Decisions of Some Parents to
  Forego Pertussis Vaccination for Their children.
  Journal of Clinical Epidemiology
  199649(6)697-703.

43
References (continued)

• Miller D, Shewchuk R, Elliot TR, Richards S.
  Nominal Group Technique A Process for
  Identifying Diabetes Self-Care Issues among
  Patients and Caregivers. Diabetes Education
  200026(2)305-10, 12, 14.
• Morgan R, King D, Turnbull C. Influenza
  Vaccination Do the Aged Reap the Benefit?
  Postgraduate Medical Journal 199571(831)22-23.
• Nichol KL, Baken L, Nelson A. Relation Between
  Influenza Vaccination and Outpatient Visits,
  Hospitalization, and Mortality in Elderly Persons
  with Chronic Lung Disease. Annals of Internal
  Medicine 1999130(5)397-403.
• Nichol KL, Goodman M. The Health and Economic
  Benefits of Influenza Vaccination for Healthy
  and At-risk Persons Aged 65 to74 Years.
  Pharmacoeconomics 199916(Suppl 1)63-71.
• Roth WM, Gabel D. A Combined Method of INDSCAL
  and Cognitive Mapping for Describing Changes in
  Students Cognitive Structure. Educational
  Psychological measurement 199252(3)769-79.
• Smith DM, Zhou XH, Weinberger M, Smith F,
  McDonald RC. Mailed Reminders for Area-wide
  Influenza Immunization A Randomized Controlled
  Trial. Journal of the American Geriatrics
  Society 1999 47(1)1-5.
• Trochim WM. An Introduction to Concept Mapping
  for Planning and Evaluation. Evaluation and
  Program Planning 198912(1)1-16.

44
References (continued)

• U. S. Department of Health and Human Services.
  Healthy People 2010 (conference edition, in two
  volumes). Washington, D.C. U. S. Department of
  Health and Human Services 2000.
• Wright P, Fortinsky R, Covinsky K, Anderson P,
  Landefeld C. Delivery of Preventive Services to
  Older Black Patients Using Neighborhood Health
  Centers. Journal of the American Geriatrics
  Society 200048(2)124-30.
• Young MD. Cognitive Mapping Meets Semantic
  Networks. Journal of Conflict Resolution
  199640(3)395-414.

45
(No Transcript)