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Population

          Evidence-based models use a process for framing a question, locating, assessing, evaluating, and repeating as needed. PICO (T) elements include: Problem/Patient/Population, Intervention/Indicator, Comparison, Outcome, and (optional) Time element or Type of Study. The question for this study is as follows:

In patients aged 60 years and above (P), what is the effect of being administered the influenza vaccine (I) on contracting pneumonia (O) compared with not receiving the influenza vaccine (C) during the Flu season (T)?

Overview

            Post-influenza microbial pneumonia is a major cause of morbidity and death associated seasonal and pandemic influenza virus (Matersky et al., 2012). Vaccination is the most common way to prevent the instances of attack from pneumonia (Heo et al., 2017).  The process in addition to reducing the prevalence of attack helps avert the economic consequences resulting from hospital admission of the patients (Iannazzo, 2011).

Among the elderly, the condition is mainly prevalent due to the reduced immunity of this group of individuals. The high risk is due to reduced immunity and other age-related conditions such as heart diseases and lung conditions like cystic fibrosis and asthma which contribute to the sickness among this group (Sollitto, 2017). Although the influenza vaccine is important in preventing pneumonia, there is little clarity on the extent of its effectiveness

Population

            The study will focus on adults aged 60 years and above who are drawn from both genders. The subjects will be collected from the community as well as those in the nursing homes in addition to others admitted to the hospital for conditions other than pneumonia. Subjects already diagnosed with the influenza strain of pneumonia will be excluded from the study.

Intervention

The subjects under study will be accorded an immunization treatment using the conventional influenza vaccines.

A standardized laboratory test will be undertaken periodically to assess the patients’ levels of resistance. A supervised exercise will also be included in the study where all the subjects will be monitored to establish any outcomes that would result from the study.

Comparison

As a comparison, a group of patients will be used that have chosen to not be administered with the vaccine and their reactions compared to those under the immunization program. The scientific term for this group is the control group. Again these are individuals who have chosen beforehand not to receive the influenza vaccine. We are monitoring them and they will receive any necessary medical interventions. 

Intervention

Outcome

A laboratory test will be undertaken periodically to assess the patients’ resistance to the influenza strain and monitor for pneumonia under the immunization program. The differing members of the control group will also be assessed to determine whether the patients not given the vaccine were able to resist infection. The impact of the vaccines will be evaluated based on the diagnosis of the two groups of patients under the programs.

From the study, the researchers will expect to see a better response to immunization with the vaccinated patients not as likely to develop pneumonia. The effect of vaccines will also be of great importance to the study in determining their effectiveness.

Time

The outcomes will be measured twice weekly during the course of the Flu season but this could be changed to more often the period of an epidemic outbreak.

Conclusion

It can be concluded that it is warranted to evaluate the usage of diverse vaccine formulations in preventing influenza infections, post-influenza pneumonia, and hospitalization of the elderly which occur as a result. In addition, based on the need to maximize cost-savings, and economic impact that results from associated hospital bills, influenza vaccines need to be tailored to the elderly to avert such eventualities

A conclusion will be made from the outcomes of the study whether it is the act of being vaccinated for the influenza virus has any determination as to the likelihood of developing pneumonia in individuals aged 60 years and above.

Respect for persons

Under this principle, every individual deserves the right to exercise their autonomy fully. There is a need for the nurses to develop a system of interaction to ensure that the individuals in the study are able to make choices regarding investigations and various laboratory processes involved in the evaluation and diagnosis. For those diagnosed with pneumonia, it is just that proper treatment is accorded to them indiscriminately. As the patients are elderly persons above the age of 60 years, proper respect should be practiced in relation to their beliefs and resolve regarding the treatment process. The nurses should also explain to the patients the importance of accepting vaccination as the process is likely to reduce their chances of infection and other influenza-related complications.

Beneficence

            The project has the benefit in raising awareness on the importance of vaccination especially to the elderly during periods of high disease outbreaks and epidemic. The study also highlights that it may be beneficial to immunize against pneumonia as influenza. The Study also shows evidence that immunization has cost reduction implications as the prevented infection will reduce the possibility of admission where admission and treatment costs are believed to bring a burden to the patient and their caregivers.

Comparison

There are risks of pneumonia infection for the group that does not receive immunization. The risk would have consequences of economic burden in relation to cost that arise when an individual is infected with influenza-related pneumonia. In averting such risks, the elderly need to be educated on the importance of undergoing vaccination as this practice would greatly help in preventing the possibilities of contracting pneumonia

Justice

Again, every individual deserves fair and equal distribution of the health benefits of immunization against influenza. In order to ensure equal treatment of every individual, I would propose that community-based sensitization mechanism to be undertaken to try to reach out to every individual who may be deemed in need of the vaccination.

The findings from the evidence-based studies also need to be distributed to all potential clients through educating their nurses involved in their care. Making the information about the study readily available to the different hospital units and departments will ensure that it reaches a wide number of interested parties who may evaluate such information with regards to their applicability and the potential benefits that would accrue.

Overview of Quantitative Study One

Pneumococcal vaccine is remarked to be the primary preventative approach to pneumonia in older adults. However, the effectiveness of the strategy is controversial though, this has not affected its usage since it is becoming more prevalent. Most notably, conflicting results have been yielded from observational studies as well as randomized controlled trials aimed at determining immune response and clinical outcomes regarding the pneumococcal injection (Vila-Corcoles, Ansa, Ochoa-Gondar, Satue, De Diego, & Rodriguez-Blanco, 2016). Accordingly, the elderly with comorbidities are more exposed to developing pneumonia since their immune system is vulnerable. Despite the fact that the pneumococcal vaccination is not adequate and an effective measure, its ability to prevent the disease ought to call for its embracement among the aged.

Type of Study – Article I

The type of study described is quantitative for the reason that information about particular cases is produced, and its conclusions are hypotheses. Also, tables and statistics were used to demonstrate the effectiveness of the vaccines in people aged 60 years and above.

Threats to Internal and External Validity – Article I

            The fact that vaccination method is not used appropriately by the healthcare workers affected the investigation. Following the study, age is a vital factor when determining the dosage of vaccine that should be administered to a particular patient. Notably, people ranging from 60-64 years ought to get the PPSV23 vaccination if they have a nephrotic syndrome or chronic renal failure, smokers, incurable cancer and other disorders (Vila-Corcoles et al., 2016). In case one has the first vaccination they need to have the second one at least after five years. Moreover, during clinical trials that aimed at determining the effectiveness of vaccines, the findings from the study lacked a placebo group and also neither investigator nor subjects blinded to the immunization assignment. Ultimately, such circumstances that were embedded in the survey undermine the vaccines validity.

Outcome

Applicability – Article I

            It is remarked in the study that the effectiveness of the PPSV23 vaccine is controversial. For example, some reviews were made and following some clinical trials a reduction in death of the older patients with pneumonia was recorded, but the mortality was not consistent. Notably, these findings threatened the healthcare workers, and according to the research, they opted for optimizing the available vaccine (Vila-Corcoles et al., 2016). More modification to the vaccines was to be done to meet the interests of different patients in the hospitals. Evidently, it was through the application of EBP that the clinicians were able to identify the gap in the type of medication and following patient’s values they were able to enhance the services. Therefore, the discussion unquestionably applied EBP in their study to get better clinical results.

Overview of Quantitative Study Two

            Vaccination is undeniably the primary preventative approach to influenza in the older adults. The health concern is a respiratory infectious disease that has contributed to high rates of death among people of 60 years and above. It is remarked that influenza is so prevalent during the winter seasons because of the unfavorable climate people get exposed to. According to Restivo, Costantino, Bono, Maniglia, Marchese, Ventura, Vitale, (2017), healthcare workers have also contributed to the spread of the influenza virus in their patients. The approximate rate of the infection in healthcare workers ranges from 20% to 47%, and remarkably they continue working while infected, thus, giving preferentiality to the spread of the virus. For this matter, persons above the age of 60 years not only acquire the infection from the other patients but also from the healthcare workers, however, with influenza vaccination it may be prevented.

Type of Study – Article II

The type of study is quantitative given the fact that the findings are centered on more significant sample dimensions to represent the population, and the research question is defined. More so, the researcher used tables to demonstrate the results of the study, for example, the one showing the effectiveness of influenza virus.

Threats to Internal and External Validity – Article II

            The primary internal threat discussed in the article is the potential overestimation of the influenza vaccination status. Most notably, some examined studies used entirely or partially referred vaccination status without any validation technique available. The approach could evaluate particular methods of vaccine uptake responsible for recall bias. For example, past influenza immunization uptake could be disorganized with the contemporary one (Restiv et al., 2017).

Time

It is imperative that researchers who depend on self-reported influenza vaccination status put in mind that approximately 10% of the infected people are likely to be misclassified. As such, immunization can be certified by an external resource to do away with misclassification. Therefore, the threat discussed in the article was misclassification that would have hindered accurate findings.

Applicability – Article II

In accord with the study, the influenza virus is prevalent in persons of 60 years and above. As such, the healthcare workers following different and several experiments concluded that with influenza vaccination the virus could be eliminated. According to Restiv et al., (2017), vaccination effectiveness was also analyzed in persons with comorbidities. The nurses were able to carry out all these trails and conclusions through the application of EBP. They used their experience and considering the values of their patients to set clear objectives. Besides, without the application EBP, they would not be able to identify the underlying factors related to the infection and the primary preventative approach. Therefore, the applicability of EBP in the article was embraced since the studies were justified and transparent.

Qualitative Study One

In this paper, the author explored the factors perceived by the nurses necessary to hinder and help the influenza rates among the elderly patients. The study is justified as the influenza rate is considerably higher in elderly and related mortality. Vaccination for preventing influenza is considered an effective tool. As per the study findings the prevalent barriers identified by the nurses are technical considerations, feeling of good health, and side effects of vaccine. According to the nurses perception the facilitators of influenza vaccine in elderly are ease of access and encouragement from the health care providers, social media networks, direct recommendations from the care providers and leading by example. 

Type of Study

The author uses semi structured interview for collecting the qualitative data. This method balances the flexibility of a focused structured ethnography survey and the flexibility of an open ended interview (Reeves et al., 2015). The interview was focused on the nurses’ view of facilitators, barriers, and health care providers in vaccinating elderly influenza patients.

Credibility, Confirmability, Dependability, and Transferability

The author of the qualitative study has ensured the credibility of the research by sharing the academic credentials. The author holds Ph.D. and highlights workplace. It explains the author has in-depth knowledge and expertise to conduct research in health sector. Moreover, the results seem to be believable from the perspective of the nurses, who are the participants of the research and are justified for data collection as they are caregivers.

Respect for Persons

However, the credibility would have been high if the nursing population was represented as a whole. The transferability may not be said to have ensured in this study as the nurses relied on the past experiences and the interviews were not conducted in the real time. In order to transfer the results to different context, the effect of the health care team on vaccine rates should be examined directly in real time (Ellen, 2017). The author has ensured the conformability of the research by checking and rechecking the data. Two researchers were used for coding each interview and highlighted the taxonomy used. 

However, judging the potential bias or distortion would have increased conformability (Kallio et al., 2016). If the same participants are chosen once again then there is chance of getting similar data but new set of nurse group would not replicate the previous data. Representing the nurse pupation as a whole would and using audit trial can make the results more dependable (Fernandez et al., 2018). 

Applicability

This study may not be applicable for my study population as I want to conduct observational study to note experiences of nurses in real time in mediating vaccination in elderly people.

Qualitative Study Two

In the second qualitative study the author explores the behavioral related factors affecting the influenza vaccination among elderly.

Type of Study

For this purpose the author conducts a systematic review and uses framework derived from the Theory of Reasoned Action and the health belief model. As per the findings the mediating variables influencing the vaccination behaviour are threat perception, beliefs related to side effects, past behavior, recommendations from the health professionals and perceived barrier such as side effects, financial burden, and transportation cost.

Credibility, Confirmability, Dependability, and Transferability

The credibility of the article seems to have decreased as the author did not involve papers that are in non-English languages. Important evidence may have excluded. As most of the data reviewed is of qualitative nature the causal relationship cannot be drawn (Kan & Zhang, 2018). No eligibility assessment was conducted before excluding the inaccessible full texts or the poor quality studies. However, reliability is ensured as the quality assessment of the selected study was conducted using STROBE and CASP checklist and presented as table.

Conformability is insured owing to the relevancy of relevant studies and less excluded studies. Dependability is minimized as the papers selected have participants from different parts of world and the culture reflected may vary. Results from systematic review cannot be directly transferred to experiences of health care services in other regions of world (Bowling, 2014). Hence, transferability in systematic review is diminished. Overall trustworthy analysis is difficult in systematic review as different studies as different aims (Holm & Severinsson, 2013).

Beneficence

Applicability

The study I believe may not be applicable to my research on elderly patients for preventing influenza as despite publish of large number of systematic reviews there is lack of consideration of information related to applicability of results (Ahmad et al., 2010).

Ranking the Evidence

According to LoBiondo-Wood and Haber (2017) hierarchy of evidence of level of evidence in nursing research are assigned on the basis of methodological quality of their validity, design and applicability. The evidence hierarchy acts as a valuable tool that permits researchers to undertake a top-down approach for identifying the best evidence. This eight part hierarchy of evidence has meta-analysis studies at level I and systematic reviews at level II, denoting that these are the two strongest forms of evidences. These are followed by randomized controlled trials, cohort studies, case control studies, case series, expert opinions and animal research studies.

Figure: Hierarchy of evidence (LoBiondo-Wood &Haber, 2017)

The research conducted by Vila-Corcoles et al., (2016) is a population-based cohort study, investigated the burden of pneumococcal pneumonia on older adults. The study thus falls into level IV evidence category. The study of Ellen (2017) is also a cohort study with data collected through semi-structured interviews for collecting data from nurses focusing on facilitators and facilitators for vaccination. In addition it assessed health care providers' roles in influencing patients to be vaccinated. 

The study thus falls into level IV evidence category. Restive et al., (2017) carried out a meta-analysis quantifying data that reported influenza vaccine effectiveness (VE) on hospitalizations and influenza visits involving cohort and case control studies carried out with high-risk groups. This study is a part of level I evidence as per the hierarchy of evidence. The study of Kan and Zhang (2018) is a systematic review that explored the behavior-related factors influencing influenza vaccination in relation to elderly people with the help of the Theory of Reasoned Action (TRA) and the Health Belief Model (HBM). This study is therefore level II evidence.

Strength of evidence

Based on the level of evidence for each study, it is to be concluded that the strength of evidence is moderate since two studiess are level IV, one is level I and one is level II.  The strength of evidence would have been high if at least two of the evidences were level I evidence and two others were either level II or level III (LoBiondo-Wood & Haber, 2017).This implies that the evidence are to undergo further scrutiny before considering application in nursing practice.

Justice

Nursing evidence based research has the aim of reviewing research studies and grading the quality of the respective articles. Ranking the bodies of evidence as per the hierarchy of evidence is useful for understanding the quality of studies. The strength of evidence addressing the present PICO question is moderate due to the methodologies of the respective studies. In nursing, evidence based research it is advisable to apply evidence of high strength into practice. 

Practice Recommendation 1

            Pneumococcal vaccines can be considered as a preventive measure for dealing with pneumonia in older adults. According to Assaad et al., (2012) vaccination is a primary preventive strategy for the elders suffering against Streptococcus pneumonia and other influenza infections.

The efficiency of the pneumococcal vaccine has not been established firmly due to the lack of the randomized control trials involving the patients greater than 65 years of age. According to Assad et al., (2012) vaccination is a primary preventive strategy for the elders suffering against Streptococcus pneumonia and other influenza infections. Studies have shown that PCV7 has been highly effective in preventing the invasive pneumococcal disease in the older adults. In 2010, FDA has given license to PCV 13, which can provide protection against infections caused by 6 more serotypes than the PCV7. CDC has recommended pneumococcal vaccines for all the adults who are 65 years older or more.

Practice Recommendation 2 

The peer reviewed literature will help to provide information regarding the effect of the influenza virus, the mode of action of the vaccine, the portals of entry of the virus and different evidences supporting the effectiveness of the influenza vaccine. Seasonal or pandemic influenza are often complicated by the bacterial infection. Influenza A virus is one of the most common pathogen that is responsible for causing respiratory illness in older adults. According to Lang ET AL.,(2012), According to the author the influenza vaccine are effective and can act as cost effective for the elderly population. The paper describes about a randomized control trial that has been done involving a group of healthy volunteers over the age of 60 and they were randomly assigned for getting a placebo or an influenza vaccine that is trivalent inactivated.

The paper aimed at identifying all the meta-analysis that can estimate the effectiveness of the influenza vaccine. All the literatures have been searched by electronic databases like PUBMED, MEDLINE. 

Strength of Recommendation 1

Type of evidence- Review

Overview of Quantitative Study One

Increased grade- As it bears a strong evidence of association with a relative risk of >5(<0.2) based on evidence.

The strength of this study is that it provides a wide view of the outcomes of the acute disease with which the physicians have to deal with. The paper gives information regarding the recent recommendations of the advisory committee on the Immunization practice for people above 65 years age. It can also be known about the various antibody responses occurring following the vaccination. The paper also reveals the fact that effectiveness of the PPSV23 in mitigating the symptoms of pneumonia is controversial. Several studies have showed that PPSV23 have brought about the reduction of the deaths among the older adults.

The strength of this study is that it provides the rationale for taking up pneumococcal vaccine by the older adults.

Strength of Recommendation 2

Types of evidence- Peer reviewed journal

Overall quality of the evidence- Moderate.

Study design- peer reviewed literature on randomized control trials ad observational studies.

The strength of this recommendation is that provides an estimate of the effectiveness of the influenza vaccine. According to this paper, a randomized control trial could actually found out that the effectiveness of the influenza vaccine in a mixed hospital and a community has been 41% and 58% respectively.  The effectiveness of the influenza vaccine for the influenza like illness was found to be 23% (with 95% confidence interval).

The paper provides an insight to the fact that influenza vaccine has been found to prevent hospitalization of the older adults in almost 49 % of the cases. The strength of this paper is that it provides information of the different factors that actually helps in measuring the effectiveness of the vaccine. The paper has also referred to the biases that can be partially or completely responsible for the data against the effectiveness of the influenza vaccine. The rising deaths and the increased rates of hospitalization due to influenza, in spite of the trivalent influenza virus vaccine raise the question on the development of the vaccine. Yet, the evidence provided by this paper indicate towards the future implication of the vaccine in this field. The information in this paper provides the rationale for choosing this paper for the topic.

Key Stakeholders

The key stakeholders for the evidence based project are older patients/participants with pneumonia, patients at risk of pneumonia, nurses, community people and clinicians and academic researchers. The stakeholder identification process is based on the stakeholder analysis, judgement of the experts and team meetings. Using the power and influence grid the stakeholders with the greater power would be closely managed and updated continuously. I will keep informing stakeholder with high power and low interest about the project. I will monitor the stakeholder with low interest and low power.  

Threats to Internal and External Validity – Article I

Strategies

In order to involve and engage them in making changes that are recommended, It will be symbolic participation. It will have a place at a table allowing the stakeholders to hear the plan. It will allow them to have a voice and have a meaningful engagement that also involves shared decision making related to pneumonia immunization.  With the help of the Participatory Social Network Analysis, it would be easy to collaborate with the stakeholders and evaluate the EBP from the community’s perspective (Peters, Bhuiya & Ghaffar, 2017). This strategy better helps to identify the stakeholders and bring together the researchers to promote the recommendations for the immunization treatment using the conventional influenza vaccines. Further, it would be effective to take the advantage of the stakeholder’s capability and address the challenges (Goodman, & Sanders Thompson, 2017).

With the help of the transformational leadership quality a dialogue can be built with the stakeholders. With the help of the profile analysis meetings, it will be easy to engage the stakeholders while assessing their role, impact, interest and expectations in the project. It will also help identify the level of stakeholder engagement. It would be beneficial to balance the expert judgement with input from the stakeholders. The communication method most appropriate for the purpose would be used along with the interpersonal skills. It will help build trust and resolve conflict (Pandi-Perumal et al., 2015).

Resistance

Initially the level of resistance of the stakeholders will be assessed. To overcome the resistance the strength of the recommendations should be explained. For the first recommendation, there is a strong evidence of association with a relative risk of >5(<0.2). The resistance can be decreased by sharing the results related to the reduction in death by PPSV23 and its implication in taking up pneumococcal vaccine to mitigate the pneumococcal vaccine.

The strength of the second recommendations should also be shared. The data from the randomised control trial could be shared with the stakeholders through graphical illustrations and poster management. There are more number of secondary papers that align with the research recommendations in the concerned EBP. To overcome the resistance, research information would be disseminated effectively. It may include interactive sessions, workshops, and video presentations.

The strategy is to discuss the issues identified by the stakeholders and highlights the solutions that would mitigate any proposed risks. The key to overcome resistance as an effective leader is to harness the resistance ad use it as the resource. The next thing would be to boost the awareness related to change. It will reduce the worries and help return to the purpose of change again and again to keep in front the positive aspects in the mind of stakeholders (Matos Marques Simoes, & Esposito, 2014).

Applicability – Article I

Evaluation of results of interventions

The evaluation would include further collection of data from the hospitals demographic information and dose delivered. The primary outcome would be the number of adults receiving atleast one dose of vaccine at the clinic as per the program, record. Further, record includes total number of doses delivered. Mixed logistic regression model would be used followed by statistical analysis.  For evaluating the outcomes of the interventions in the community a mix-method evaluation will be conducted. It will include a post intervention comparison of vaccination uptake.

Randomly six interventions maybe selected and compared with the control group communities. The initiative may be delivered in partnership with government. In conducting the investigation the errors and flaws of other researchers in similar process will be eliminated. The patents reason for immunisation, barriers to immunisation would be characterised. Surveys will be conducted to know the reason for refusal (Taddio et al., 2015).

The key questions to be considered during evaluation are-

  • Level of partnership on the continuum of the stakeholder engagement?
  • Was the stakeholder engagement meaningful?
  • Is there an improvement in the fit of evidence based practice in comm. unity settings?

Another strategy to evaluate is conducting interrupted time series analysis. It is effective in evaluating the population level health interventions after it is implemented in implemented at a clearly defined point in time (Bernal, Cummins & Gasparrini, 2017).

References

Heo, J. Y., Song, Y. J., Noh, Y. J., Choi, M. J., Yoon, G. J., Lee, S. N., . . . Kim, J. W. (2017). Effects of Influenza immunization on pneumonia in the elderly. Human Vaccines & Immunotherapeutic, 1-23.

Iannazzo, S. (2011). Pharmacoeconomic evaluation of the MF59- adjuvanted influenza vaccine in the elderly population in Italy. Torino: AdRes Health Economics & Outcomes Research.

Matersky, M. L., Masterton, R. G., Lode, H., File, T. M., & Babinchak, T. (2012). Epidemiology, microbiology, and treatment considerations for bacterial pneumonia complicating influenza. International Journal of Infectious Diseases, 16(5), e321-e331.

Sollitto, M. (2017, July 13). Why Seniors Are More Susceptible to Pneumonia. Retrieved from AgingCare.com:

Restivo, V., Costantino, C., Bono, S., Maniglia, M., Marchese, V., Ventura, G, Vitale, F. (2017). Influenza vaccine effectiveness among high-risk groups: A systematic literature review and meta-analysis of case-control and cohort studies. Human Vaccines & Immunotherapeutics, 1-12. doi:10.1080/21645515.2017.1321722

Vila-Corcoles, A., Ansa, X., Ochoa-Gondar, O., Satue, E., De Diego, C., & Rodriguez-Blanco, T. (2016). Pneumococcal pneumonia in adults 60 years or older: Incidence, mortality and prevention. Medicina Clínica, 146(5), 199-202. doi:10.1016/j.medcli.2015.09.015

Ahmad, N., Boutron, I., Dechartres, A., Durieux, P., & Ravaud, P. (2010). Applicability and generalisability of the results of systematic reviews to public health practice and policy: a systematic review. Trials, 11(1), 20.

Bowling, A. (2014). Research methods in health: investigating health and health services. McGraw-Hill Education (UK).

Ellen, M. (2017). Factors that influence influenza vaccination rates among the elderly: nurses’ perspectives. Journal of nursing management. 

Fernandez, R., Sheppard-Law, S., Curtis, S., Bancroft, J., & Smith, W. (2018). Exploring the experiences of neophyte nurse mentors: A qualitative study. Nurse education in practice, 29, 76-81.

Holm, A. L., & Severinsson, E. (2013). A qualitative systematic review of older persons’ perceptions of health, ill health, and their community health care needs. Nursing research and practice, 2013.

Kallio, H., Pietilä, A. M., Johnson, M., & Kangasniemi, M. (2016). Systematic methodological review: developing a framework for a qualitative semi?structured interview guide. Journal of advanced nursing, 72(12), 2954-2965.

Kan, T., & Zhang, J. (2018). Factors influencing seasonal influenza vaccination behaviour among elderly people: a systematic review. Public Health, 156, 67-78. 

Assaad, U., El-Masri, I., Porhomayon, J., & El-Solh, A. A. (2012). Pneumonia immunization in older adults: review of vaccine effectiveness and strategies. Clinical Interventions in Aging, 7, 453–461. 

Lang, P.-O., Mendes, A., Socquet, J., Assir, N., Govind, S., & Aspinall, R. (2012). Effectiveness of influenza vaccine in aging and older adults: comprehensive analysis of the evidence. Clinical Interventions in Aging, 7, 55–64. http://doi.org/10.2147/CIA.S25215

Bernal, J. L., Cummins, S., & Gasparrini, A. (2017). Interrupted time series regression for the evaluation of public health interventions: a tutorial. International journal of epidemiology, 46(1), 348-355. DOI:

Bernal, J. L., Cummins, S., & Gasparrini, A. (2017). Interrupted time series regression for the evaluation of public health interventions: a tutorial. International journal of epidemiology, 46(1), 348-355.

Goodman, M. S., & Sanders Thompson, V. L. (2017). The science of stakeholder engagement in research: classification, implementation, and evaluation. Translational behavioral medicine, 7(3), 486-491. DOI:  

Matos Marques Simoes, P., & Esposito, M. (2014). Improving change management: How communication nature influences resistance to change. Journal of Management Development, 33(4), 324-341. Retrieved from

Pandi-Perumal, S. R., Akhter, S., Zizi, F., Jean-Louis, G., Ramasubramanian, C., Edward Freeman, R., & Narasimhan, M. (2015). Project stakeholder management in the clinical research environment: How to do it right. Frontiers in psychiatry, 6, 71. 

Peters, D. H., Bhuiya, A., & Ghaffar, A. (2017). Engaging stakeholders in implementation research: lessons from the Future Health Systems Research Programme experience. DOI: 

Taddio, A., Shah, V., McMurtry, C. M., MacDonald, N. E., Ipp, M., Riddell, R. P., ... & Chambers, C. T. (2015). Procedural and physical interventions for vaccine injections: systematic review of randomized controlled trials and quasi-randomized controlled trials. The Clinical journal of pain, 31(Suppl 10), S20. DOI:  

Population

PICO(T) Question

In patients aged 60 years and above (P), what is the effect of being administered the influenza vaccine (I) on contracting pneumonia (O) compared with not receiving the influenza vaccine (C) during the Flu season (T)?

PICO(T)
P-adults aged 60 years
I-immunization with influenza vaccines
C- group of patients not administered with the vaccine
O-vaccinated patients not as likely to develop pneumonia
T-measured twice weekly  

Overview of findings

Findings from research

  • Quantitative study by Vila-Corcoles et al. (2016) recommends pneumococcal vaccine as primary preventive approach for aged
  • Qualitative study by Restivo et al. (2017) argued that older adults above 60 years acquire infection from other patients as well as health care workers. As per results it can be prevented by influenza vaccination
  • Qualitative study by Ellen (2017) identified that  nurses perceives side effects of vaccine, technology and feelings of good health as barriers to influenza immunisation. The facilitators  includes recommendations from health care providers, social media networks,  access to health care providers
  • As per Kan and Zhang (2018) barriers to influenza vaccine among older adults are transportation cost, side effects of vaccine, ad mediating variables are recommendations from health care providers and threat perception

Strength of Evidence

Summary of the evidence

Overall strength of the study is moderate as per LoBiondo-Wood & Haber (2017)

Rationale-

  • Two studies are level IV- study of Ellen (2017) and Vila-Corcoles et al., (2016)
  • one is level I- study of Restive et al., (2017)
  • one is level II- study of Kan and Zhang (2018)

Practice recommendations

Recommendations

  1. For older adults with pneumonia Pneumococcal vaccines can be considered primary preventive agent. It is recommended by CDC. PCV 13 approved by FDA protects agonist 6 more serotypes than the PCV7

Strength of evidence (review) provides rationale for older adults to uptake  take pneumococcal vaccine. Evidence has relative risk  of >5(<0.2) based on strong evidence of association (Assad et al., 2012)

  1. Influenza vaccine is recommended as evidence from randomized control trials signify the 23% effectiveness of vaccine  (with 95% confidence interval)

Strength of evidence (peer reviewed journal) is moderate and the rationale for the choice is the estimate of the efficacy of the influenza vaccine (Lang et al., 2012)

Key Stakeholders

  • Older patients or participants with pneumonia

  -They are important to team being directly involved with the target of the effort and are beneficiaries

  • Patients at risk of pneumonia

  -May help in preventing proposed illness by taking benefits of the efforts  and pass the health information  for community awareness

  • Nurse

  - Important as care provider and  to pass the information and aid in enforcing laws

Evaluation Plan

Intervention

  • Participants will be immunized using influenza vaccine
  • Periodic assessment of the study population’ level of resistance
  • Monitoring subjects to demonstrate any outcomes

Plan for evaluation

  • Data collection- from hospitals
  • Mixed logistic regression model- statistical analysis
  • Evaluation in community- Mixed method
  • Surveys (Taddio et al., 2015)
  • Time series of analysis (Bernal, Cummins & Gasparrini, 2017).

References

Assaad, U., El-Masri, I., Porhomayon, J., & El-Solh, A. A. (2012). Pneumonia immunization in older adults: review of vaccine effectiveness and strategies. Clinical Interventions in Aging, 7, 453–461. 

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Restivo, V., Costantino, C., Bono, S., Maniglia, M., Marchese, V., Ventura, G, Vitale, F. (2017). Influenza vaccine effectiveness among high-risk groups: A systematic literature review and meta-analysis of case-control and cohort studies. Human Vaccines & Immunotherapeutics, 1-12. doi:10.1080/21645515.2017.1321722

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