running head: lemhi county senior immunization...

Lemhi County Senior Immunization Project 1

Running head: LEMHI COUNTY SENIOR IMMUNIZATION PROJECT

Lemhi County Senior Immunization Project

Ann Butt, Faith Chennette and Linda Orchard

Idaho State University


Abstract

The Lemhi County Senior Immunization Project (LCSIP) is an effort by Idaho State

University advanced practice nursing students to promote rural health with the goal of increasing

the rates of senior (defined as age 65 years and older) seasonal influenza vaccinations towards

the Healthy People 2010 target value of 90% (U. S. Department of Health and Human Services,

2004). Lemhi County is a largely lower income, high-school educated, rural community with

limited health care access and a larger than Idaho state average senior population (U. S. Census

Bureau, 2009). These factors place Lemhi County seniors at risk for lower than average

immunization rates per Rural Healthy People 2010 (Hutchinson & Peck, 2005).

The LCSIP is a community-based and focused program that will recruit local volunteers

and health care providers, along with the three primary project leaders, to support, promote,

implement, and evaluate seasonal influenza vaccine clinics. Advanced practiced nurses (APNs)

will work with other health care disciplines and community groups/leaders, collaborating and

utilizing diverse experience, models, rural theories, and interventions to anticipate Lemhi County

seniors’ needs/problems and define outcomes. As program directors, APNs have advanced

training in rural health promotion, health program planning and evaluation (Issel, 2009). The

LCISP allows APNs to integrate rural health theory and to promote rural, senior health in a

community that has a demonstrated risk set and deficit in health care.

The LCISP has a time range of 5 years associated with completion of the project. The

first year objectives are to: immunize and register 50% of Lemhi County seniors; send out

educational packets to all target audience members; promote the immunization program with

strategically placed advertisements; and secure vaccinations for 100% of target population.

Evaluation of the program will be based on target variables such as the number of seniors


immunized per year and the comparison of variable numbers and change in numbers of variables

in years 2010-2015. The target value will be assessed using the 90% influenza immunization rate

benchmark from Healthy People 2010 (U. S. Department of Health and Human Services, 2004).

Each year, analysis of the target variables will be evaluated and progress towards target value

assessed. Interventions and goals will be adjusted to achieve the LCSIP goal and target value.

The anticipated budget of this 5-year program is $50,000 but it is possible that portions of this

estimate may be defrayed with grants.


Lemhi County Senior Immunization Project

The Lemhi County Senior Immunization Project (LCSIP) is an effort by Idaho State

University advanced practice nursing students (the AFL Team) to promote rural health with the

goal of increasing the rates of senior (defined as age 65 years and older) seasonal influenza

vaccinations towards the Healthy People 2010 target value of 90% immunization (U. S.

Department of Health and Human Services, 2004). The Lemhi County public health department

is currently overwhelmed with coordinating the seasonal flu immunizations, and now has the

added stress of preparing to administer vaccinations to the at-risk populations for the H1N1 flu

(M. Baker, personal communication, October 1, 2009). In addition, rural senior populations, in

particular, have been identified as an at-risk population for inadequate vaccination rates

(Hutchinson & Peck, 2005). The intended overarching goal of the LCSIP, a community-based,

community-focused program, is to facilitate higher access, availability, and opportunity for the

senior population of Lemhi County to obtain the seasonal influenza vaccine.

Program Description

The LCSIP will provide the senior population of Lemhi County with seasonal influenza

education and access to seasonal influenza vaccination. The goal of the program is to increase

the rate of vaccination over the next five years, eventually achieving the Healthy People 2010

target rate of 90%. The LCSIP is a collaborative effort between ISU APN students, the Eastern

Idaho Public Health Department (EIPHD), senior citizen agencies of Lemhi County and area

healthcare providers including those in established private practice, area clinics, the local

hospital and pharmacies, working together to promote, provide access to and track seasonal

influenza rates for the elderly of Lemhi County. Program directors understand the importance of

engaging these agencies and utilizing their inside experience when working with a rural


population to help ensure success of the program by assisting in establishing trust, anticipating

potential problems and helping to define interventions to reach the desired program outcomes.

According to rural nursing theory, rural dwellers define health primarily as the ability to work

and to be productive, information that has been taken into account when planning the education

and interventions of this program (Long & Weinert, 1989).

Key stakeholders in this program include Lemhi County seniors, their families,

community healthcare providers, the EIPHD RN and the community leaders of Lemhi County,

all of whom share an interest in keeping the seniors of Lemhi County healthy. If grant money is

involved, those providing the grant would be key stakeholders as well.

Resources needed for this program include program personnel (program directors, staff

and volunteers) as well as financial resources, estimated at $50,000.

The overarching goal of the LCSIP is to bring seasonal influenza vaccination rates of

Lemhi County senior citizens closer to the 90% goal of Healthy People 2010. Specific objectives

include sending out seasonal flu packets to target audience, displaying educational information

throughout the community in high senior citizen access areas, securing enough vaccine to

support the program need and, then, actually administering vaccinations and registering those

seniors that have been vaccinated. Once the intervention is completed, we will conduct process

and outcome evaluations, analyze the evaluation data, produce reports, complete a registry and

finally, disseminate program findings. The goal of our program is ongoing and includes

repetitive interventions and data collections over a five-year period. As the first year of the

program unfolds and data is analyzed, it may be necessary to reassess and readjust our

interventions for subsequent years.


Statement of Need

Influenza causes disease in all age groups, but according to the CDC (2009), the risks for

complication, hospitalizations, and deaths from influenza are higher among those aged 65 and

older. The Advisory Committee on Immunization Practices reported that “during 1990-99,

estimated average rates of influenza-associated pulmonary and circulatory deaths per 100,000

persons were 0.4-0.6 among persons aged 0-49 years, 7.5 among persons aged 50-64 years, and

98.3 among persons aged 65 years or more” (Fiore, Shay, Broder, Iskander, Uyeki, Mootrey,

Bresee & Cox, 2009, p. 17).

Influenza is a preventable disease and vaccinations are among the most cost efficient and

effective ways to prevent disease. For every dollar spent on immunization, savings of as much as

$29.00 in indirect and direct health costs may be realized. Since the introduction of

immunizations, vaccine-preventable diseases have declined by more than 99% (Nebraska

Department of Health and Human Services, 2007). Studies of influenza vaccination in the United

States among persons aged 65 years and older have estimated substantial reductions in

hospitalizations and deaths and overall cost savings to society (CDC, 2009).

An exhaustive search (state and county databases; public health nurses and districts, etc.)

for existing data on the number of immunizations administered to the target population was

completed. Currently, the data is not available regarding the number of seniors immunized in

Lemhi County. The data that is available indicates that 2203 immunizations (all ages) were given

in 2008 in Lemhi County (Lemhi County, 2009) while the total population estimate of Lemhi

County was 7808, with 18.7% of the population 65 years of age or older (U.S. Census Bureau,

2009).


Several key causal factors were identified in Lemhi county senior influenza vaccinations

including: (1) Lack of knowledge: several seniors arrived at the public health department to

receive H1N1 vaccinations in response to a rotary phone message for seasonal flu

immunizations. These seniors responded to media efforts to education regarding H1N1 not

realizing that they were not an at-risk population for this vaccine. (2) Beliefs: the public health

nurse reported that some Lemhi County residents believe that herbal remedies prevent the need

for vaccinations (M. Baker, personal communication, October 1, 2009). (3) Education: in

addition, only 17.9% of the population of Lemhi County has an education level higher than high

school (U.S. Census Bureau, 2009). (4) Access to Health Care: Lemhi County encompasses 4564

square miles and the county is separated by a mountain range (U.S. Census Bureau, 2009). There

are towns on both sides of the mountain range that vary in distance of 30 to 82 miles from

Salmon where the hospital and public health office are located. Some roads are unpaved and

distances of 13 miles can take up to 40 minutes to travel (M. Baker, personal communication,

October 1, 2009). (5) Poverty: statistics of those using the food bank in Lemhi County indicate

that 72% of Lemhi County residents live at or below the poverty line and 38% have no health

insurance (Lemhi County, 2009).

According to rural theory, isolation and distance are identified barriers to health care

access. Rural Healthy People 2010 states that rural dwellers decreased immunization rates are

associated with factors such as poverty, less education, lack of health insurance and longer travel

times to access health care (Hutchinson & Peck, 2005). These identified risk factors are all

reported characteristics of Lemhi County residents, substantiating the need for the proposed

program.


Current interventions at the national level include educational programs for health care

professionals and consumers such as print ads, public service announcements, media tours, on-

line educational materials, fact sheets, and other resources provided by the CDC. The CDC is

also updating websites on a weekly basis with the latest trends of diagnosed influenza cases

(CDC, 2008). Regionally, the Idaho Department of Health and Welfare (IDHW) launched the

PanFluidaho website with information on public advertisements, pandemic information,

prevention, education, updates and resources for the healthcare provider and consumer (IDHW,

2007). The Eastern Idaho Public Health department has developed and distributed a brochure

throughout the district which gives contact information for all the health district’s office’s, along

with information for their website (Eastern Idaho Public Health District, 2005). Locally, in

Lemhi county, the newspaper has advertised information such as the Steele Memorial

Immunization clinic, as well as the Public Health Department (PHD) contact information. There

are informational posters displayed in the community and the public health nurse has arranged to

travel to the locations of various community organizations such as the high school and Fish and

Game at their request, to provide on-site immunizations to faculty and staff. The public health

office also enlists the help of the rotary phone, “a system that contacts the people who were

immunized last year to remind them to contact the public health office for this year’s

vaccination” (M. Baker, personal communication, October 1, 2009).

Despite the fact that there is effort by EIPHD and Lemhi County to immunize the seniors,

there is still a huge need for the LCSIP program. The community assessment has identified a

significant need and the APN can develop strategies and implement them with the help of

community members, as well as the available health care team. Besides making influenza

vaccination more accessible to the senior residents of Lemhi County, this program will produce a


registry to record the number of persons aged 65 and older who receive seasonal influenza

immunizations and track this data over a five year period, 2010-2015.

Community Assessment

The epidemiological model was selected for community assessment in preparation for

program development and implementation. This model allows for quantification of health

problems and focuses on trends, prevention, treatment, and intervention for the identified issue

(Issel, 2009). By applying the epidemiological model, available information was used to

determine the importance and prevalence of the problem and develop a program to address that

problem. Statistics collected by the U.S. Census Bureau (2009) and the Center for Disease

Control (CDC, 2009) assisted in identifying the problem and, subsequently in developing this

program to address the need.

Data shows that in the United States, influenza is responsible for greater than 36,000

deaths annually and the estimated annual cost associated with flu and pneumonia treatments is

over 37.5 billion dollars in the U.S. alone (Reynolds, Snow, Qaseem & Verbonitz, 2008). Ninety

percent of deaths from influenza occur in those aged 65 and older. As our nation ages (the CDC

predicts doubling of the over 65 population by 2030), the costs of treating influenza are expected

to rise as well (CDC, 2009). Currently, the vaccination rate for influenza is 66 percent for those

aged 65 years and older in the United States (CDC, 2009) while the Healthy People 2010 goal is

for 90% vaccination rate (U.S. Department of Health and Human Services, 2004). Clearly, there

is a deficit at the population level in regards to senior influenza vaccinations. Issel (2009)

cautions that the epidemiological model may fail to address the perceived needs of the

community, a factor that was taken into account as the program was developed and addressed by

communicating with stakeholders and established healthcare providers in the Lemhi County area.


The target audience for this program is the senior population (defined as 65 years or

older) of Lemhi County, which includes Salmon, Idaho, in central eastern, rural Idaho, near the

Montana border. Lemhi County is designated as rural with 1.7 persons per square mile. Lemhi

County was chosen for this program because with 18.7% of the population over the age of 65, it

is the county with the largest rural senior population in Idaho, well above both the Idaho average

of 12% and the United States average of 12.8% (U.S. Census Bureau, 2009).

Information collected in the community assessment led to this causal theory statement for

the proposed health program: Risk of increased mortality and morbidity secondary to influenza

among the rural, senior population of Lemhi County indicated by a national increased rate of

mortality and morbidity in the senior population related to influenza, less than targeted Healthy

People 2010 rates of immunization in this age group, and increased risks of inadequate

immunizations associated with rural populations, is caused by attitudes and beliefs, annual flu

season, immunization status, vulnerability, knowledge deficits, motivation and accessibility for

and to immunizations, but is mediated by vaccine supply/cost/availability, health care

professional availability and accessibility, public beliefs/knowledge of vaccinations, given that

the extent of public awareness and education, media attention, health care services/availability

and government interventions moderate the causes and that being of age 65 years and greater,

pre-existing health conditions, environmental pathogens, and availability of health care services

exist prior to the causes.

The Role of Advanced Practice Nurses in This Program

The roles of the advanced practice nurse (APN) in this program are multiple, as well as

integral. APNs will identify and elicit understanding of the needs of the rural community.

Utilizing models and assessments, the APN will plan the program according to Lemhi county


needs and priorities, ensuring that interventions match the needs of the recipients. Using the

collected data, APNs will identify where to most effectively intervene in the different levels of

the public health pyramid. APNs will work with other health care disciplines and community

groups, collaborating and utilizing diverse experience to anticipate problems and define

outcomes. APNs will identify community leaders and use the model for communicating the

program plan with stakeholders. APNs will take on several roles in program planning which

range from conceptualization of the program to evaluation, including facilitation and education.

The sustainability of the implemented program will depend largely on how it is planned and

implemented (Issel, 2009). Due to advanced training and understanding of rural populations and

program planning, APNs are particularly suited to development and facilitation of this program.

Idaho is a largely rural state with 35 out of 44 counties designated rural communities (Hyer,

2006). The LCSIP is an opportunity for APNs to promote, pilot and develop a needed program

for Idaho’s rural health need. It is the AFL team’s hope that the LCSIP will be expanded across

the state and country to address health needs across rural America with APN’s direction.

Program Goals and Objectives

The overarching goal of our influenza immunization program is to bring seasonal

vaccination rates of Lemhi County senior citizens closer to the 90% goal of Healthy People 2010

and ultimately, decrease the morbidity and mortality related to influenza in the 65 and older

population in Lemhi County (Healthy People rate per the U. S. Department of Health and Human

Services, 2004).

Objectives for the Proposed Program

The following process objectives focus on the activities of the program staff for the

implementation and sustainment of the program (Issel, 2009).


1. By August 1, 2010, ALF group and volunteers will send out seasonal flu packets to all

identified target audience members (1,460 seniors per the U.S. Census Bureau, 2009) that

will include the following: information sheet, reminder of clinic days with sticker or

magnet, and a personal prevention record/immunization card.

2. By August 1, 2010, ALF staff and volunteers will display a minimum of 200

(approximately 100 in medical related areas and 100 in public areas) informational

posters in all senior public access sites including: the Steele Memorial Hospital, medical

and dental offices, pharmacies, nursing homes, the public health office, assisted living

centers, the Senior Citizen Center, the library, government offices, grocery and

department stores.

3. By August 1, 2010, ALF staff will secure vaccines and supplies for 100% of Lemhi

Seniors (1,460 seniors per the U.S. Census Bureau, 2009).

The following effect objectives focus on the target audience and the benefits they will

receive as a result of participation in the program.

1. By October 2010, at least 50% of Lemhi County seniors (730 seniors) will receive

seasonal flu vaccinations.

2. During 2010, at least 50% of Lemhi seniors (730) will be registered with Eastern Idaho

Public Health Department for call back service and mail reminders in the next year.

Variables for Measuring Objectives Success

Variables or indicators of a program must be feasible to collect, analyze, and interpret.

Selection of variables may also be effected by requirements of funding agency criteria. The

variables must reflect the specific health domain that the program intends to target. The


measurements of the variables (or the “what” portion of the objective) indicate the success or the

failure of the project (Issel, 2009).

For the purposes of our rural community-focused project, the following variables are

identified for measurement of program success.

1. The number of Lemhi County seniors immunized for influenza per year, 2010-2015.

2. The number of Lemhi County seniors registered for reminder services for

immunizations per year, 2010-2015.

3. Qualitative measurement of the attitudes and beliefs of target audience towards

influenza immunization 2010 and each subsequent year, after

outreach/education/community involvement.

4. The comparison of variable numbers and change in this data in years 2010-2015 (we

will hire a statistician for interpretation).

Measurement of these variables will allow the program managers to monitor the progress

of the program towards the target value in the defined period. Annual measurement and analysis

of these variables will allow program managers to change interventions as necessary to achieve

the goal/target value (Issel, 2009).

Target Value

Success in a program is defined as meeting, exceeding or making significant progress

towards a target. Therefore, one of the most important elements in program design is developing

or setting the target value (Issel, 2009).

After careful consideration, our team decided that using an existing benchmark, the

Healthy People 2010 immunization goal, will serve as our project target. This option allows for

use of the existing standard applied over an extended period of time, ideal for our long-term


program. For this option to work, the program must show improvement, which we intend to

facilitate.

Unfortunately, Lemhi County does not currently have baseline data established for the

number of senior citizens immunized for influenza. Part of our program will be to establish this

baseline information and track the number of Lemhi County senior immunizations given in each

year to target and then compare to subsequent years. The target value to be assessed will be

progress towards the Healthy People 2010 goal of 90% immunization rate in our target audience.

According to Issel (2009), the following sequence of formulas will be employed by our

statisticians to assess our project’s progress:

• Annual % change= [(long-term objective - current value) / current value] / # of

yrs

• Next year target value= (annual % desired change x current value) + or - current

value

• Subsequent year target value= (annual % desired change x past year value) + or -

past year value

In order to judge whether or not a program is successful, it is imperative that program

planners set out with specific and measurable goals and objectives. Goals, objectives, and target

values have been outlined in order to help ensure a successful program for the senior residents of

Lemhi County. See figure 1.

Timeline and Budget for Program Delivery

In order to ensure successful program delivery, it is essential to have a timeline for

implementation. Several steps included in the successful execution of our program have already

been completed while others are ongoing. After convening a program planning group and


conducting a community needs and asset assessment, the ALF team used that information to

develop a problem statement, objectives and formulate a program theory, including articulating

the process theory. We developed a timeline, budget, and identified organization and service

utilization inputs and outputs. Specific activities remaining for implementation and completion

of our program include advertising for volunteers and subsequently hiring and training those

volunteers, choosing dates and setting up the vaccination clinics, sending out seasonal flu

packets and following up with reminders and conducting the vaccination clinics in various

locations. Once the intervention is completed, we will conduct process and outcome evaluations,

analyze the evaluation data, produce reports, complete a registry, and finally, disseminate

program findings.

Timeline

See Table 1

Budget with Justifications

See Table 2.

Budget and Timeline Evaluations

The budget and timeline are designed to account for the first year of the program. Costs

are based on current prices and will need to be adjusted for inflation and assessed yearly as

described in the timeline paragraph. Continual evaluation is necessary for success.

Immunization Program Evaluation

The CDC (2009) has defined immunization program evaluation as the systematic

collection of information about the activities, characteristics, and outcomes of programs to make

judgments about the program, improve program effectiveness, and/or inform decisions about

future program development.


figure 1

Moderating Factors: Public Awareness Education Media Attention Health Care Services

Causal Factors: Attitudes and Beliefs Annual Flu Season Immunization Status Vulnerability Knowledge deficits Motivation and Accessibility

ORGANIZATION PLAN PROCESS OBJECTIVES

Mediating Factors: Vaccine supply/Cost/Availability Health Care provider availability

Interventions: Education - Causal Provide Access- Causal Media blitz - Moderating Provide Resources- HCP/Supplies - Mediating PROCESS OBJECTIVES

1. By August 1, 2010 ALF team and volunteers will send out seasonal flu packets which will include the following: information sheet, reminder of clinic days with sticker or magnet, and a personal prevention record/immunization card.

2. By August 1, 2010 ALF staff and volunteers will display informational posters in 100% healthcare offices including Hospital, MD’s, pharmacy’s, nursing homes, and public health office, 100% Senior access: assisted living and Senior Citizen Center, 100% grocery and department stores

3. By August 1, 2010 ALF staff will secure vaccine supply for 100% of Lemhi Seniors.

Eligibility Criteria Service plan process objectives

Health Outcome Objectives

EFFECT OBJECTIVES 1. By 2010, 50% of

Lemhi Seniors will receive seasonal flu vaccinations by October 1.

2. During 2010, 50% of Lemhi seniors will be registered with EIPHD for call back service next year.

Health Impact Goals

The overarching goal of our flu immunization program is to bring seasonal

vaccination rates of Lemhi

County senior citizens closer to the 90% goal of Healthy People

2010.


Table 1

Calendar Months: 1 2 3 4 5 6 7 8 9 10 11 12 Convene Program planning group X X

Conduct Community needs and asset assessment

X

Translate assessment information into health problem statement and objectives

X

Formulate program theory; articulate process theory

X

Identify Organization plan inputs • RN’s, MD’s, • Grants • Advertise for volunteers • Training volunteers • Set up Clinics • Supplies-material resources • Transportation (1X Month) • Time

Identify Organization outputs • Timeline • Operations manual • Organizational chart • Budget Variable/Direct/Indirect • Evaluation (Process/Outcome) • Analysis • Produce reports • Complete Registry

- X

- X

- X X X X X

X - X X X

- X X X

- X X X X

- X X X X

- X X

- X X X

- X X X X

- X X

- X X X

Identify service utilization inputs • Marketing (4 P’s) • Eligibility/Inclusion-Research to

ID (Seniors 65 and older)

• Cueing • Intervention delivery

Identify Service Utilization outputs • # of immunization clinics • Marketing/Educational material • Send out packets • Send out reminders

X X

X

X

X X X X X

X X X X X X

X X

X

Disseminate findings X Calendar Months: 1 2 3 4 5 6 7 8 9 10 11 12

Table 1


Budget with Justifications

Lemhi County Senior Immunization Project Budget 2009


Category Total cost

Individual costs Justification Description

Supplies: Educational Materials Provide the information necessary to educate and inform the seniors and public of the program and goals.

Seasonal Flu Packets (1420 total) $910

* Letter $58.40 Letter explaining the project and the benefits of participation.

* Information sheets $58.40 Seasonal Flu information for education and to dispel potential negative beliefs/attitudes

* Fridge Magnets $613.20 To remind seniors of Saturday Clinic dates/locations/contact information

* Immunization Card $180.00 For Seniors to keep to track of immunizations

Information Posters (200)- 8.5X11 Glossy Cover $62 $3.23

Marketing for program to be placed in various targeted public areas of Lemhi County- stores, HCP offices, govt. offices, churches, senior citizen center, etc.

Copying for Consents/Surveys/Post FAQ $348.00 $4.20 Copying fees

Supplies: Vaccination Clinics Supplies necessary for implementation of program – vaccine related costs

1460 Influenza Vaccines (unit dose with needles) $35,040 $24 Necessary for achievement of program goal- potential for insurance/Medicare/grant reimbursement

Refreshments for the seniors 0 0

Encourage camaraderie/annual participation. 8 clinics- coffee, water, and cookies for 200- coffee- in-kind from clinic site. Cookies in-kind donations from churches, 4H, and senior centers.

Gloves $300.00 .20/pair Necessary for achievement of program goal- potential for insurance/Medicare/grant reimbursement

Band-aids (1500 for error margin) $85.50 .06 = 30 boxes of 50 at $2.85, “

Alcohol Wipes (2920 for error margin) $551.88 .53 Necessary for achievement of program goal- potential for insurance/Medicare/grant reimbursement

Hand Sanitizers $97.00 $48.50 2 cases Purell sanitizer pumps, “

Sharps Containers $31.60 $3.95 Necessary for achievement of program goal- potential for insurance/Medicare/grant reimbursement

Disposal of Sharps containers 0 0 Public Health Department, Lemhi County- In-kind donation.

Storage of materials 0 0 Public Health Department, Lemhi County- In-kind donation of space/refrigeration for storage

Supplies: Office Supplies necessary for implementation of program- ancillary offices fees

Paper, Envelopes, Stickers, Files, postage $500.00 $2.92 Misc. fees for office supplies- paper, copies, etc.

Lap tops 0 0 Use of existing resources- in-kind donation

Internet access 0 0 Use of existing resource- in-kind donation

Cell phones $300 $100/per team member

Adjust existing plans to cover increased usage- utilizing in-network minutes for AFL Team.

Web page 0 0 Design and upkeep- in-kind donation- Mountain States Networking

Travel $3726.00 .27/mile

Program directors (alternating ALF Team members) to travel to Salmon 1X/mo from Boise (carpool)/Rexburg 9 months a yr. Schedule 8 days for implementation of project during flu season. Estimated total miles travelled = 7326 for 9 months/ 6472.32 flu season= 13, 800 miles

Boise to Salmon to Boise $2272.69 495.14 miles, 9 hrs, 40 minutes- for 1 trip, 17 trips needed

Rexburg to Salmon to Rexburg $1453. 31 313.9, 6 hrs, 25 minutes- for 1 trip, 17 trips Needed

Meals for travel times $1477.00 $7.00

51 meals for AFL Team and 160 meals for volunteers (incentive/thank you for participation) = 211 meals. Potential in-kind donations.


The evaluation processes that the AFL team selected to use to measure outcomes of the

proposed program are based on the CDC framework for evaluation of immunization programs.

The AFL team considers evaluation as a tool that helps to support our program implementation,

and therefore have included the evaluation process starting at month 3 of our program. Our goals

with the evaluation are: to evaluate whether immunization program outcomes meet the objectives

that have been identified, address program needs, determine operations, components and

activities that need to be improved, and resolve program problems which may arise.

There are six steps which have been identified by the CDC (2009) in the evaluation

process. These steps are combined with the standards of utility, feasibility, propriety and

accuracy. Each of the steps and standards are defined in Table 3.

Consultant: Statistician $3600 $35.96/hr

Analysis of information collected regarding annual immunizations; comparison of variable numbers and variable number change over years 2009-2015; interpretation of qualitative survey results; compilation of reports of measured outcomes and evaluation of intervention effectiveness; assess target value as per Issel, (2009 p. 436.) AFL team will collect data and submit for interpretation. 100 hours.

Dissemination Costs

Poster fees= $63 1008 miles= $272.05 mileage: $328 hotel: $189 meals= $852.05

27/mile 670 (Boise to SLC, round trip), 338 (Rexburg to Tremonton, roundtrip

Presentation of project paper abstract for the poster or podium session at the Western Institute of Nursing Conference. Hotel accommodations for this year were $149.00 with an additional $15/person fee. Driving from Boise and Rexburg (meeting in Tremonton) to SLC (carpooling) would be 1008 miles.

Space 0 0 In-kind donation of space in senior centers, churches, hospital, pharmacy, and store lobbies.

Personnel Services: Volunteer Materials 0 0

20 Lemhi County-based volunteers committed to at least 50 hours/yr of service, in addition to the AFL team’s 3 RN program heads that are committed to at least 100/yr of voluntary service. Voluntary/In-kind hours= at least 1600 hrs.

Volunteer Information (20) 2 pages $16 $1.25 Copies for training- background check, HIPPA, safety training, etc.

Volunteer Background Checks $200 $10.00 Ensure safe/reliable care for target audience

Information for Medical staff (100) $40.00 $2.50 Copies for HCP training and education on program benefits/goals and dates/times/referral strategies.

Identification Badges $103.50 $4.50 For identification purposes- use for 5 years for 23 volunteers

Total Anticipated Costs= $48,240.53 Table 2


figure 2 (CDC, 2005, figure 1) Steps

1. Engage stakeholders Those involved, those affected, primary intended users

2. Describe the program Need, expected effects, activities, resources, stage, context, logic model

3. Focus the evaluation design Purpose, users, uses, questions, methods, agreements

4. Gather credible evidence Indicators, sources, quality, quantity, logistics

5. Justify conclusions Standards, analysis/synthesis, interpretation, judgment, recommendations

6. Ensure use and share lessons learned Design, preparation, feedback, follow-up, dissemination (CDC, 2005, p. 1).

Standards 1. Utility

Serve the information needs of intended users -Who needs the evaluation results? Will the evaluation provide relevant information in a timely manner for them?

2. Feasibility Be realistic, prudent, diplomatic, and frugal- Are the planned evaluation activities realistic given the time, resources, and expertise at hand?

3. Propriety Behave legally, ethically, and with due regard for the welfare of those involved and those affected- Does the evaluation protect the rights of individuals and protect the welfare of those involved? Does it engage those most directly affected by the program and changes in the program, such as participants or the surrounding community?

4. Accuracy Reveal and convey technically accurate information- Will the evaluation


produce findings that are valid and reliable, given the needs of those who will use the results?

5. This framework for program evaluation helps to answer these questions by guiding users in using evaluations that are appropriate (CDC, 2005, p. 1).

The program outcome objectives (as listed on the Logic model, figure 3) are:

1. By 2010, 50 % of Lemhi Seniors will receive seasonal flu vaccinations by October 1.

2. During 2010, 50% of Lemhi seniors will be registered with EIPHD for call back service next

year.

The number of Lemhi County seniors vaccinated against influenza will be measured for baseline

in 2010 and rate will increase by > 10% each year (after interventions applied).

Evaluation Questions

Data Collection and Analysis Indicator Target Data Source Data Collection Analysis

Were the programs activities delivered as designed? Defined actions are carried out according to the program and timeline assigned.

Timeline followed 100%.

Program directors, staff and volunteers.

Method: Activity log, checklists Timeline: Ongoing Person Responsible: Program Directors

Method: Comparison of activity log to Timeline Timeline: Ongoing and end of the year Person Responsible: Program directors

What percentage of Lemhi seniors received seasonal flu vaccinations by October 1, 2010? Quantitative data which indicates the number of Lemhi seniors who receive the seasonal flu immunization.

50% of all Lemhi seniors to receive flu immunization.

Seniors will fill out paperwork at Table one, Staff will then input information into a computer database and registry in order to prospectively continue to gather data in

Method: Organizational records-registry Timeline: Directly after immunization

Method: Compilation of all participants of immunization clinics or other will be submitted to the statistician. Timeline: End of the year


the future years. Person Responsible: Staff assigned to keep registry complete accurate and updated

Person Responsible: Statistician

What percentage of Lemhi seniors were registered with EIPHD for call back service next year? Quantitative data which indicates the number of Lemhi Seniors who register for call back service. This should be synonymous with the number of Lemhi seniors who receive the flu immunization

50% of all seniors to be registered for the EIPHD call back service

Seniors will fill out paperwork at Table one, Staff will then input information into a computer database and registry in order to prospectively continue to gather data in the future years.

Method: Organization record/ Registry Timeline: At the time of immunization Person Responsible: Record keeping staff assigned to assist participants in filling out paperwork

Method: Compilation of all participants of immunization clinics or other will be submitted to the statistician. Timeline: End of the year Person Responsible: Statistician

Was the program run according to budget of time and money? Program’s activities were produced with appropriate use of resources such as budget and staff time.

Program will be completed on or under proposed budget

Program developers

Method: Organizational Records Timeline: Ongoing Person Responsible: Program developers will oversee. Staff and volunteers will maintain records

Method: Organizational records and Budget Timeline: Ongoing and at the end of the year. Person Responsible: Program developers.

Was the percentage increase of Lemhi seniors receiving seasonal flu vaccinations increased because of the LCSIP?

• What prompted Lemhi senior to receive vaccination?

• Was the only reason the Lemhi senior

Participation is 100% because of the program

Program developers and staff

Method: Self report/questionnaire/survey

Method: Compilation and comparison of answers to determine if participation is due to the


received the immunization a result of the LCSIP?

• Satisfaction with the program

• Qualitative assessment of attitudes and beliefs towards influenza immunization

Timeline: At the time of immunization Person Responsible: Volunteers can assist participants to complete the questionnaire after they are immunized

program. Timeline: At the end of the year. Person Responsible: Program developers and staff.

Table 3 The evaluation of a program should be specific to the program’s worth, merit, and significance

as these are what the evaluation demonstrate. The evaluation findings may be applied to make

decisions about program implementation and improvement on the effectiveness of program

interventions (CDC, 2007).

Dissemination

The AFL team intends to annually disseminate the results of the LCSIP at the Western

Institute of Nursing Conference. In the years 2010 through 2015, abstracts of the project will be

submitted for poster presentations as in-progress projects are ineligible for podium presentations.

In 2016, when the project is complete and the evaluations and data are analyzed, the project will

be submitted to the Western Institute of Nursing (WIN) for podium presentation evaluation

(WIN, 2009).

Submission of the annual in-progress and completed project papers will be made to the

Online Journal of Rural Nursing and Health Care, The Journal of Rural Health, and The

American Journal of Nursing. In addition, to address the Idaho specific need, the annual in-

progress and completed project paper 1500 word briefs (as per the publishing guidelines) will be

submitted to the RN Idaho magazine published by the Idaho Nurses’ Association (Idaho Nurses’

Association, 2009). It is the ALF team’s hope that the project will inspire other rural


communities to create similar rural health promotion projects. As most of Idaho is rural (35 out

of 44 counties), this project is clearly relevant, worthwhile, and needed in Idaho (Hyer, 2006).

The ALF team recognizes that dissemination of the LCSIP results is needed for

sustainability and expansion of the project, development of additional and subsequent projects,

and for findings to become part of evidence base for future project developments (Issel, 2009).

For this reason, submission to multiple journals and serial submissions to WIN will be made.

Conclusion

The LCSIP is a well-designed program utilizing rural theory. It is targeted towards the at-

risk, rural, senior population in Lemhi County, Idaho. U.S. Census Bureau statistics and the CDC

have identified the senior population as at-risk for suffering serious consequences of seasonal

influenza. Though not tracking these statistics specifically, it would seem logical that by

increasing immunization rates among seniors, this program will ultimately decrease the cost as

well as the incidence of morbidity and mortality related to yearly influenza outbreaks. If the

model is successful, the program will continue to be utilized to ensure that at-risk seniors will

obtain their yearly immunization. Once shown to be successful, the program could be expanded

across the state as well as the country. The project is supported by the Healthy People 2010 goal

of increasing immunizations to 90%. The AFL team is dedicated to this project and has identified

many roles which APNs have been educated and trained for including: community assessment,

program development and implementation, evaluation and dissemination. It is our belief that the

implementation of this program will benefit and impact people in many ways. As APNs, we lend

a particular credibility and professional aspect to this program and our desire is to make a lasting

effect in the lives of the rural, senior population across the country.


PROGRAM DEVELOPMENT Planning – Implementation – Evaluation

time, education materials, HCP accessibility, home services, advertisement, volunteer (community) education, vaccine costs and accessibility

provide public/HCP education, advertisement, accessibility of vaccine,/HCP, community volunteers to assist with screening and outreach

Rate of immunization in Lemhi seniors will approach HP 2010 goal of 90% by 2015.

# of Lemhi County seniors vaccinated against influenza will be measured for baseline in 2010 and rate will increase >10% each year(after interventions applied)

Increased awareness, education and accessibility of vaccines and HCP to Lemhi County seniors

Lemhi County senior residents (defined as age 65 or older)

-community -rural theory -access to healthcare -poverty -education -baseline -records

Lemhi County Senior Seasonal Influenza Vaccination


References

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Centers for Disease Control. (2005). Framework for program evaluation in public health.

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Centers for Disease Control. (2007). Guideline to immunization program evaluation for

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(2009). Prevention and control of seasonal influenza with vaccines

recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009

[Electronic version]. Morbidity and Mortality Weekly Report, 58(RR08), 1-52.

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