Running head: IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 1 Improving Pediatric Influenza Vaccination Rates in the Primary Care Setting Channan M. Kositzke & Luke W. Linscheid Michigan State University College of Nursing April 21, 2022 IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 2 Table of Contents Abstract …………………………………………………………………………………………...5 Introduction ……………………………………………………………………………………….7 Purpose of the Project …………………………………………………………………………….7 Problem Statement & Clinical Question…………………………………………………………..7 Background ……………………………………………………………………………………….8 Significance ……………………………………………………………………………………….9 Description of the Clinical Organization …………………………………………………..……10 Strengths, Weaknesses, Opportunities & Threats ……………………………………………….12 Fishbone Diagram ……………………………………………………………………….13 Synthesis of the Evidence ……………………………………………………………………….13 Search Strategy ………………………………………………………………………….13 Selection Criteria …………………………………………………………………..……14 Literature Synthesis Review …………………………………………………………………….15 Setting Related to Motivational Interviewing …………………………...………………15 Gap Analysis …………………………………………………………………………….15 Vaccine Hesitancy ………………………………………………………………………16 Motivational Interviewing ………………………………………………………………17 Quality Improvement Framework ……………………………………………….………………18 Goals, Objectives, & Expected Outcomes …...………………………………………….………19 Methods ………………………………………………………………………...……....……......20 Ethical Considerations …………………………………………………………………..20 Setting Facilitators …………………………………………………...…...……………..20 IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 3 Barriers ………………………………………………………………………….……….21 Intervention & Data Collection Procedure ………………………………………...……21 Timeline ………………………………………………………………………………....23 Measurement Instruments & Tools ……………………………………………………...24 Analysis ………………………………………………………………………...…….………....24 Epic Slicer Dicer ……………………………………………………………...…………24 Limitations ……………………………………………………………...…….………....25 Anecdotal Clinical Data …………………………………………………………………25 Sustainability Plan ……………………………………………………………………………....26 Discussion & Implications for Nursing …………………………………………………………27 Cost Benefit Analysis & Budget ………………………………………………………………...28 Conclusion ………………………………………………………………………………………28 References ……………………………………………………………....……………………….30 Appendix ………………………………………………………………………………………...36 Appendix A - Gap Analysis; Clinic SWOT Matrix Analysis …………………………...36 Appendix B - June 25, 2021, Literature Inquiry Method Table …………....…………...38 Appendix C - Literature Review Table ……………………...………….…………...39 Appendix D - Fishbone Diagram ………………………………………………………..42 Appendix E - Timeline …………………………………………………………………..43 Appendix F - Letter of Support ………………………………………………………….45 Appendix G - Clinical Data Collection Chart ...…………………………………………46 Appendix H - Potential Budget Considerations …………………………………………47 Appendix I - MOTIVE-Flu Tool ………………………………………...….…………..48 IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 4 Appendix J - Cedarville University MOTIVE-Flu Tool Approval ……………………..52 Appendix K - Participating Provider and Tool Agreement ……………………..………53 Appendix L - Participating Provider 2020 vs 2021 Z 23 Code Use ………….…………54 Appendix M - Participating Provider 2021 vs All Practice Provider Z 23 Code Use ..…55 Appendix N - Participating Provider 2021 Anecdotal Clinical Data Total Visits ...…………………………………………………….56 Appendix O - Participating Provider 2021 Anecdotal Clinical Data Eliminating Up to Date ...………………………………….…….57 Appendix P - MSU IRB Approval ………………………………………………..……..58 IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 5 Abstract Background and Significance: Caregiver vaccine hesitancy (VH) is a barrier to pediatric health. Current pediatric vaccination rates nationwide fall below the national recommendations. Understanding contributors to individualized hesitancy while employing motivational interviewing (MI) techniques can reduce caregiver hesitancy, improve influenza vaccination rates, decrease pediatric disparities, improve community health, and reduce healthcare costs. Purpose: The purpose of this quality improvement (QI) project was to reduce caregiver influenza vaccine hesitancy through provider education and the use of MI techniques with the MOTIVE-Flu (Motivational Interview Tool to Improve Vaccination Adherence) algorithm point of care tool. The intended outcome goal was to increase seasonal influenza vaccination rates by 10% when comparing the participating providers 2020 (without the intervention) to the 2021 (with the intervention) vaccination acceptance rate. Methods: A literature review guided the selection of the tools and techniques selected, which substantiated the effectiveness of MI within the pediatric population in the primary care setting. De-identified aggregate data was reviewed and provided by the organizational data manager and the participating Medical Assistant (MA). Statistical analysis was provided via Michigan State University (MSU). To assist with MI techniques and the MOTIVE-Flu tool use education was completed by the participating MA’s, provider, and nurse practitioner student. Implementation: Implementation occurred from October 2021 to December 2021 within peak influenza vaccine administration season. The intervention occurred during all pediatric primary care visits for children aged six months through seventeen years. The Knowledge into Action Framework guided the development and monitoring process with bi-weekly clinical staff progress, evaluation, and support. Implications: Practical implications include reducing pediatric influenza morbidity and IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 6 mortality, reducing the spread of influenza within the community, and decreasing healthcare costs. Keywords: Vaccine, Hesitancy, Motivational Interviewing, Pediatric, Primary Care IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 7 Improving Pediatric Influenza Vaccination Rates in the Primary Care Setting Influenza viruses are orthomyxoviruses that result in acute respiratory illness (World Health Organization [WHO], n.d.). The Centers for Disease Control and Prevention currently identify the best way to prevent an influenza illness is to obtain an annual influenza vaccination (Centers for Disease Control and Prevention [CDC], 2021a). Data reveals that among vaccine- preventable diseases, influenza is responsible for the most hospitalizations (CDC, 2021b). Caregiver vaccine hesitancy is an ongoing barrier to pediatric health as evidenced by the most recent 2019-2020 CDC data identifying only 54.9% of children between the ages of six months and seventeen years were immunized for influenza (CDC, 2020b). Current pediatric influenza vaccine rates fall below the Healthy People 2030 influenza vaccination goal of 80% (Office of Disease Prevention & Health Promotion, n.d.). The World Health Organization defines vaccine hesitancy as “...delay in acceptance or refusal of vaccines despite availability of vaccine services” (WHO, 2016). Purpose of the Project The purpose of this quality improvement project was to reduce caregiver influenza vaccine hesitancy through provider education and implementation of motivational interviewing techniques with the point of care MOTIVE-Flu tool, The outcome intention was a ten percent improvement of seasonal influenza vaccination rates compared to the participating providers previous 2020 rates. The intervention occurred during all pediatric primary care visits for children aged six months through seventeen years. Implementation occurred from October 2021 to December 2021 within the peak influenza vaccine administration season. Problem Statement & Clinical Question Data reveals an increase in pediatric influenza vaccine hesitancy from a macro to micro IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 8 level with significant community and individual health consequences. This quality improvement project evaluates if the MOTIVE-Flu algorithm tool could help to reduce caregiver hesitancy and improve pediatric influenza vaccination rates. Background There has been a longstanding paradigm between vaccinations and hesitancy (Marshall, 2019). Recent vaccine hesitancy behaviors can be traced to a 1998 article by Wakefield that attempted to link autism to the measles, mumps, and rubella vaccination (Marshall, 2019). The article has been found scientifically invalid and removed from circulation but has contributed to a significant increase in vaccine hesitancy (Marshall, 2019). Additionally, the ease of access to readily available mixed content lacks credibility and contributes to caregivers’ fatigue, confusion, and skepticism of vaccinations (Marshall, 2019). To transition caregivers from vaccine hesitant to vaccine compliant, there are evolutionary thought processes and characteristics within human nature that have the potential to evolve and can be applied to aid in this transition (Marshall, 2019). The constructs are rooted in MI techniques and include moving from anecdotal thinking to scientific thinking, from risk versus benefit to analysis and analytical thinking, and from heuristics thought to deductive reasoning (Marshall, 2019). Understanding perceived barriers and grasping the disease burden can assist in reducing caregiver VH and improve vaccination rates resulting in decreased influenza-related morbidity and mortality within the pediatric population (Marshall, 2019). The pediatric population is especially vulnerable to respiratory conditions and complications because of their decreased adaptability to potential rapid concomitant conditions such as pyrexia, dehydration, croup, and/or epistaxis (Sanderson & Gaylord, 2020). Severe influenza infections can be fatal resulting from atelectasis, myocarditis, pneumonia, and/or sepsis IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 9 (Sanderson & Gaylord, 2020; WHO, n.d.). In the United States (U.S.) during the 2017-2018 influenza season 188 children died of influenza, while 199 died of influenza during the 2019- 2020 season (CDC, 2021f). Comparing U.S. 2010-2011 seasonal rates to the 2017-2018 seasonal rates, the incidence of symptomatic illness, medical visits required, and deaths doubled, while hospitalizations more than tripled (CDC, 2020a). The State of Michigan and Kalamazoo County mirror this increase in influenza cases (CDC, 2021b; LiveStories, n.d.). In 2018, the influenza and pneumonia mortality rate per 100,000 persons within the U.S. was 15.2 persons, within the State of Michigan 14.5 persons. In Kalamazoo County, the location of the clinical site where this quality improvement project was performed, was above the state and national average at 67 deaths per 100,000 (CDC, 2021d; CDC, 2021c; LiveStories, n.d.). Improving vaccination rates at any age including the pediatric population will decrease community spread resulting in reduced influenza-related mortality and improve community health. Significance Many factors contribute to caregivers' hesitancy of the pediatric influenza vaccination. The World Health Organization, Immunization Strategic Advisory Group of Experts, or SAGE outlined a Vaccine Hesitancy Model (WHO, 2016). The Vaccine Hesitancy Model identifies three contributing factors: complacency, confidence, and convenience (WHO, 2016). Hesitancy is multifactorial and varies across geographical locations, populations, cultures, socioeconomic conditions and is rooted in social determinants of health (WHO, 2013). Exploring community driven contextual influences such as poor-quality information provided on social media, political climates, and historical experiences can help to identify the degree of each vaccine hesitancy contributor (WHO, 2013). IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 10 The growing trend of pediatric influenza infections, coupled with vaccine hesitancy in the general population, contributes to a substantial healthcare-associated economic burden. A 2018 study found within the U.S. healthcare system the estimated total economic burden of influenza was $11.2 billion annually (Putri, Muscatello, Stockwell, & Newall, 2018). Annual average influenza-related direct medical costs were estimated to be $3.2 billion and indirect costs resulted in $8 billion in expenses (Putri, Muscatello, Stockwell, & Newall, 2018). The CDC reviewed the cost-effectiveness associated with annual vaccination of children with average health risk with an inactivated influenza vaccine (IIV) ranged from $12,000 per quality-adjusted life year (QALY) savings for children aged six to 23 months, to $119,000 per QALY saved for children ages 12 through 17 years, further quantifying and substantiating the need for annual pediatric influenza vaccinations (Prosser, Bridges, Uyeki, Hinrichsen, Meltzer, Molinari, .... Lieu, 2006). Understanding individualized hesitancy factors while employing MI can reduce hesitancy and improve influenza vaccination rates resulting in reduced influenza-related pediatric disparities and reduced healthcare costs. Description of the Clinical Organization The participating pediatric primary care clinical practice is a part of a larger university’s school of medicine, located in Kalamazoo County, Michigan. The university school of medicine has a dual-purpose micro system with a focus on education and providing quality patient care. The overarching school of medicines mission statement is to: “Inspire lifelong learners to be exceptional clinicians, leaders, educators, advocates, and researchers of tomorrow” (Western Michigan University Homer Stryker School of Medicine, 2021). There is not a separate defined mission statement for the pediatric primary care subspecialty. The clinic exemplified their dual purpose through inspiring learners in various stages of training including residents, medical IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 11 students, and nurse practitioner students. The organization utilizes a model of care that emphasized care coordination and communication to meet the needs of patients and their families (A. Sheehan, personal communication, June 10, 2021). The pediatric population served by the clinic site was defined as ‘newborn to early adulthood’ (WMed Health, 2020). The population served was composed of insured, underinsured, and uninsured patients including self-pay (A. Sheehan, personal communication, June 10, 2021). The clinic does not discriminate against patients based on their ability to pay or vaccination status, race, sex, religion, or gender preferences (A. Sheehan, personal communication, June 10, 2021; WMed Health, 2020;). The participating pediatric primary care microsystem team was composed of two certified Medical Assistants, a doctorly prepared Pediatric Nurse Practitioner and a senior Family Nurse Practitioner student in training. The macrosystem support team consisted of a data manager, clinic support staff, and two senior Family Nurse Practitioner students completing a doctoral project who helped facilitate the project. The participating staff were eager to learn the new technique via the MOTIV-Flu tool and provide support to the project. The clinic provided core processes include a wide variety of acute, chronic, and well- child medical services. Services were available in person and through telemedicine visits when appropriate. Acute services included any non-emergent pediatric care needs with follow-up. Well-child services included an overview of health and safety with immunization status review and administration. The primary care office also partnered with the local health department to participate in a low-cost or free Vaccines for Children program (VFC) (A. Sheehan, personal communication, June 10, 2021). IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 12 Before this quality improvement project, the immunization status review, education and administration process was driven by the MAs. It included generating the patient’s individualized Michigan Care Improvement Registry (MCIR) report for review, assessing vaccine acceptance with the caregivers, followed by provider education reinforcement if needed and MA vaccine administration (A. Sheehan, personal communication, June 10, 2021). A clinic wide data review identified a steady decline in pediatric influenza vaccinations since 2018, as evidenced by 46.8 % acceptance in 2018, compared to the 2019 acceptance rate of 32.9% (A. Sheehan, personal communication, June 10, 2021). Strengths, Weaknesses, Opportunities, & Threats Prior to project implementation, a strength, weaknesses, opportunities, and threats (SWOT) analysis was performed with key stakeholders of the pediatric primary care clinic to better understand how to best implement the intervention. The purpose of performing a SWOT analysis is to show positive and negative factors that could affect project outcomes (Harris, 2020). Appendix A provides a comprehensive SWOT analysis based on factors specific to the participating primary care clinic setting. Strengths related to the primary care clinic included a well-documented electronic health record (EHR) that provided detailed accounts of when vaccines were provided and what vaccinations were outstanding. Vaccine status was further substantiated by a clinic report from the state of Michigan database MCIR that indicated the up-to-date status of the patient’s immunizations on record regardless of the location it was administered. An additional strength for implementation included no conflicting QI projects within the location setting within the same time frame. Weaknesses identified included a narrow window for vaccine administration, potential staff turnover, and no motivational interviewing technique training for support staff IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 13 outside of the clinical setting. An additional weakness revealed there was no previous required vaccination training for the MA or provider (A. Sheehan, personal communication, June 10, 2021). The evaluation of opportunities revealed that the primary care setting was an ideal place to implement the use of motivational interviewing. When considering the World Health Organization Vaccine Hesitancy Model’s three contributing factors; complacency, confidence and convenience, the primary care setting allowed for status review, education, and immediate vaccine administration, reducing all three contributing barriers at once (WHO, 2016). Additionally, an opportunity existed related to the partnership with the local health department for free vaccines for at-risk or underprivileged children reducing potential financial barriers for caregivers. Threats related to the success of the project included potential missed opportunities for vaccination education related to telemedicine visits and a loss to follow up for patients who were inconsistent with care. Potential threats considered included staff fatigue and turnover of unrelated nature. Fishbone Diagram A fishbone analysis is a diagram data tool that provides significant value by revealing cause and effect relationships (Riley & Harris, 2020). Appendix D provides a visual representation and understanding of the reciprocal relationships within the practice to assist in identifying vulnerabilities during the improvement process. Synthesis of the Evidence Search Strategy A systematic research review was conducted to explore established literature and data available regarding vaccine hesitancy and motivational interviewing. The search was completed on June 25, 2021, via the Cumulative Index to Nursing and Allied Health Literature (CINAHL), IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 14 PubMed of the U.S. National Library of Medicine National Institutes of Health, and Cochrane Review database (Appendix B). Motivational interviewing is defined by employing and activating each patient's individual motivation for change (Rollnick, Miller, & Buttler, 2008). The CINAHL and PubMed reviews were guided by limitations including: the English language and articles published within the last five years. The Cochrane review limitation included: within the last 5 years. Truncation and Boolean key phrases for all three searches included: Vaccin*, “Motivational Interviewing” OR “Motivational Interview”. CINAHL search query yielded 37 results, PubMed yielded 52, and Cochrane yielded 27 query matches. After eliminating duplicates, a title and abstract review was completed resulting in further elimination of 97 articles. Full article review was completed on 19 articles with final appropriateness selection based on level of evidence, and outcomes analysis with MI, resulting in nine articles for the literature review (Appendix C). Selection Criteria All studies were reviewed based on the reciprocal relationship of vaccine hesitancy and motivational interviewing. Upon conclusion of each database review, all articles underwent a title and abstract review. Inclusion required to vaccine hesitant caregivers, the outpatient setting, and educational components of MI. Studies were excluded based on their geographical location. Those not conducted or published within the United States were eliminated. Additional exclusion criteria were based on population discrepancies such as postpartum mothers, men who have sex with men, studies related to the novel Corona 19 virus, and studies not completed within the last five years. Final selection of applicable studies yielded nine relevant articles (Appendix C). These nine articles highlighted common themes and gaps within the literature. A common theme identified included the appropriateness of the primary care setting for employing IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 15 motivational interviewing to overcome vaccine hesitancy. Gaps within the literature identified: a lack of influenza specific content related VH, discrepancies among confounding variables contributing to VH, and a variety of educational techniques employed for MI. Literature Synthesis Review Settings Related to Motivational Interviewing The literature review revealed a consistent theme confirming that reducing vaccine hesitancy is ideal for the primary care setting and can be facilitated by MI techniques. Two studies identified in the literature review substantiated that the primary care setting serves as an ideal opportunity to implement MI and foster trust with caregivers (Mical, Martin-Velez, Blackstone, & Derouin, 2021; Wermers, Ostroski, & Hagler, 2021). A benefit to the primary care setting is that it allows providers to build rapport with patients which reduces VH in caregivers (Bernstein, Bocchini, & Committee on Infectious Diseases, 2017). Dempsey et al. (2018), note that there was an increased opportunity for employing MI with adolescents if vaccination status was addressed during all visits, as opposed to only well-child visits. The primary care setting can facilitate provider/caregiver autonomy when establishing a vaccine schedule when used in conjunction with MI. This allows for a cost effective and convenient way to address concerns related to vaccine safety (Gagneur et al., 2019). According to Tokish and Solanto (2020), 80% of caregivers stated that their decision to vaccinate their children was influenced by a positive trusting provider relationship within the primary care setting. This further indicates that the primary care setting is beneficial for reducing vaccine hesitancy. Gap Analysis The literature review highlighted the lack of available content regarding overcoming vaccine hesitancy in relation to seasonal influenza vaccinations. Of the nine articles reviewed, IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 16 three specifically reviewed improving Human Papillomavirus (HVP) (Dempsey & O’Leary, 2017; Reno, O’Leary, Garrett, Pyrazanowski, Lockhart, Campagna, Barnard, J., & Dempsey, 2018; Dempsey et. al., 2018) and five reviewed improving all acceptance of vaccinations (Bernstein, Bocchini, & Committee on Infectious Diseases, 2017; Cole, Berman, Gardner, McGuire & Chen, 2020); Gagneur et al., 2019; Mical, Martin-Velez, Blackstone, & Derouin,2021; Tokish & Solanto, 2020). The final article reviewed vaccine outcome improvement data for influenza, Human Papillomavirus (HPV), and meningitis B (MenB) rates within a university health care setting (Wermers, Ostroski, & Hagler, 2021). In the primary care setting, fostering positive influenza vaccination interventions through patient/provider conversations creates a unique opportunity to provide education and support vaccine positivity on an annual consistent basis. Tokish & Solanto, (2020) reveal that approaching the influenza vaccination with MI techniques facilitates communication that is built on trust and empathy. Employing this technique annually with the seasonal influenza vaccine could foster consistency and reduce overall hesitancy. Vaccine Hesitancy Each article reviewed vaccine hesitancy and echoed the World Health Organization definition of Vaccine Hesitancy as a “...delay in acceptance or refusal of vaccines despite availability of vaccine services” (WHO, 2016). Individualized variables reiterate specific factors that contribute to the complex problem of vaccine hesitancy. In accordance with the Vaccine Hesitancy Model provided by the World Health Organization, the variables reviewed consistently align with the three significant contributors: complacency, confidence, and convenience (WHO, 2016). Tokish and Solanto (2020) reviewed concerns regarding complacency, they identified that many caregivers consider the perceived disease risk as IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 17 minimal. Caregivers also inaccurately believed that becoming naturally infected with a disease will increase immunity contributing to complacency (Tokish & Solanto, 2020). Cole et al. (2020) reviewed VH related to confidence, citing the 2011 National Immunization Survey, indicating that health beliefs such as vaccine safety influenced caregivers to refuse or delay immunizations. Bernstein, Bocchini, & Committee on Infectious Diseases (2017) reviewed convenience concerns based on pediatric healthcare utilization trends which decreased as the pediatric population grew older. Ensuring that consistent and convenient care is established and continued with one provider allowed providers to foster a congruent reciprocal relationship (Bernstein & Bocchini, 2017). Allowing provider/caregiver autonomy with implementation schedules can create convenience and improved acceptance rates (Bernstein & Bocchini, 2017). Motivational Interviewing The use of motivational interviewing is consistently noted in the literature review to improve vaccination rates. Wermers, Ostroski, and Hagler (2021) found that when MI was applied continuously over time by primary care providers in a university clinic, it led to higher rates of influenza vaccination. Bernstein, Bocchini, and Committee on Infectious Diseases (2017) and Bernstein, Bocchini, & Committee on Infectious Diseases, (2017) identify that when MI was employed with proper technique it encouraged caregivers to reflect on why their adolescent child needed to be protected against vaccine preventable diseases. Mical, Martin- Velez, Blackstone, and Derouin (2021) noted that for MI to be effective, certain attributes like compassion and understanding must be engaged to overcome VH. Additionally, Tokish and Solanto (2020), noted that MI is a powerful technique to overcoming VH, as it emphasizes a dialogue with the patient’s caregiver based on their individual values and specific concerns. Establishing, promoting, and maintaining trust with consistent communication was vital with IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 18 vaccine hesitant caregivers, and cited to be the most important factor as caregivers made decisions related to vaccinations (Tokish & Solanto, 2020). Dempsey and O’Leary (2017), noted that when providers were trained and utilized motivational interviewing, the vaccination rates improved and became significantly higher, demonstrating that MI is an impactful resource available to providers. Cole et al. (2020) noted the lack of clinical tools available to assist health care professionals with caregiver motivational interviewing conversations. MOTIVE-Flu (Motivational Interview Tool to Improve Vaccination Adherence) created by Cole, Berman, Gardner, McGuire, and Chen in 2020, established a point of care algorithm specifically for influenza vaccine conversations (Appendix I). The tool guides clinicians through difficult vaccine hesitant conversations with the use of open-ended questions, affirming the patient's ability to change and summarizing the caregivers’ thoughts and goals while moving toward vaccination compliance (Cole et. al., 2020). Quality Improvement Framework The pediatric influenza vaccination quality improvement project was based on the Knowledge into Action Framework developed by Graham, Logan, Harrison, Straus, Tetroe, Caswell, and Robinson (2006). The framework was created to improve understanding and implementation of the “concepts of knowledge translation, knowledge transfer, knowledge exchange, research utilization, implementation, diffusion, and dissemination” (Graham et al., p. 13., 2006). The framework has two distinct components; first a funnel of Knowledge Creation which is dynamic and influential to the second component, the Action Cycle (Graham et al, 2006). The Knowledge Inquiry component of the Knowledge into Action Framework identified data indicating a decreased acceptance rate of seasonal influenza vaccine administration within the pediatric population from a micro to macro level, from the clinic wide, to Kalamazoo IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 19 County, the State of Michigan and on a national level (A. Sheehan, personal communication, June 10, 2021; CDC, 2021d; CDC, 2021e; LiveStories, n.d.). The Knowledge Inquiry set the stage for the intention of the selected intervention to reduce vaccine hesitancy. This was facilitated by improved provider knowledge and employing the MOTIVE-Flu tool to foster motivational interviewing techniques in the pediatric primary care setting. The intervention selection was evidenced by and supported through the literature review. Following the Knowledge Inquiry portion of the framework was step two the Action Cycle. This process served as a guide for data collection, analysis, sustainability, further development, and continued research. Goals, Objectives, & Expected Outcomes Success of the quality improvement project was evaluated by a ten percent increase in the participating providers' influenza vaccination acceptance compared to the previous year. The objective was to provide MA and provider education and the MOTIVE-Flu point of care tool when working with identified vaccine hesitant caregivers. The expected outcome is an increase in influenza vaccination acceptance with the use of the MOTIVE-Flu tool. Practical implications for the project outcome included improving morbidity and mortality related to the influenza within the pediatric population, reducing the spread of influenza within the community, and decreasing healthcare costs related to influenza. The timeline for the project was based on the release of the 2021-2022 seasonal influenza vaccine during the months of October through December (Appendix E). Following the intervention, implementation data was collected and reviewed. During the implementation process data was collected via the Clinical Data Collection Chart (Appendix G), where it was reviewed bi-weekly by the project facilitators, then verbally reviewed with stakeholders for IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 20 ongoing feedback and process improvement. Following the implementation process data was collected via the organization's data manager via the EPIC Slicer Dicer to compare 2020 to 2021 acceptance rate of the participating provider. Within the spring of 2022, the project facilitators synthesized the data to better understand the results compared to the expected outcomes, to determine if the expected outcome was achieved. Methods Ethical Considerations Prior to project implementation or data collection, the project was submitted for review and approved by the Michigan State University’s Institutional Review Board (Appendix P). The review board’s approval satisfied the ethical requirements for the clinical site standards. The project was determined to be quality improvement without human subjects. The intervention reinforced the use of MI with the provider and MA through a structured learning opportunity and the using the MOTIVE-Flu tool was intended to decrease vaccine hesitancy in caregivers, resulting in improved influenza vaccination rates at a pediatric primary care clinic. Motivational interviewing is standard practice within many clinics, the use of the MOTIVE-Flu tool was facilitated as intended and approved by the creators (Appendix J). The project focused on improving the current procedure to reflect the healthcare industry norms. All data provided to the project facilitators was aggregated and de-identified. Setting Facilitators The pediatric primary care setting was structured as part of a larger university medical institution, located in Kalamazoo County, Michigan. This specific primary care site was a stand- alone clinic with a mix of providers that were both faculty and non-faculty of the university. They included five physicians and one pediatric nurse practitioner. Additional support staff at IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 21 the clinic included social work, MAs, a Family Nurse Practitioner senior student, office assistants and administrative staff (A. Sheehan, personal communication, June 10, 2021). Services offered included acute and non-acute pediatric care, well child visits, immunization, and care coordination (WMed Health, 2020). Interactions with site staff personnel were facilitated through in person coordination that was pre-approved and structured to the project. The project did not require patient interaction by the project facilitators. The project was supported by the facility and administration within the site organization as evidenced by the Letter of Support (Appendix F). Careful considerations were reviewed within the SWOT Analysis (Appendix A) including the resources, constraints, facilitators, and barriers that influenced the implementation of the project. Barriers Barriers to implementation of the project included: resource limitations of competing universities, the Covid-19 global pandemic, and provider scheduling limitations (A. Sheehan, personal communication, June 10, 2021). The project facilitators and the clinical site were represented by two competing universities with limited resources resulting in logistical challenges. An additional non-modifiable barrier included the political and social climate related to the Covid 19 pandemic and vaccination status. Consideration was given to the time constraints of the staff as well as the participating provider who facilitated the intervention. This provider was limited to patient interaction two days per week, which created an accessibility barrier and limited sample size (A. Sheehan, personal communication, June 10, 2021). Intervention & Data Collection Procedure Provider education was the foundation of the intervention for the project. Education and employing the MOTIVE-Flu tool with MI techniques was used to reduce caregiver vaccine IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 22 hesitancy, resulting in the expected outcome of a ten percent increased acceptance of the seasonal influenza vaccination compared to the previous year. The tool and technique were selected based on the literature review substantiating effectiveness of MI within the pediatric population in the primary care setting. The MOTIVE-Flu tool was created by Cole, Berman, Gardner, McGuire, and Chen with the support of Cedarville University in 2020 (Cole et.al., 2020). The use of this tool was approved by the creators (Appendix J) and agreed upon by the participating provider and the project facilitators (Appendix K), approval included agency stakeholders such as the organizations Pediatric and Adolescent Medicine Department Chair, and the participating provider and the Medical Assistants. The MOTIVE-Flu is specifically designed as a guide for provider use during difficult vaccine hesitant caregiver conversations, focusing on caregiver engagement (Cole et.al., 2020). The MOTIVE-Flu tool education presentation was facilitated by a four-part module. This education presentation was completed by the provider, the FNP student and MA’s. The educational presentation was developed by the MOTIVE-Flu creators Cole, Berman, Gardner, McGuire, and Chen (Cole et al, 2020). Each module session was 30 to 45 minutes long with active learning opportunities (Cole et.al., 2020). The four learning modules including: Module One: Vaccine Health Beliefs and Current Vaccine Rates, Module Two: Motivational Interviewing, Module Three: Introduction to the MOTIVE Tool and Module Four: Role Playing using the MOTIVE-Flu tool and motivational interviewing (Cole et al., 2020). Provider education was geared toward tool use and MI simulation. Education for the MA was geared toward identifying VH caregivers (Cole et al. 2020). The Family Nurse Practitioner student completing a clinical rotation during the time of intervention implementation and data collection was willing to participate in the project and participation was approved by the participating IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 23 provider who also served as the student’s preceptor (A. Sheehan, personal communication, June 10, 2021). The MOTIVE-Flu education tool was shared with the student and a review session was completed to ensure the student was comfortable with implementing the tool with patients' caregivers. All implementation by the student was reviewed, supervised, and reinforced with the preceptor/participating provider (A. Sheehan, personal communication, June 10, 2021). Following the education implementation, the influenza vaccination process within the clinic was altered. After MA identification of vaccine hesitant caregivers, the MOTIVE-Flu point of care algorithm reference tool (Appendix I) was provided with the MICR documentation for the provider to reference through difficult VH conversations. The MAs no longer fostered VH conversations. The provider initiated the MOTIVE-Flu tool with open ended questions to facilitate vaccination acceptance. The MA recorded if the patient accepted the vaccination, refused the vaccination, or was not applicable if the vaccination was not due on the Clinical Data Collection Chart (Appendix G). Throughout the implementation process, data was analyzed by the investigators bi-weekly to review project development within the clinic. The information was verbally shared with key stakeholders to provide updates, receive feedback, and instill team enthusiasm and encouragement. In December 2021, after completion of the intervention, project facilitators began data analysis. Data collection strategies were facilitated by the medical assistant Clinical Data Collection Chart and the organization's Data Manager using the EPIC Slicer Dicer. Data was collected and reviewed in accordance with the ethical considerations (Appendix G). A potential budget of the project is reviewed in Appendix H. Timeline IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 24 A timeline was established with participating project facilitators, faculty, and the community liaison for project implementation (Appendix E). Project creation began in May of 2021, intervention implementation began in October of 2021, conclusion and data collection occurred in December of 2021, data analysis began in January of 2022. At the conclusion of the project in April 2022, dissemination was approved and presented via an executive summary to all participating agency stakeholders, including the Pediatric and Adolescent Medicine Department Chair, data managers, the participating provider, and the MAs as well as other clinic staff at the site location, the Michigan State College of Nursing and Cedarville University MOTIVE-Flu creators. Measurement Instruments & Tools Outcome’s measurement was facilitated in two forms, the Medical Assistant’s anecdotal Clinical Data Collection Chart during the project implementation and via the Data Managers EPIC Electronic Medical Record, Slicer Dicer post project. All data was collected in accordance with the IRB approval (Appendix P). The Epic slicer dicer data was statistically reviewed by Michigan State University for difference in proportion hypothesis testing. Analysis Epic Slicer Dicer Data Evaluation and analysis were completed based on EMAR ICD-10 code Z23 ‘Encounter for Immunization’ at all appointments from October 4, 2021, to December 13, 2021. Total use of the Z23 use was collected via the EPIC slicer dicer and compared to the same dates from the previous year's total visit ICD10 code. The participating provider previous 2020-year ICD 10 code Z23.0 was utilized during 73 of the 177 visits resulting in 43% of the visits (Appendix L). During the 2021 dates while the intervention was being employed the ICD 10 code Z23 was IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 25 employed at 96 of the 177 visits resulting in 54% of visits, a 11% improvement (Appendix L). Additionally, 2021 data was compared via the EMAR Slicer Dicer ICD-10 codes with the participating provider using the intervention results in Z23 code use during 54% of visits compared to all other providers, not using the intervention, use of the Z23 code during the same time frame was 37% (Appendix M). This comparison was reviewed for statistical analysis by Michigan State University and yielded statistically significant difference in proportion hypothesis testing results. The proportion of those who accepted vaccines in the intervention group was significantly higher (p-value = 0.003) as compared to the proportion of patients who accepted the vaccination within the nonintervention group. Limitations Limitations were identified with the Epic Slicer Dicer tool data collection including the inability to decipher which patients were up to date with their influenza vaccination resulting in no need to employ the ICD 10 Z23 code. Of the anecdotal data collected via the Clinical Data Collection Chart, it is indicated that up to 28% of patients seen within the clinic were up to date with their immunizations (Appendix N). An additional limitation of the Slicer Dicer is the ICD 10 code can be employed for other vaccinations. Anecdotal Clinical Data Based on the limitations identified above, the clinical data collection by the Medical Assistants provided anecdotal inference for context. Data indicated that within the 2021 defined time frame time 28% of the total patients seen by the participating provider were up to date and did not need the influenza vaccination at that time (Appendix N). An inference can be drawn by eliminating the 28% that were up to date, resulting in an acceptance rate of 65.3% and refusal rate of 34.6% (Appendix O). IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 26 Sustainability Plan In accordance with the selected quality improvement Knowledge into Action Framework, the Action Cycle guided the sustainability plan (Graham et al., 2006). At the conclusion of the project implementation and analysis, dissemination occurred to seek recommendations, feedback, and sustainability potential. The first meeting was completed with the two MAs who identified that they felt the intervention was impactful and warranted the allocation of their time as a resource within the clinical setting (L. Ebbitt, personal communication, December 15, 2021). During their reflection the MAs noted that the intervention reduced their workload and streamlined the communication with the provider for who needed vaccinations and who was vaccine hesitant (L. Ebbitt, personal communication, December 15, 2021). The second sustainability meeting was completed at the conclusion of the project with the participating provider who identified that the intervention was useful and improved her communication with vaccine hesitant caregivers to foster evidence-based knowledge during the decision-making process (L. Ebbitt, personal communication, December 15, 2021). The provider noted that she felt some of her colleagues may be looking to improve their pediatric influenza vaccination rates (A. Sheehan, personal communication, December 15, 2021). Project dissemination to drake holders, clinic providers and the facility medical staff was completed during a staff lunch in April 2022. During the staff meeting an executive summary reviewed project intervention, outcome, tools, and training options. The providers and their support staff who indicated interest were given the intervention education and MOTIVE-Flu tool to employ with their patient population. Clinical sharing of the MOTIVE-Flu tool, and training was approved by the creators (Appendix J). The third dissemination was provided via an executive summary to the participating facility overarching leadership including the medical chair and the organization's IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 27 data manager. The content covered included a review of the intervention, data results, project outcomes, implication potential and a final statement of encouragement to consider implementation site wide. The executive summary was also provided to the MOTIVE-Flu creators with participant’s feedback. Final dissemination and project presentation was provided by the project facilitators to Michigan State University College of Nursing. Discussion/Implications for Nursing Vaccine hesitancy is a growing concern among providers and community health leaders. The MOTIVE-FLU can serve as a guide for medical professionals with difficult vaccine hesitant conversations. This tool can have lasting health benefits for the pediatric population and community health. Project results support the use of the MOTIVE-Flu tool to reduce caregiver vaccination hesitancy and improve pediatric influenza acceptance rates. Practical implications for the project include increased provider use of the tool to reduce morbidity and mortality related to the influenza within the pediatric population, while reducing the spread of influenza within the community and decreasing healthcare costs related to influenza. The Healthy People 2030 pediatric influenza vaccination goal is 80% (Office of Disease Prevention & Health Promotion, n.d.). Employing this tool can help providers to move toward this goal and improve trust between patients, their caregivers, and the clinician. This quality improvement project validated the use of a motivation interviewing algorithm within the clinical setting to overcome vaccine hesitancy. Related additional potential implications of the MOTIVE-Flu tool’s success warrant consideration of developing this tool to guide pediatric COVID 19 vaccine hesitant caregivers could be a powerful tool as this novice vaccination requires overcoming educational barriers. The use of the MOTIVE-Flu tool was with permission (Appendix J) at no cost to the organization and required minimal time allocation for implementation further warrants expansion IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 28 of this asset site wide. Kalamazoo County Michigan’s pediatric influenza mortality rate is higher than the state and national average indicating that improved influenza rates within the pediatric population will slow the spread of influenza within the community to save lives (CDC, 2021d; CDC, 2021c; LiveStories, n.d). Cost-Benefit Analysis/Budget Cost considerations during this quality improvement project included both financial implications and time allocation (Appendix H). Donations were provided in the form of refreshments brought to the clinic during the bi-weekly monitoring process by the project facilitators and three lunches, at the beginning, conclusion, and dissemination of the project, totaling $284 (Appendix H). This cost was not required but provided an opportunity for the project facilitators to connect with members of the intervention team. Potential budget considerations were provided for donations and time compensation totaling $13,687.32 including project facilitators involved and training time for the intervention team members (Appendix H). Each compensation estimate was taken from the 2020 median pay estimate statistics of the U.S. Bureau of Labor Statistics (U.S. Bureau of Labor Statistics, 2021a; U.S. Bureau of Labor Statistics 2021b; U.S. Bureau of Labor Statistics, 2021c). This QI project was implemented through volunteer participation and at no personnel or resource costs to the organization. No official cost to benefit ratio was implemented due to IRB limitations that prevented further depth to show the economic benefit. Conclusion Utilizing the influenza vaccine is a proven primary prevention strategy that is useful in protecting pediatric patients, their peers, family members, and the community from the seasonal influenza virus and its spread. Motivational interviewing is a helpful, low-cost technique that IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 29 can effectively reduce vaccine hesitancy and increase influenza vaccine administration as evidenced by the data conclusion in this quality improvement project. Time allocation and resources required to employ MI are minimal, demonstrating that MI is a strategic approach for providers in the pediatric primary care setting. Despite the data collection limitations identified, evidence in this project demonstrates that in the pediatric primary care setting, when providers employ the MOTIVE-Flu tool with motivational interviewing techniques, caregiver vaccination hesitancy decreases and rates of influenza vaccination acceptance increase. The use of motivational interviewing has a long-standing presence within healthcare. Employing this technique with the MOTIVE-Flu algorithm tool in the primary care setting has proven decreased VH and increase in vaccine acceptance. Project facilitators encourage additional research and development of specific tools to serve as an educational guide to vaccine hesitant caregivers within pediatric primary care. Vaccination education for immunizations such as the novel Covid-19 series could be applied within any clinic setting globally to achieve improved pediatric vaccine adherence rates. IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 30 References Bernstein, H. 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Saint Louis, Missouri: Elsevier Schmid, P., Rauber, D., Betsch, C., Lidolt, G., & Denker, M. L. (2017). Barriers of Influenza Vaccination Intention and Behavior - A Systematic Review of Influenza Vaccine Hesitancy, 2005 - 2016. PloS one, 12(1), e0170550. https://doi.org/10.1371/journal.pone.0170550 Tokish, H., & Solanto, M. V. (2020). The problem of vaccination refusal: a review with guidance IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 34 for pediatricians. Current opinion in pediatrics, 32(5), 683–693. https://doi.org/10.1097/MOP.0000000000000937 U.S. Bureau of Labor Statistics. (2021a). Medical Assistants. Retrieved from https://www.bls.gov/ooh/healthcare/medical-assistants.htm U.S. Bureau of Labor Statistics. (2021b). Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners. Retrieved from https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse- midwives-and-nurse-practitioners.htm U.S. Bureau of Labor Statistics. (2021c). Registered Nurses. Retrieved from https://www.bls.gov/ooh/healthcare/registered-nurses.htm Wermers, R., Ostroski, T., & Hagler, D. (2021). Health care provider use of motivational interviewing to address vaccine hesitancy in college students. Journal of the American Association of Nurse Practitioners, 33(1), 86-93. https://doi- org.proxy1.cl.msu.edu/10.1097/JXX.0000000000000281 Western Michigan University Homer Stryker School of Medicine. (2021). Mission, Vision, and Values. https://med.wmich.edu/node/277. WMed Health. (2020). Pediatric and Adolescent Medicine. https://med.wmich.edu/sites/default/files/Pediatrics%20Mall%20Drive%20practice.pdf. World Health Organization. (2013). The SAGE Vaccine Hesitancy Working Group. What influences vaccine acceptance: A model of determinants of vaccine hesitancy. Retrieved from https://www.who.int/immunization/sage/meetings/2013/april/1_Model_analyze_driversof vaccineConfidence_22_March.pdf World Health Organization. (n.d.). Influenza. Vaccine Preventable Diseases. Surveillance IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 35 Standards. Retrieved from https://www.who.int/immunization/monitoring_surveillance/burden/vpd/WHO_Surveilla nceVaccinePreventable_09_Influenza_R1.pdf?ua=1 World Health Organization. (2016). Vaccine Hesitancy: What it means and what we need to know in order to tackle it. Retrieved from https://www.who.int/immunization/research/forums_and_initiatives/1_RButler_VH_Thre at_Child_Health_gvirf16.pdf World Health Organization. (2017). Estimate of Respiratory Death due to Seasonal Influenza 290,000 - 650,000 Annually. Retrieved from https://www.who.int/influenza/surveillance_monitoring/bod/WHO-INFLUENZA- MortalityEstimate.pdf?ua=1 IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 36 Appendix A Gap Analysis: Clinic SWOT Matrix Analysis Strengths Weaknesses What do you do well? What could you improve? What unique resources can you draw on? Where do you have fewer resources? What do others see as your strengths? What are others likely to see as weaknesses? - Support from providers and staff towards increasing the -Time constraints of when to administer the vaccine due to it influenza vaccine administration due to decreased numbers being seasonal and predicted availability of August 2021 from the year before related to the Covid-19 Pandemic and -Hesitancy of caregivers due to the Covid vaccine becoming access to care. available with specific parameters for administration -Access to comprehensive data from the clinic EHR showing -Inconsistent lack of providers due to the various providers previous influenza rates to measure the effectiveness of the seeing other provider’s patients intervention -Lack of staff training related to motivational interviewing -Well trained staff specifically trained in motivational -Staff turnover interviewing related to vaccine hesitancy -Lack of reminders for pediatric patients and their caregivers -Consistent pediatric population within clinic allows for -The pediatric clinic being studied does not give covid focus on this community vaccine which brings up less encounters for other -The Michigan Care Improvement Registry, MCIR, is vaccinations printed for every patient encounter to ensure review by the -Lack of notifications within EHR for patients who have not providers vaccinations are being met been to the clinic and in need of vaccinations. -No limitation of time frame related to covid vaccine - Lack of MA or Provider clinic specific training for -No other vaccine education program being rolled competing vaccination education or administration for staff attention - Monthly staff meetings are pre planned to allow for education -Quarterly faculty meetings with the clinic where teaching and announcements can be made. -Covid restrictions have loosened at clinic site allowing researchers and stakeholders to come into the clinic IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 37 -Clinic being studied has strong relationship with the local health department and Vaccine For Children program Opportunities Threats What opportunities are open to you? What threats could harm you? What trends could you take advantage of? What is your competition doing? How can you turn your strengths into opportunities? What threats do your weaknesses expose to you? -Direct access to primary care where majority of influenza -Fear of seeking primary care due to COVID-19 pandemic vaccines are administered -Unknown amount of provider turnover within the clinic -Forecasted higher prevalence of influenza related to -Lack of education about consequences of flu from providers predictions of more in person gatherings and staff -A specific MA who is willing to assist and develop research -Media inconsistency regarding influenza and its risks team -Staff fatigue -Participate in Vaccines for Children from the local health -Telemed is not appropriate for administration but is department allowing free vaccinations for low-income appropriate for screening and MI as well as vaccination patients. scheduling -Patients do not have to go to another location for -Inconsistent follow up for prevention of missed vaccinations immunizations - Increased risk for infection related to return-to-work school and sports transition post covid (MindTools, 2020) IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 38 Appendix B June 25, 2021, Literature Inquiry Method Table Database Searched Keyword Truncation Limitations # of Results CINAHL Vaccin*, “Motivational Interviewing” OR English Language 37 “Motivational Interview” Within the last 5 years PUBMED Vaccin*, “Motivational Interviewing” OR English Language 52 “Motivational Interview” Within the last 5 years COCHRANE Vaccin*, “Motivational Interviewing” OR Within the last 5 years 27 LIBRARY “Motivational Interview” IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 39 Appendix C Literature Review Table Level of Implications for evidence/ Purpose of the Framework Results Relation to Practice/ Title Authors Design project/research (Theoretical) Outcomes our project Intervention(s) Health care Wermers, R., Level 4 - Although vaccination Theory of MI can be an effective Influenza Provider provider use of Ostroski, T., & Longitudinal decisions are complex, a Planned part of a strategy to Provider Edu Education MI motivational Hagler, D. Cohort Study recommendation from a Behavior increase vaccination MI interviewing to health care provider is rates. address vaccine one of the key motivators hesitancy in for individuals receiving a college students. vaccine. Improving Provider Reno, J.E., Level 2 Providers and staff at Not identified Demonstrates HPV but Provider Edu Communication O’Leary, S., Randomized eight pediatric and family possibilities for the use RCT with MI with MI about HPV Garrett, K., Control Trial medicine clinics received of MI as a technique for intervention Vaccines for Pyrazanowski, (RCT) communication training effectively facilitating Vaccine-Hesitant J., that included MI conversations with HPV Parents Through Lockhart, S., techniques. Assessed vaccine-hesitant the Use of Campagna, E., the perceived efficacy of caregivers. Motivational Barnard, J., the intervention. Improves providers’ Interviewing. & Dempsey, A.F. communication with caregivers that are HPV vaccine-hesitant Can lead to increased adolescent HPV vaccine utilization and public health benefit. Vaccine Hesitancy Mical, R., Martin- Level 6 The study determined if Not identified Routine VH screening Motivational Presumptive in Rural Pediatric Velez, J., Qualitative early identification of Implementing Interview Language MI Primary Care. Blackstone, T., & Study parental VH via a survey interventions Peds Derouin, A., could decrease VH successfully decreased Primary scores. VH scores and Care Setting IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 40 improved vaccine compliance. The problem of Tokish, H. & Level 3 - The purpose of this Not identified MI was successful in MI MI vaccination refusal: Solanto, M.V., Literature literature review was to reducing vaccine Primary care, a review with Review demonstrate that hesitancy (HPV) Resources to guidance for pediatricians can apply Rated by providers as overcome pediatricians. research from cognitive more effective than vaccine behavioral research to other communication hesitancy reduce vaccine hesitancy techniques, without in caregivers increasing the length of the appointment. Human Dempsey, A. F. Level 4, The purpose of this Not identified Using self-affirmation to MI among MI Papillomavirus & O'Leary, S. T. Literature literature review was to improve VH caregivers' vaccine Vaccination: Review provide up to date, well willingness to hear pro- hesitant Narrative Review designed information vaccine messages. caregivers of Studies on How regarding communication Creative Providers' Vaccine related to vaccines, communication Communication specifically the HPV strategies Affects Attitudes vaccine. and Uptake. Development of Gagneur, A., Level 3, The purpose of this Questionnaire The MISI questionnaire MI Evaluation of MI motivational Gosselin, V., Control Trial questionnaire was to to assess MI training interviewing skills Bergeron, J., evaluate the specific to in immunization Farrands, A., & effectiveness of MI immunization. (MISI): a Baron, G. training related to Psychometric questionnaire to immunizations. measures showed high assess MI reliability. learning, knowledge and skills for vaccination promotion. IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 41 Practical Bernstein, H. H., Level 5, The purpose of the Not identified Authors used literature MI American Approaches to Bocchini, J. A., Literature literature review was to to address vaccine Academy of Optimize Jr, & Committee Review examine current hesitancy within the Pediatric Adolescent on Infectious guidelines and literature adolescent population, guidelines to Immunization. Diseases in order to empower and also gave help promote providers to overcome evidence-based vaccines vaccine hesitancy suggestions to help predominantly in overcome vaccine adolescents. However, hesitancy with any the information could be caregiver. applied to all pediatric populations. Effect of a Health Dempsey, A., Level 2 A health care Survey The study of 43,152 Provider Using Care Professional Pyrznawoski, J., Cluster professional patients showed that training, communication Communication Lockhart, S., Randomized communication when providers had adolescent Training Barnard, J., Clinical Trial intervention significantly improved training to increase immunizatio Intervention on Campagna, E. J., improved HPV vaccine related to n adherence Adolescent Human Garrett, K., series initiation and communication Papillomavirus Fisher, A., completion among techniques related to Vaccination: A Dickinson, L. M., adolescent patients. HPV, the vaccination Cluster & O’Leary, S. rates improved Randomized significantly Clinical Trial. Implementation of Cole, J., Berman, Level 3 This study aims to Pilot study Outcome results were MI, training Implementation a motivational S., Gardner, J., Pilot Study develop a validated based on the not provided because providers in of MI, great interviewing-based McGuire, K., & parental communication Health Belief this was a pilot study. motivational information decision tool to Chen, A.M.H. tool utilizing motivational Model However, the interviewing, related to using improve childhood interviewing to increase researchers were vaccine MI in infants and vaccination rates: vaccination adherence in hopeful for positive hesitancy, toddlers. Pilot study children ages 6 years results. protocol. and younger. IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 42 Appendix D Fishbone Diagram IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 43 Appendix E Timeline Summer Semester 2021 Fall Semester 2021 Spring Semester 2022 Task May June July August September October November December January February March April Meet with Agency Clinical Question Literature Review Project model, SWOT, and Fishbone Diagram Develop Methodology IRB Presentation and Submission Meet with Clinic Staff Implement Project and Data Collection IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 44 Analyze Data Interpret Results Finalize Project Disseminate Project IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 45 Appendix F Letter of Support IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 46 Appendix G Clinical Data Collection Chart 1 2 3 4 5 6 7 8 9 10 11 12 13 14 10/4/21 U U Y Y Y U U R U Y U U 10/8/21 Y Y Y U R Y Y Y R R R Y R 10/11/21 R Y U U Y U R R Y Y U R U Y 10/13/21 Y Y U Y U R Y Y Y 10/18/21 U Y U Y U R 10/19/21 U R R R U 10/20/21 U U Y R R 10-25-21 Y R Y R R R U Y Y 10-27-21 Y U Y Y Y Y U Y 11-1-21 Y R R R Y R Y Y Y R U Y Y U 11-3-21 Y R R Y 11-8-21 Y U U Y Y U Y Y R U R U 11-10-21 Y Y Y R U Y U U 11-15-21 Y Y Y U Y R U U R R U 11-17-21 Y Y R Y R R 11-22-21 Y Y Y Y U R R 11-24-21 Y Y Y Y U R U 11-29-21 U Y Y Y U Y Y Y Y U R 12-13-21 Y U Y Y Y Y U U Y U R R Key Y = Influenza Vaccination Acceptance R = Vaccination Refusal N/A = Vaccination not due IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 47 Appendix H Potential Budget Considerations Personnel Pay Total Luke Linscheid RN BSN $36.22/hour x 180 hours $6,519.60 Channan Kositzke RN BSN $36.22/hour x 180 hours $6,519.60 2 Medical Assistant module training $17.23/hour x 4 hours $137.84 Nurse Practitioner module training $56.57/hour x 4 hours $226.28 Facilitator Food Donation Lunch x 3, Snacks x 3 $284.00 TOTAL $13,687.32 IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 48 Appendix I MOTIVE-Flu Tool IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 49 IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 50 IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 51 IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 52 Appendix J Cedarville University MOTIVE-Flu Tool Approval IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 53 Appendix K Participating Provider and Tool Agreement IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 54 Appendix L Participating Provider 2020 vs 2021 Z 23 Code Use IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 55 Appendix M Participating Provider 2021 vs All Practice Provider 2021 Z 23 Code Use IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 56 Appendix N Participating Provider 2021 Anecdotal Clinical Data - Total Visits IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 57 Appendix O Participating Provider 2021 Anecdotal Clinical Data - Eliminating Up to Date IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 58 Appendix P Michigan State University Institutional Review Board Approval IMPROVING PEDIATRIC INFLUENZA VACCINATION RATES 59