College life brings people into close proximity in dormitories, classrooms, libraries, and cafeterias. These gatherings create an opportunity for respiratory illnesses such as influenza to spread quickly (Benjamin & Bahr, 2016). Despite the increased risk of transmission of influenza on college campuses, a Harris Poll from the National Foundation for Infectious Diseases (NFID, 2016) of 1,005 18- to 24-year-old undergraduate students in the United States showed that although 70% of them felt it was important to get an annual flu vaccine, less than 46% of them actually did. Monn (2016) stated that 20% or fewer of college students in the United States receive the flu vaccine. In fact, low levels of flu vaccination among undergraduates is a public health concern across the nation (Svokos, 2014). With the COVID-19 crisis, college students have been impacted in many significant ways including having to transition to online learning, unusual social distancing, and new infection control practices in an academic setting.
However, prior to the novel coronavirus (COVID-19), college students may not have realized the potential severity and impact of communicable respiratory diseases, including the more common influenza virus, on the population. During the 2017-2018 flu season, an estimated 49 million cases of flu resulted in approximately 960,000 hospitalizations and 79,000 deaths (Centers for Disease Control and Prevention [CDC], 2018). Symptoms of an influenza-like illness often cause students to miss class, do poorly on a test or an assignment, miss work, take time to visit a healthcare provider, and pay for over-the-counter and prescription medications (Nichol et al., 2005). Being sick with the flu is more than inconvenient; it can be dangerous and costly to students and to the community.
PROMOTING COMMUNITY HEALTH
Community health nurses aim to improve the health of populations, communities, and aggregate groups. The public health nurse advocates for the community by providing education on how to maintain health and prevent disease. Primary prevention is a key role of the community nurse. Christian nurses are called to go even further; they are asked to pray for and “bear one another's burdens” (Galatians 6:2, ESV). Desiring the well-being of others is a biblical principle. “Beloved, I pray that all may go well with you and that you may be in good health, as it goes well with your soul” (3 John 1:2, ESV).
Nurses already show concern for the needs of others in providing tertiary care while caring for patients after they have contracted a disease, but how could nurses bear one another's burdens in a way that promotes upstream thinking such as disease prevention? Offering factual information about the means to avoid contracting a disease is a logical approach to loving one's neighbor. This information can be as simple as hand washing and environmental cleanliness or as complex as explaining the CDC's immunization recommendations. Nurses are privileged to understand the research that validates the necessity of vaccines. Promoting immunization for vaccine-preventable diseases, with education and accessibility, is a tangible way for nurses to demonstrate brotherly love for the community.
To say there are mixed opinions on vaccination is an understatement. Although the antivaccination movement has gained traction in the United States, nurses can approach families and individuals with respect and empathy to explain common vaccination myths. Instead of making parents feel badly for questioning the safety of a vaccine, the nurse could state, “I understand that you want what is best for your child and you may have heard mixed messages about vaccination. Can we discuss your questions or concerns?” Nurses should explain the science surrounding the role vaccinations have had in improving health and even eradicating disease. We must approach this topic with graciousness and education rather than with judgment and division. Although a vaccine for COVID-19 is not available, awareness of contagious disease has been especially evident since the early months of 2020.
College students also have heard mixed messages about vaccination. Their post-high school years may be the first time they can make their own decisions regarding vaccination. Students may feel conflicted between what they have heard from their parents and what they see and read in the media. They may question the efficacy and risks of vaccination. Students may not prioritize the importance of taking a few minutes to receive an injection, something that may cause discomfort. It is important to acknowledge that the actions students take in college may set a trajectory that continues after graduation and as they start families of their own. Addressing students' questions and concerns should be a priority for community health nurses, including campus clinicians, as students' decision-making impacts future generations. Helping students to deal with barriers to vaccination, such as convenience and cost, can encourage the habit of yearly influenza vaccination at the threshold of their adult lives.
THE CLINICAL PROBLEM
The clinical problem at the university where this Doctor of Nursing Practice (DNP) project took place was a low uptake of influenza vaccine on the campus. Among various reasons, the one tested for this project was out-of-pocket expense for students. The health clinic at the university did not offer billing of students' private health insurance; therefore, a student opting to receive a flu shot on campus had to pay $20.
BACKGROUND AND SIGNIFICANCE
Research has shown that “college students are notoriously difficult to vaccinate against the flu” (Lawrence, 2014, p. 425) and that students have “unwarranted optimism about their own health” (Svokos, 2014, para. 12). Low vaccination rates are ubiquitous at college campuses across the nation (Svokos, 2014). College students may not realize the potential severity and impact of the influenza virus on other people and on society at large.
The challenge for the university where this project was conducted was the inability of the campus health clinic to bill students' private health insurance. The clinic did offer the flu vaccine for an out-of-pocket charge of $20 to students, faculty, and staff. Even though this was a reasonable price, many students are on tight budgets and may not prioritize spending money on preventative measures over the cost of food, entertainment, or living expenses. As a result, the university health clinic had historically low numbers of students choosing vaccination through the campus clinic. The average over the past 6 years was 4.09% of the student body receiving the influenza vaccine.
The health clinic director stated she had considered partnering with a pharmacy to offer a mobile clinic. However, due to time constraints, she was unable to develop the partnership. As a result, the DNP project initiated the pilot program for this opportunity. This author volunteered to help with the pilot program and to analyze the data as part of the program review for the DNP project. This author partnered with a local pharmacy that could offer private billing of most major health insurances.
PURPOSE OF THE PROJECT
This project was originally part of a DNP requirement; the project has continued as a community outreach program. The purpose of the initial evidence-based project was to examine a local university's health clinic influenza vaccination program and explore the impact of a pilot program to partner with a local pharmacy. A program review looked at the university health clinic's flu vaccination activities from 2012 through 2017 and compared the findings with results from 2018 when the pharmacy partnership and mobile flu shot clinic took place.
The Six Sigma DMAIC (define, measure, analyze, improve, and control) tool was used to determine if the partnership with a local pharmacy had a significant impact and should continue. By sustaining the partnership, more students have opportunity to receive flu vaccine that is covered by private insurance. Sharing this information with fellow community health nurses allows for possible duplication of the interprofessional flu shot clinic at other postsecondary sites across the nation.
The project's aim was to examine the effect on flu vaccination rates among undergraduate students at a private university campus as a result of collaboration with a pharmacy within the time frame of the flu season (September through February) compared with the practice of offering flu vaccination only in the health clinic that incurs an out-of-pocket expense.
The theory of planned behavior (TPB) supported the theoretical foundation for this project (Agarwal, 2014). The TPB guided recommendations for future marketing of the flu shot clinics for students. This theory builds on the “assumptions that individuals can rationally evaluate their options and beliefs associated with a behavior before formulating their intention to perform the behavior” (Agarwal, 2014, p. 417).
Many researchers have utilized the TPB in examining vaccine behavior (Schmid et al., 2017). In a systematic review of the use of the TPB as a behavior change framework for studies involving influenza vaccination, Schmid et al. (2017) noted that it was the second most often used theory to predict healthcare workers' intentions toward influenza vaccinations. This base of information was used to provide recommendations for marketing the mobile flu shot clinic to students.
The Professional Nursing Practice and Development Framework (PNPDF) guided the project from a conceptual perspective. The PNPDF consists of three interconnected concepts that include (a) contribution to the patient, (b) contribution to the profession, and (c) contribution to society (Mensik et al., 2011). This project examined how increasing flu vaccination is beneficial for the person and for society. Although the patient is placed in the center of the model, it also represents individuals, families, groups, and even communities as the center of focus and primary commitment of the PNPDF (Mensik et al., 2011). For this project, the term patient represented the aggregate group of undergraduate students attending the same university.
REVIEW OF LITERATURE
A literature review provided a scientific basis for the proposed project. After reviewing and synthesizing the information, three relevant themes emerged. First, a theme of using the TPB was prevalent in research to explore the rationale of why students do not get vaccinated; therefore, a portion of the literature review focused on the mindset of students in relationship to the flu vaccination, using the TPB to explain human tendencies.
Secondly, interventions were explored to see which, if any, were most effective in increasing vaccination rates against influenza among college students in the undergraduate setting. Third, the literature review included research on the impact of location and the use of mobile clinics on college campuses to expand options for students to obtain vaccinations.
Attitudes of students toward influenza and vaccination
Researchers have generalized the attitudes of university students in an attempt to explain why college students may not get vaccinated. Bednarczyk et al. (2015) documented attitudes common to college-age students. These findings were considered when deciding the recommendations for this program. For example, because convenience is a factor, recommendations were made for the mobile clinic to be set up in an area of high convenience to improve vaccination uptake. The concept of bringing a mobile “no-appointment necessary” flu shot clinic to the student center is an example of how the project addressed convenience and overcame the issue of making an appointment at the health center. Additionally, because a large number of students do not get vaccinated because they think of themselves as healthy and not needing the flu vaccine, it was important to market the concept that students should consider the effects of influenza infection on others, such as an immunocompromised roommate, a grandparent, or a baby. The findings of the study by Bednarczyk et al. (2015) were helpful to determine prevalent attitudes and make specific program recommendations.
Interventions that effectively increase flu vaccination among students
Specific interventions have been identified as potentially effective in increasing flu vaccination rates among undergraduate students. Several themes emerged: (a) provider education; (b) media (social media, college web portal, wellness newsletters, posters); (c) immunization clinics; and (d) provider recommendations (Monn, 2016). The National Foundation for Infectious Diseases (NFID, 2016) recommended (a) building solidarity among college, professional, and student organizations to highlight the importance of flu prevention; (b) encouraging uptake of flu education and vaccine resources to raise awareness; (c) instilling the flu vaccination habit as part of college readiness; and (d) making flu vaccination accessible through college health services. Other researchers found that economics played a role, reporting that financial incentives, even as small as $10, and peer endorsement may effectively increase flu vaccination rates among college students (Anskis, 2014).
Another important consideration is timing and convenience. Many students have good intentions to get vaccinated (25%), but only a small portion (9%) carry out the intention (Anskis, 2014). Similarly, Bronchetti et al. (2015) tested interventions in a randomized controlled trial and found that a financial intervention of $30 per patient raised vaccination rates by 34% and had a more significant impact on peer endorsement. However, implementing this recommendation can be challenging due to the financial limitations of most college health centers. Overall, convenience and cost affected student intentions to get vaccinated.
Offering flu shot clinics in a variety of locations, including mobile clinics
A part of this evidence-based practice (EBP) project literature review included an analysis of whether collaboration with a local pharmacy to provide an on-site mobile clinic that would bill student insurance would increase the number of on-campus flu vaccinations compared with previous years when this service was not used. Fennell and Escue (2013) specifically addressed how a mobile clinic could provide health promotion and clinical services for college students in the United States. The population used in Fennell and Escue's study fit perfectly with this project focusing on undergraduate students. The study researchers also examined innovative ideas about how to reach this challenging demographic other than through the traditional university health clinic, giving greater options to students.
Fennell and Escue's 2013 study provided valuable details on how to use mobile clinics to reach college students. For example, the mobile clinic could be parked in a variety of locations convenient to students. Thus, the health clinic partnered with the Department of Nursing to provide the mobile clinic in addition to the on-site university health clinic already offering vaccines. Four clinics of 3 hours each were offered for a total of 12 hours of outreach time. Nursing students in the community health clinical rotation administered vaccinations to students in four residential halls and in the mobile clinic, which was parked next to the dining hall. The university handled charges for these vaccines by billing $20 to students' accounts rather than having students pay out of pocket at the time of service.
This project used a nonexperimental research design as this project was a program review and evaluation. The CDC (2012) explained that “program evaluation is one of ten essential public health services and a critical organizational practice in public health” (para. 10). Therefore, the pilot partnership was evaluated as part of the health clinic's influenza vaccination program. Approval was obtained from the health clinic director on campus to gather historical data as well as data from the current year with the addition of the pilot mobile flu shot clinic. The host university granted institutional review board (IRB) approval in November 2018. The program review was considered exempt.
Setting and scope
This project took place at a private Christian university in a western state with approximately 1,400 traditional undergraduate students on campus.
The scope of the project was limited to analyzing health services related specifically to undergraduate students. The project analyzed the portion of the health services offered related to influenza vaccinations and observed the impact of adding a partnership with a pharmacy. The number of students who obtained the flu shot either in the clinic or from the mobile flu shot clinic was collected (Table 1). Overall vaccine rates were not collected due to the complexities of obtaining accurate data from surveys of college students.
Implementation and evaluation
Project staff contacted a local pharmacy to suggest piloting a mobile flu shot clinic option on campus; the pharmacy could bill students' private health insurance. A goal of the 1-day event was to increase vaccination by 20% above the historical average of past years. The results of the mobile flu shot clinic would be evaluated to determine if the partnership was valuable and sustainable.
A local pharmacist was contacted to partner with the university to offer the 1-day flu shot clinic. Details of the timeframe of the project and implementation steps can be found in the Supplemental Digital Content, Table 2, located at http://links.lww.com/NCF-JCN/A76.
Data were collected from 2012 to 2017 to gather a historical average uptake of flu vaccine relative to the number of undergraduate students. Additionally, the data were gathered from 2018 when the pharmacy partnership and mobile flu shot clinic occurred. Data analysis was completed and any challenges were noted. This information was used to make recommendations for future partnerships and for the overall influenza vaccination program on campus.
The 2018-2019 flu season was the only year evaluated in which the pharmacy's mobile clinic was in operation. That year, 61 students received flu shots in the university health center following the usual procedure and 71 students received vaccinations from the local pharmacy during a 1-day mobile clinic. Within the 5 hours the mobile clinic was open, more students received vaccinations than the health clinic provided for the entire influenza season. In summary, the mobile flu shot clinic immunized 5.08% of the student population in a 1-day, 5-hour clinic.
Figure 1 illustrates the impact of the program extension pilot on the overall percentage increase of influenza vaccines on campus. The graph shows a 131% increase in vaccination in 2018 compared with previous years. The average proportion of undergraduate students who received a flu vaccine between 2012 and 2017 was 4.09%. After opening a mobile pharmacy clinic for a single day, the percentage of students who obtained a flu vaccine rose to 9.46%. This outcome exceeded the original project goal of increasing the uptake of flu vaccine on the campus by 20%.
One issue that emerged after the mobile clinic was that students' insurance providers rejected 11 of the 71 flu vaccine payments requested. The pharmacy charged $41 per injection; thus, the total funding gap was $451. The pharmacy agreed to write off the expenses for the pilot but could not guarantee it would do so for future clinics. This is a significant and important challenge for the mobile pharmacy clinic in that students could possibly end up with an out-of-pocket bill that would have been higher than the cost of receiving the vaccine from the campus health center. If the pharmacy had not written off the uncovered immunization cost, students might have been less trusting of future events or even angry about receiving a bill. For these reasons, planning with the pharmacy must occur to ensure students will not end up with an unexpected out-of-pocket charge.
Interprofessional collaboration of pharmacy, nursing, and faculty proved essential for this pilot project. The partnership with the local pharmacy to bring in a mobile flu clinic required collaboration with a pharmacist to surmount the insurance billing situation and also included the nurse practitioner who is the health clinic director and the EBP project manager (this author) who was an assistant professor of nursing at the university.
The pharmacist who supervised the mobile clinic was chosen because he had an affiliation with the university. This affiliation may have enhanced student motivation to receive the flu vaccine. Relationships and interpersonal dynamics are important for team collaboration. Collaboration and communication between all involved parties was crucial to gain needed information. In general, interprofessional collaboration is invaluable for community nurses when seeking to overcome hurdles to successful community outreach.
Sharing of responsibilities was necessary to accomplish the project. The clinic director was busy with providing healthcare on campus and had other responsibilities outside of the influenza immunization subcomponent of the university health clinic. The director validated that she would not have had time to complete a thorough program evaluation and detailed research related to this project. By working in partnership on this scholarly project, the clinic director obtained useful information that benefitted her student population.
This project provided valuable information to the health clinic. Program evaluation included the completion of a detailed analysis of data related to flu vaccinations given through the health clinic from 2012 through February 2017. Additionally, the program included discussion and planning with the clinic director as the key stakeholder for the health clinic and interdisciplinary collaboration with a pharmacist to overcome the limitation of billing students' insurance. The TPB supported this project and the concepts were supported by project results. Another strength of this project was the examination of creative ways to improve the number of flu vaccines given on campus, such as having sports teams offer to pay for flu vaccinations out their athletic budgets. There are many options that the health clinic can consider for increasing the uptake of flu vaccine on campus in future years based on this analysis and recommendations from this project.
One study limitation was that information was not gathered to determine how many students obtained an influenza vaccination off campus. Therefore, it was difficult to accurately know if the students were falling within the normal range of approximately 20% of college students being immunized (Monn, 2016). This information would have provided a more holistic view of the immunization rates on campus, but it would have been challenging to obtain accurate figures. Research shows that only a small number of college students will go off-campus to get their yearly flu vaccination (Svokos, 2014), but this project did not survey all students to determine the number of students vaccinated at locations off-campus to gather the exact vaccination rate of the student body. However, this project was conducted on a relatively small, private university campus, so the generalizability to larger university settings may be limited.
Although the Bible may not address interprofessional collaboration, Scripture does affirm that members of the Body of Christ have varied strengths to contribute and also stresses the importance of community: “Are all apostles? Are all prophets? Are all teachers? Do all work miracles? Do all possess gifts of healing? Do all speak with tongues? Do all interpret?” (1 Corinthians 12:29-30, ESV). Just as individuals have unique gifts, each profession is trained to provide a unique perspective and service to the community.
Additionally, the Bible describes the interdependency of believers to enable functioning at the highest level. First Corinthians 12:21 illustrates this by describing the members of the church as various parts of the body: “And the eye cannot say to the hand, ‘I have no need of you,’ nor again the head to the feet, ‘I have no need of you’” (ESV). Professions need each other to best meet the whole person needs of individuals and communities.
This project was realized because of the willingness of two colleagues to partner for the greater good of improving the rate of flu vaccinations among college students. Without the willingness of the pharmacist to partner with the nurse, students in this community would not have had the option of receiving a free flu shot on campus.
Program-specific recommendations include the following:
- Continue the pharmacy partnership and mobile flu shot clinic.
- Use a written plan that outlines how any denied insurance payment claims will be handled, ensuring that students will not receive a bill if their insurance denies coverage of the vaccine.
- Expand the mobile clinic to a 2-day event.
- Market the mobile flu shot clinic using specific recommendations from the TPB.
Additional research on collaboration with outside agencies such as pharmacies would provide supportive data and validate if this intervention could be effective at other universities. Further interprofessional research is recommended to explore flu vaccinations options for students on college campuses.
Nurses can use the results of this project to share with community leaders who desire optimum health for their residents. The findings of this project may be of particular interest to directors of university health clinics to help validate similar programs on their campuses. Nurses are vital public health ambassadors in their work to improve the health of communities by increasing vaccination rates against the flu and other communicable diseases. Epidemiological studies indicate that college students are at higher risk of contracting influenza (Benjamin & Bahr, 2016). According to objectives related to students in the Healthy Campus initiative (2018), one goal is to increase the proportion of students who receive the flu vaccine each year.
Partnering with community businesses and service agencies, such as a pharmacy in this example, is a means of interprofessional collaboration that nurses can develop to improve patient and population health outcomes.
The results from this project showed the vaccination rate of a student population can be increased with planning and collaboration. Through an innovative effort, the number of flu vaccinations at the project site increased when a mobile clinic provided vaccinations and could bill private insurance, eliminating the barrier of students' out-of-pocket cost. The percentage of flu shots given to the student body on campus during the 2018-2019 flu season (9.46%) increased significantly (131%) compared with the average for 2012-2017 (4.09%), demonstrating the positive impact of the pharmacy expansion pilot. This potentially improved the health of students on campus and served as a benefit to public health to increase immunization rates of this aggregate group.
Additional research on collaborations with outside agencies such as pharmacies would provide supportive data and validate if this intervention could be effective at other universities. Further research is recommended to explore additional options to motivate students on college campuses to become immunized.