Chapter One: IntroductionThe Center for Disease Control reported 1,254 cases of meningococcal disease in the United States and its respective territories for 2005 (CDC 2006).

Meningococcal disease is an umbrella term for several specific serogroups which share the same cause as the bacterium Neisseria meningitidis or meningococcus. There are thirteen serogroups of this bacterium, referred to by the CDC’s 2006 report as: A, B, C, D, 29E, H, I, K, L, W-135, X, Y, and Z. Of the 1,254 cases reported in 2005, serogroups A, C, Y and W-135 accounted for a national total of 297 cases, serogroup B totaled 156, all other serogroups accounted for 27 cases, and unknown serogroups accounted for 765 cases (CDC 2006).

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Meningococcal disease can also be caused by viral, fungal, and parasites. Fungal and parasitic meningitis are the most rare, most fatal, and do not have a vaccination procedure (Myers 2000). The CDC (2005) reports that the majority of viral meningococcal illnesses are resolved without specific treatment, thus the following paper focuses on bacterial meningococcal disease. The bacterial meningococcal disease is the only form with available vaccinations. The CDC (2005) explains that there are currently two vaccinations available against the serogroups A, C, Y, and W-135. This means that at least 297 cases of a contagious bacterium could have been prevented with vaccination in 2005.The issue of concern is that meningococcal disease caused by the bacterium can be prevented with adequate parent education. There have been several vaccination campaigns occurring after a localized outbreak of meningococcal disease, yet there does not seem to be a strong initiative of the government and health care industry to require meningococcal vaccinations.

In part this is because in the United States, meningococcal disease has not yet reached epidemic proportions. Yet, because meningococcal disease is a highly contagious bacteria it holds potential for reaching epidemic proportions in the United States as it has in third-world nations. Therefore, because there is a low ratio of meningococcal disease in the nation, it may not be cost effective to launch a national campaign requiring vaccinations.Therefore, it is important for the nursing profession to have the ability to explain the causes, consequences, and vaccinations available of meningococcal disease for the benefit of educating parents and saving children’s lives. This issue is important on a personal and nursing postgraduate level because the core philosophy for being a nurse is to assist the health care industry in preventing and treating maladies on a societal level. The concern of lacking a strong national campaign to prevent a socially contagious disease such as meningococcal disease is directly related to the concern of promoting a healthy, strong, and viable society. This research paper is conducted based on the belief that the nursing profession can increase the number of vaccines issued through parent education, with the overall benefit of decreasing the number of outbreaks.

To develop the following research paper with a goal towards continuing parent education, the literature review will examine meningococcal disease and vaccinations with a focus on enhancing nursing to parent education and communication and cost effectiveness. These theories will be utilized to develop a conceptual framework for launching a campaign of meningococcal disease and vaccinations parent education, which will explore cost versus benefits to develop a rationale for a continuing education campaign.Chapter Two: Theoretical LiteratureMeningococcal disease is caused by pathogens which enter the body through a wound, incision, or mucous membranes (Meyer p 52 2000). The pathogens “Meningococcai bacteria can be transmitted through the air by way of droplets of airway secretions and direct contact with individuals infected with the disease” (Estep p 112 2005).

The pathogens are more than a simple irritation of the three membranes located near the brain and spinal cord, they cause “cerebral vasculitis and infarcts, edema, hydrocephalus, decreased cerebral blood flow, and loss of cerebral autoregulation” (Myers p 52 2000). This often represents itself to the infected person as a headache, fever, and stiff neck which is found in over 95% of meningococcal infections (Myers p 52 2000).The major concerns with meningococcal disease are that there are multiple causes, which can cause problems while developing a treatment. The cause of meningococcal disease can be explained as viral, bacterial, fungal, and parasitic.

The only manner in which to differentiate the cause of meningococcal disease is through analyzing the patient’s cerebrospinal fluid, which is obtained via lumbar puncture (Myers p 55 2000). The only preventable form of meningococcal disease is bacterial meningitis, the focus of the research is on the bacterium Neisseria meningitidis which, when left unvaccinated has the potential to invade the body, multiplying and entering the cerebrospinal fluids through the cerebral capillary system (Myers p 52 2000).When speaking about bacterial meningitis, it is important to understand that there are thirty-two different types of bacteria associated with meningococcal disease (Myers p 54 2000).

However, only Neisseria meningitis and Streptococcus pneumonia are responsible for the majority of hospitalization in bacterial meningitis cases (Myers p 54 2000). Neisseria meningitis is highly fatal, often causing death within twelve hours of fever (Myers p 54 2000), and “Despite antimicrobial therapy, it has a 10% mortality’ rate and of the survivors, 11% to 19% have long-term effects including netirological disabilities, deafness, and limb loss” (Estep p 111 2005). Streptococcus pneumonia is the leading cause of bacterial meningitis in children under five years of age, with 6000 cases reported annually and a mortality rate of 30% (Myers p 54 2000).Meningococcal VaccinationAcute bacterial meningitis is still an important cause of morbidity and mortality in children worldwide (Yogev p 1097 2005). As the resistance of Streptococcus pneumoniae to penicillin and cephalosporins continues to evolve, vaccination has become an important antibacterial in the treatment of bacterial meningitis (Yogev p 1110 2005).

The overwhelming success of the conjugated Hib vaccine and the encouraging results of the new conjugated pneumococcal and meningococcal vaccines suggest that the ideal management of bacterial meningitis is prevention and vaccines development against the most common bacterial agents are the best solution (Yogev p 1111 2005).Invasive disease caused by Neisseria meningitidis can be rapidly fatal or result in severe neurologic and vascular sequelae despite antibiotic therapy (Kimmel p20492005). Although the majority of cases of meningococcal disease are sporadic, vaccination of the affected population often is necessary (Kimmel p2050 2005). Serogroup B accounts for the highest incidence of disease in young infants but is not contained in any vaccine licensed in the United States (Kimmel p2050 2005).

Adolescents and young adults 15 to 24 years of age have a higher incidence of disease and a higher fatality rate than other populations (Kimmel p2050 2005). Because 70 to 80 percent of these infections in the United States are caused by meningococcal serogroups C, Y, and W-135, which are contained in the tetravalent meningococcal vaccines, they are potentially preventable (Kimmel p2051 2005). The U.S. Food and Drug Administration recently approved a meningococcal conjugate vaccine containing serogroups A, C, Y, and W-135 (Kimmel p2050 2005). This T-cell-dependent vaccine induces bactericidal antibody production and promotes immunologic memory that should result in a longer duration of immunity (Kimmel p2050 2005). The Advisory Committee on Immunization Practices recommends that this vaccine be given to 11- and 12-year-old adolescents, to adolescents entering high school, and to college freshmen living in dormitories (Kimmel p2059 2005).Neisseria Meningitis Vaccination EvidenceAcute bacterial meningitis remains an important cause of morbidity and mortality in children.

Children under 2 years of age are particularly susceptible to infection with encapsulated bacteria due to their immature response to polysaccharide antigens (Makwana, Riordan, and Andrew p p355 2007).Outbreaks of meningococcal disease that occurred during the period of 1 July 1994 through 30 June 2002 were identified through state health departments, Centers for Disease Control and Prevention records, and a review of newspapers and the medical literature  (Brooks et al p49 2006). The assessed cases associated with outbreaks were compared with sporadic cases identified through population-based surveillance resulting in the identification of 69 outbreaks of Neisseria meningitidis infection (median, 9.5 outbreaks per year; range, 3-14 outbreaks per year), which involved 229 patients from 30 states (Brooks et al p 50 2006). Notably, forty-three (62%) of the outbreaks involved N. meningitidis serogroup C, 17 (25%) involved serogroup B, and 9 (13%) involved serogroup Y  (Brooks et al 50 2006). Twenty-five outbreaks (36%) occurred in communities, and 44 (64%) were organization based, including 12 that occurred in colleges and universities, 19 that occurred in primary and secondary schools, and 8 that occurred in nursing homes  (Brooks et al p 50 2006).

Vaccination campaigns (with the A/C/Y/W-135 meningococcal polysaccharide vaccine) were conducted for 31 outbreaks (28 involving serogroup C and 3 involving serogroup Y) resulting in a decrease of cases amd the cause of the end of the localized epidemics (Brooks et al p 51 2006). After controlling for age, serogroup, and clinical presentation, outbreak-associated cases were associated with a higher case-fatality rate than were sporadic cases finding that outbreaks remain an important but infrequent public health issue, representing <2% of all cases of meningococcal disease (Brooks et al p 54 2006).  However, given the increased case-fatality rate found among outbreak-related cases of N. meningitidis infection, additional investigation of factors that favor the transmission and virulence of outbreak-related strains is warranted (Brooks et al p 53 2006).In Quebec, a case-controlled study to evaluate the effectiveness of the polysaccharide vaccine, while controlling for the potential confounding effects of selected risk factors for serogroup C meningococcal disease found that the polysaccharide vaccine remains a cost-effective option for the short-term protection of school-aged children and adults; however, conjugate vaccines are needed for younger children (De Wals p1116-1122 2005). The case patient group comprised 74 individuals with confirmed serogroup C meningococcal disease reported after the beginning of the campaign until 31 March 1998 (De Wals p1116 2005).  Four control subjects, matched for age and place of residence, were randomly selected from the Quebec health insurance registry and case information was obtained from regional public health departments (De Wals p1116 2005). Interviews conducted by telephone with the case patients or their family were analyzed with the results showing that a high level of protection was found among children aged ? 6 years, during the first 2 years after vaccination (vaccine effectiveness, 95%; and protection remained high during the following 3 years (De Wals p1116-1122 2005).

For children aged 2-5 years, the estimated effectiveness was positive during the first 2 years but was negative during the following period (De Wals p1116-1122 2005).Streptococcus pneumonia Vaccination EvidencePneumococcal conjugate vaccines (PCVs) are highly effective in preventing invasive disease in infants and young children, with favourable safety and immunogenicity profiles (Bernatoniene p 229-55 2005). These vaccines have also shown efficacy in reducing cases of non-invasive disease (i.

e. otitis media), nasopharyngeal acquisition of vaccine-specific serotypes of S. pneumoniae, and protection against pneumococcal disease caused by resistant strains (Bernatoniene p 229-55 2005).The heptavalent pneumococcal conjugate vaccine was licensed in the United States in 2000 for use in infants and children (Shah and Ratner p 4 2006). Data from the 1998-2003 National Hospital Discharge Survey and population estimates from the National Center for Health Statistics were used to calculate rates of hospital discharge for patients admitted with invasive pneumococcal disease, defined as meningitis or bacteremia caused by Streptococcus pneumonia (Shah and Ratner p 4 2006). The rates of hospital discharge for patients admitted with invasive pneumococcal disease decreased during the study period from a peak of 12.03 discharges per 100,000 population in 1999 to 5.

60 discharges per 100,000 population in 2003 (Shah and Ratner p 4 2006). Hospital discharge rates for persons admitted with invasive pneumococcal disease, including meningitis, have decreased since introduction of the heptavalent pneumococcal conjugate vaccine (Shah and Ratner p 5 2006).To prevent Streptococcus pneumoniae infection among persons at highest risk for invasive pneumococcal disease (IPD), the pneumococcal polysaccharide vaccine (PPV) is currently recommended for persons ?65 years old and persons 2-64 years old with certain underlying conditions (Guarner et al p 141 2006). Studying information from 2001 to 2003, researchers performed a case series study of IPD in adults at 6 sites of the Active Bacterial Core surveillance-Emerging Infections Program Network (Guarner et al p 149 2006). The findings were that among 1878 case patients, 1558 (83%) had at least 1 current vaccine indication; of these, 968 case patients (62%) were unvaccinated (Guarner et al p 1412006).

The case study conclusion found that adherence to existing vaccine recommendations would have prevented 21% of all cases (Guarner et al p 1412006). Increasing vaccine coverage rates among persons with a current indication may prevent more cases than expanding existing indications (Guarner et al p 158 2006).Other researchers in Tennessee found that in one measure to combat IPD is vaccination with PCV vaccination of children has resulted in dramatic declines in the proportion of antibiotic-nonsusceptible isolates in Tennessee. PCV vaccination of children also appears to be a highly effective method for reducing the burden of IPD in adults (Talbot et al p 646 2004). The case study presented showed information from IPD cases from January 1995 through December 2002 identified through in 5 Tennessee counties was examined.

For each case, clinical data were collected, and antibiotic susceptibility testing and sero typing were performed (Talbot et al p 645 2004). The case study results found that among children younger than 2 years, IPD rates peaked at 235 cases per 100,000 in 1999 before decreasing, after PCV licensure, to 46 cases per 100,000 in 2002, where the proportion of penicillin-nonsusceptible 1PD isolates from this age group declined from 59.8% in 1999 to 30.4% in 2002 (Talbot et al p 641-648 2004). After 2001, similar decreases in IPD rates and in the proportion of antibiotic-nonsusceptible isolates recovered were seen among persons aged 2 years and older (Talbot et al p 640 2004). Rates of IPD due to PCV-associated serotypes declined after vaccination introduction in all age groups while the rate of IPD due to non-vaccine serotypes increased among persons aged 2 years and older (Talbot et al p 647 2004).

There is not any quantitative evidence that meningococcal vaccination will not prevent illness, however there is some discrepancy regarding the viability of meningococcal vaccinations to prevent meningococcal disease. Vaccination effectiveness in Quebec decreased after the first two years, where in the United States it was found to decrease epidemic outbreaks. However, the majority of literature on Neisseria meningitis points to the importance of vaccination to decrease rates of illnesses, it is only the rates and viability of the decrease in meningococcal diseases that is in question. When examining Streptococcus pneumonia caused meningococcal diseases, one article examines that vaccination effectiveness would only have prevented 21% of the cases, while other authors cited that it had declined by 29%, creating a concern for the vaccine’s viability on a community wide scale and a slight variance in quantitative analysis which may be due to the difference of geographic location and vaccine distribution to the impacted arenas.In conclusion, while the importance of meningococcal vaccines is not in question, researchers do not entirely agree on the effectiveness and viability of meningococcal vaccines.

The logical conclusion that can be drawn from the literature review is that the vaccinations are important to save lives, even if the results are sometimes presented as less than 25% effectiveness. Most research points to the ability of meningococcal vaccines to prevent the furtherance of an outbreak, which most often occurs in organizational facilities such as schools. Meningococcal vaccines do save lives and prevent the spread of meningococcal diseases caused by Neisseria meningitidis and Streptococcus pneumonia.Nursing to Parent Education in VaccinationsThe following section explores the role of nursing in parent education regarding vaccinations in general, thus it may explore vaccinations not directly related to meningococcal disease. In part this is because the qualitative evidence for the role of nursing in parent education regarding meningococcal disease is lacking, however the above sections describing the importance and viability of meningococcal disease is prevalent in current quantitative literature. To understand how to increase knowledge and education in meningococcal disease vaccinations, it is important to examine the viability of other vaccination campaigns due to the low volume of current evidence regarding nursing to parent dissemination and occurrences of meningococcal vaccinations.

Childhood immunization is a key tool in protecting the health of the nation’s children from indigenous infectious diseases such as measles, mumps and rubella (Griffith p 2492005). However, vaccination rates have fallen from the 95% required for population immunity to around 84% and the Health Protection Agency is concerned that an epidemic might result (Griffith p 2492005). There is some evidence noted in the previous quantitative sections that these rates of inoculation may be lower for meningococcal vaccinations.The risk factors for parents delaying immunizations are an important concept in understanding nursing to parent education. Knowing the risk factors for lack of immunizations can better develop a framework for parent education. Despite extensive study of vaccine safety and decades of effort to immunize infants and toddlers, little is known about the comprehensiveness of vaccine coverage in US children younger than 2 years of age (Bobo et al p 308 1993). Several variables for immunization delays including child birth order, family income, maternal education, and marital status significantly predicted failure to immunize on schedule (Bobo et al p 310 1993).

Compared with first-born children, those who were later-born were 1.7 times more likely to be incompletely immunized at 2 years of age (Bobo et al p 311 1993). Children of more educated mothers were less likely to lack immunization at all ages (Bobo et al p 311 1993). These highlight the general need to continue promoting immunizations to the broad population of US parents and a specific need to aggressively target children with identifiable risks (Bobo et al p 313 1993).Another concern in risk factors regarding vaccination is between home school and traditional school children, primarily because it is assumed that because children attending public school are required by federal and state laws to receive inoculations that these parents would have more knowledge and commitment to vaccination. The results of a study which examined the vaccination beliefs of parents with children in different educational settings, with a specific focus on home schools, finding that homeschooling parents appeared to have the most concern for vaccine safety as well as the least belief in the importance or necessity of vaccination  (Kennedy and Gust p 276-280 2005).

There was an overall lack of adequate vaccination information among parents in the study, regardless of where the child attended school (Kennedy and Gust p 276-280 2005).Other research found the demographic variables independently associated with completion of the basic series were increased paternal education, increased maternal education, smaller family size and higher socioeconomic status, as determined by census tract or rural town of residence (Marks et al p 305 1979). Race was not found to be a factor associated with vaccination rates when socioeconomic status was controlled (Marks et al p 305 1979). Patients who received their vaccinations from private physicians had a better vaccination rate than those who attended health department clinics (Marks et al p 307 1979).

By using paternal and maternal education level and family size as screening variables, children at high risk for failure to complete their immunizations could be identified prospectively and made the target of intervention programs to improve compliance (Marks et al p 310 1979).Communication within the nursing profession has also been explored within the risk and benefits of vaccination. United States law requires that immunization providers use Centers for Disease Control Vaccine Information Statements (VISs) and inform parents about vaccine risks and benefits prior to every childhood immunization (Davis et al p 228 2004). However, relative to the low education and income level, the authors found that many of thirty percent of parents read below a ninth grade level, were low income, and there is a correlation of racial heritage to risk factors of not receiving children vaccination.

The authors noted that Public health nurses (PHNs) frequently discussed potential vaccine side effects (91%), treatment of side effects (91%), and the vaccine schedule (93%), which improved the rates of returning inoculation (Davis et al p 234 2004). The national Vaccine Injury Compensation Program (VICP) was never discussed. Vaccine communication of side effects, risks, benefits, screening for contraindications, and the next visit lasted less than a minute for most nursing to parent discussions regarding vaccination (Davis et al p 235 2004). Thus, room for improvement exists in discussion of benefits, and serious risks associated with vaccinations (Davis et al p 235 2004).This raises the concern that if vaccination discussions between nursing staff and parents are not adequate, what are the beliefs of parents regarding vaccinations? In a quantitative study, Bardenheier (p 269-74 2003) examined parental knowledge in hepatitis vaccinations, a vaccination that has been available much longer than meningococcal vaccinations. A random cluster sample survey was conducted of parents of children who attended kindergarten in Butte County, California, in 2000. Because of a history of recurrent epidemics, an aggressive hepatitis A vaccination program was ongoing during the time this study was conducted (Bardenheier p 271 2003). This study found that factors associated with not receiving the vaccine included lack of provider recommendation,  not having heard of the vaccine and parent’s not perceiving child is likely to get hepatitis A (Bardenheier p 270 2003).

Vaccination coverage among kindergartners did not reach high levels (i>90%), despite aggressive vaccination efforts in this community (Bardenheier p 273 2003). Lack of provider recommendation and lack of parental awareness of hepatitis A vaccine were the 2 most significant factors associated with failure to receive vaccine (Bardenheier p 274 2003).Overcoming Risks and Failures in VaccinationFulginiti (p 961-964 1994) examined that many physicians and parents consider immunizations routine; as a result, they fail to discuss this important aspect of health care. To ensure that parents will be able to give informed consent to have their child immunized, the physician should provide information on the nature, prevalence, and risks of the disease; the type of immunization product to be used; expected benefits; risk of side effects; and required follow-up (Fulginiti p 9621994). In addition, the concept of individual immunity as a contribution to community well-being should be discussed (Fulginiti p 963 1994). Verbal communication of this information at the time of vaccination can be reinforced by written documents (Fulginiti p 963 1994).

In an interesting qualitative perspective regarding Asian and Pacific Islander Kids, Sworts (p 283-285 1997) found that while challenges exist for effective health communication and health education within diverse populations of the United States, the development process for educational materials and lessons learned from the Healthy Asian and Pacific Islander (H.A.P.I.) Kids Program, a vaccination demonstration project funded by the Centers for Disease Control and Prevention to promote catch-up hepatitis B vaccination for older American Asian and Pacific Islander children, has been well received and more children were inoculated because of the focused program (Sworts p 283 1997).

The author states that simplicity and a common message were incorporated in multiple strategies to disseminate information to a diverse population, which contributed to the increase due to the low education levels of the majority parents in this specific demographic Asian and Pacific Islander Kids (Sworts p 283 1997). Another contributing factor was strong community representatives from the Cambodian, Hmong, Filipino, Lao, and Vietnamese communities who were instrumental in the material development process, which included needs assessment, design, and translation (Sworts p 284 1997). Sworts concluded that the key to increased vaccination is making the target community part of the development process, important health messages can be disseminated effectively, carrying great impact to an otherwise hard-to-reach community (Sworts p 285 1997). Similarly, Suarez, Simpson and Smith (p 845 1997) explored the immunization rates of American children who were enrolled in a community education programs Women, Infants, and Children (WIC) and Aid to Families with Dependent Children (AFDC); food stamp; and Medicaid programs.

The findings correlate with Sworts’s study on Asian Pacific children where children were more likely to be inoculated in a community education campaign than any other arena. The study found that WIC members, who must attend specific classes and are given more education and information, were more likely to be vaccinated. Interestingly, the study found that AFDC and Medicaid children less likely to be up to date than others, which may be directly related to the income risk factor previously noted (Suarez, Simpson and Smith p 845 1997). The higher immunization status of WIC and uninsured children suggests that integrating immunization practices with government programs may be effective (Suarez, Simpson and Smith p 845 1997).The importance of proper vaccination is highlighted by the Health Protection Agency, which has noted a decline in the amount of vaccinations.

Most research agrees that the risk factors for lack of inoculations are low income and education, however one researcher found that racial heritage was not a factor while another researcher found that it was a factor. This may be due to differences of demographics in certain areas, where a high or low population of a specific racial heritage impacts the ratio and thus the quantitative results. Researchers also found that other risk factors include being home schooled and family size as well as geographic location. Parental understanding of vaccinations and parental education levels seem to be a consistent theme throughout inadequate vaccinations. The causes of this are of slight difference, where some researchers lean towards the parents being at fault (particularly in the lack of inoculation in older children) and others lean towards the nursing staff’s lack of proper time and attention to parent education regarding vaccinations.However, since it can be established that nursing staff cannot control parental beliefs and choice, but can control the amount of time and attention spent on vaccination education that a commitment to increased meningococcal vaccination education on behalf of the nursing staffs part should be the framework for resolving the situation.

Logically, it becomes important to understand that the demographic that is of the highest concern (low income) may also be the demographic with the least ability to comprehend vaccinations (low education). This may also be why in areas where community involvement is extremely high vaccination rates are also increased, as seen in the Pacific Islander case and the case of WIC members. Therefore, to overcome a lack of meningococcal vaccinations in the nation, nursing to parent education should be simple, but not quick, and focus on community involvement.Chapter Three: Identification and Feasibility of the ProjectBased on evidence that the concern with parental education in meningococcal vaccinations can be increased through nursing communication and community involvement, the project format will take on the task of implementing a program which educates community nurses in ways to overcome the risks associated with lack of meningococcal vaccinations, including communication with parents and time spent with parental education. This would also include establishing a community wide network of health professionals and community members who can assist in developing easy to disseminate educational methods. The program to be implemented therefore is based on parental education and community involvement.

This program should take into consideration the education levels of at risk families, as well as focusing on establishing parameters for a community to become part of meningococcal vaccinations. This program to be implemented should focus on the importance of preventing outbreaks in schools and other organizations where children are involved, such as daycares and public swimming pools.Conceptual FrameworkThe conceptual framework is based on the tenets of societal education where community involvement at multiple levels as private, educational, and government is paramount to adequate parental education. The conceptual framework is sectioned into several small components: Competencies, Scope, and Arena. Competencies refer to what must be disseminated for nursing practitioners to understand how to identify risks associated with lack of meningococcal vaccinations. Scope refers to what must occur for nursing to parent education to improve meningococcal vaccinations. Arena refers to the involvement of the community at differing levels.Competencies1.

                 A nursing-education focus with a focus on risk assessment of parents knowledge and beliefs regarding meningococcal vaccinations.2.                 A nursing-education focus on understanding the need for more adequate explanations to parents regarding meningococcal vaccinations.

3.                 A nursing-education focus on creating opportunities to disseminate meningococcal vaccination information to parents within a short amount of time, based on the previous contention that nursing practitioners do not spend adequate time explaining vaccinations to parents.4.                 Exploring different formats of parental education in multiple medias such as videos and brochures at several literacy levels.Scope1.                 Understanding of central concepts of meningococcal vaccinations as an outbreak preventative measure, thus establishing both a medical and societal need.2.

                 Understanding of creating learning opportunities for nurses and parents that develops meaningful information regarding meningococcal vaccinations regardless, but considerate of parental socio-economic status and demographic3.                 Developing an environment of parental motivation to create active participation in meningococcal vaccinations.4.                 Creating different forms of media that can be disseminated throughout the community.

Arenas1.                 Medical and Health Care Professionals must become involved in a conscious effort to explain and explore parental education regarding meningococcal vaccinations.2.                 Community involvement including volunteers, interpreters, and multi-media intensive persons will enhance the advertising of meningococcal vaccinations.3.                 Governing involvement at the local level, particularly with arenas established as not having high inoculation rates as AFDC and Medicaid to increase information that is understandable at multiple educational levels regarding the societal need for meningococcal vaccinations to prevent outbreaks within the community.

Figure 1: Conceptual Framework DisseminationRationale for Implementing the ProjectThe literature review has shown that there is a quantitative correlation to reducing the outbreaks of death and hospitalization due to meningococcal disease. The research has also shown that the two most common forms of meningococcal disease are preventable with vaccinations.However, vaccinations are not always distributed to children who could benefit from them, either from parental understanding and beliefs or from lack of proper nursing to parent education regarding vaccinations, as shown in the following chart:Figure 2 Needs Assessment of Risk Factors for Parent EducationMeningococcal disease is a severe illness that causes hospitalization and fatalities. It is a highly communicable disease that is most often found in organizational outbreaks instead of isolated cases. These outbreaks can be prevented with education and vaccination, saving the community from epidemic fears, hospitals from the cost of the illness, and parents from losing a child.It is highly likely that this project can come to fruition, especially if respected members of the community become involved and government agencies such as ADFC begin working with healthcare staff in explaining the importance of meningococcal vaccination to parents.Chapter Four: Methodology and ImplementationThe objectives to be met through the project are to establish stronger nursing to parent education capabilities through risk assessment, increased communication medias, and community involvement. The project can be implemented in all communities, beginning with increasing nursing education on ways to communicate the importance of meningococcal vaccination to parents in better formats and multiple media.

The stakeholders in this project can be identified as the project leader, the nursing staff, the parents, and the community. It is important to remember that rarely is meningococcal disease an isolated case, but rather an outbreak that can threaten epidemic proportions, thus all members of the local community can become stakeholder advocates with proper education regarding the risks of meningococcal disease.Figure 3 Stakeholder AnalysisThe driving forces of this project are increasing parent knowledge and beliefs about meningococcal disease and meningococcal vaccination with the benefit of increasing community safety. The restraining forces are the risks most commonly assessed with lack of vaccinations, as noted in the literature review. Parental resistance due to incorrect beliefs about vaccinations may be an important restraining force that can only be overcome by patience and communication, thus a strong community involvement framework can benefit the project:Figure 4 Community Involvement StrategyThe timeframe for project development is three months to prepare nursing education in the above-defined section of Competencies. This is because literature already exists regarding the vaccinations, but it is also important to educate nurses on parent risks, proper dissemination techniques (which must be developed within these three months.) The involvement at the community level is an ongoing process without a strict timeframe; however within one month of developing the Competencies package it will be imperative that local government become involved to properly increase dissemination, as well as volunteers to assist in developing verbal and non-verbal information in a variety of languages and for different education levels.This project must be approved by the health board because it is highly related to the manner in which nursing staff perform their duties in parental education, thus it would become important to receive legal authority prior to establishing a community wide implementation.

The effectiveness of the project will be evaluated within one year by benchmarking the amount of children inoculated the previous year against the amount of children inoculated the following year of the project implementation. The project may also be evaluated based on nursing and parent interviews or surveys.Chapter Five: The Research Utilization ProjectThe process of project development first focuses on nursing education regarding inoculation at risk parents.

This includes dissemination from the literature. The goal of Competencies is to develop a foundation for nursing improvement, so that nurses will be able to pass information onto parents who are at risk for not fully comprehending the importance of meningococcal vaccinations due to income, education, and socio-economic status. Without the primary Competencies step in the process of project development, it would be impossible to expect nursing staff to be able to commit to strong parent education. The process of project development must also take into consideration the Scope of the project, where Scope has previously been established as parental and community education. The Arenas are important in the project development plan to encourage the state of community involvement which has been shown to improve inoculations.

Unexpected occurrences during the project development phase were the lack of information regarding meningococcal vaccination campaigns and the number of meningococcal vaccination that are current in the United States. Little to no information exists on a national scope to evaluate children who have or have not received meningococcal vaccination—although pharmaceutical information exists on the number of meningococcal vaccinations sold and information exists on the benefits of meningococcal vaccination to prevent epidemics and outbreaks, these are not indicative of children who have actually received meningococcal vaccination. Therefore, the lack of information in this category means that there may be more—or, tragically less– meningococcal vaccinations occurring than thought. This may impact the Scope and Arena project development plans in that many children may already be vaccinated, or many children may not be vaccinated.Barriers for this project development plan were lack of information directly related to parental education regarding meningococcal vaccination.

While it is true that much information directed towards parents and communities exists on the CDC Website, this information cannot be expected to reach the at risk parents. Therefore, the project plan had to look at other vaccination in the category of parental education, which is correlated but not directly indicative of meningococcal vaccination. Breakthroughs can be considered as the identification of not only at-risk parents, but the possible lack of nursing responsibility towards meningococcal vaccination. This may be because the majority of nursing staffs are overworked and only have a certain amount of time to spend with each family.

It is the authors belief that if nurses are only spending a few moments explaining vaccinations to parents and relying on brochures which are highly medical in their orientation and not contusive to educating parents who are below an 9th grade reading level (identified previously in the literature review as a risk), then the nursing community must begin to understand that parents who are at risk need more attention and easy to understand education regarding the importance of meningococcal vaccination.The project development plan is very satisfactory. Previously the author thought that perhaps all the occurrence for lack of meningococcal vaccination information and occurrences was simply due to bad parenting. In fact, the literature review showed that it has nothing to do with parenting skills, but rather the ability of nurses to disseminate information to the parents in a manner the parents can understand with the goal of increasing knowledge about meningococcal vaccination.The project evaluation presents data that is highly successful for creating an adequate project plan. The goal of the project was to develop a plan that would increase the ability of nursing to parent education regarding meningococcal disease and vaccination.

This has been developed, with some minor concerns relative to the lack of information as previously noted. The primary goal has been reached, and a project development plan has been created.The strategies and work plans utilized a project framework that incorporated the main reasons for children not receiving meningococcal vaccinations. This is important because it shows that the secondary goal of developing a framework for increased rates of meningococcal vaccination is possible based on current literature, although it would have benefited the work plan to have more information regarding community and local government involvement in meningococcal vaccinations.The basic approach of the project plan in relation to community development was another goal identified in the project framework. Notably, this is the area with the least information, which is almost odd because meningococcal disease is a contagious disease that can have a wide impact in the community, yet the communities seem uninterested in meningococcal vaccinations until after an outbreak has occurred. This was part of the concern that the project framework attempted to address by establishing parameters for community and local government involvement.In retrospect, some changes that would benefit the project plan would be to incorporate more quantitative pre- meningococcal vaccination and post- meningococcal vaccination to truly prove that meningococcal disease can be prevented by continuous and strong meningococcal vaccination campaigns.

The problem, as noted above, is that there is little pre- meningococcal vaccination evidence other than the numbers relative to the 20% effectiveness of Streptococcus pneumoniae vaccinations.The literature review and project plan did not take into account the regions which have the highest rates of  meningococcal disease, according to the CDC (2006) this is the South Atlantic and Pacific regions of the United States, but the state with the most occurrences of meningococcal disease is California (CDC 2006). This is relative to the ability of nursing community to present meningococcal vaccination information to parents, particularly in California where schools have long been hailed as being overcrowded, particularly in the inner city regions where education levels of parents and language barriers exist in higher rates than in more rural areas such as Oregon. This highlights the importance of community involvement in meningococcal vaccination as noted in the literature review of the Asian Pacific children. Establishing the importance of meningococcal vaccination, particularly in areas where there is low socio-economic status and language barriers has been shown to increase vaccinations with other socially communicable diseases such as hepatitis.The relevance to the nursing profession is that it becomes more important for nurses involved with children to be able to communicate with parents and express the importance of meningococcal vaccination to parents with the ultimate goal of lessening the occurrences and outbreaks of preventable meningococcal disease. This is because meningococcal disease is an illness with high rates of hospitalization and fatalities, particularly in children. Many of these may be preventable with stronger meningococcal vaccinations.

Because the nursing professions should focus on preventing, rather than treating, diseases in children it is paramount that nurses be able to communicate better with at risk parents. This will result in more children receiving meningococcal vaccinations and fewer children becoming infected with meningococcal disease, which will lessen the rates of hospitalization and fatalities for at least two forms of meningococcal disease.Recommendations to improve the project plan process are to establish better parameters for community involvement regarding meningococcal vaccination. It would benefit the project to have more available information on community education and involvement from interviews and discussions with community education groups such as nurses and local governments.Future research should include the incidences of meningococcal vaccination as this was found to be an area with the least amount of research, especially regarding a quantitative analysis of meningococcal vaccination in children. Another area of future research that may improve the project plan is a stronger examination of the risk factors and socially conscientious ways in which communities and nurses can overcome the risks, especially in regards to low education and language barriers where they exist. Examples include developing simple language and translation information packets that a parent with language barriers or lower than 9th grade education would be able to comprehend and act upon.

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