Huelva en las décadas centrales del siglo
2.1. La riqueza agropecuaria entre los viejos y los nuevos usos
Findings showed that fewest flu vaccines were administered from October through December 2012, and thus, the most cold and flu-like symptoms were observed in January and February of 2013. This project showed the benefits of having an accessible flu vaccine clinic in a homeless shelter. Most vaccines were administered when a flu clinic was implemented onsite for the 2014-2015 cold and flu season. Results also indicated that the fewest number of cold and flu-like symptoms were recorded in 2014-2015 when the most vaccines were administered.
These findings echoed a previous study when a shelter-based immunization program improved vaccine accessibility to hepatitis B, leading to higher rates of immunization (Schwarz et al., 2008). After interventions, which included educational videos, printed material and free vaccines, 85% of children and adolescents had completed the series as compared to 68% prior to the intervention (Schwarz et al., 2008). Increased vaccination rates were also noted when an accessible shelter-based flu vaccine program, the intervention, allowed more vaccines to be administered in the Community House. Therefore, shelter-based vaccine programs can assist in increasing vaccination rates.
Although there was an increase in unvaccinated patients from 2010-2015, there were an even greater number of patients not seen in the RNFC for cold and flu-like symptoms. Results from chart reviews indicated that the greatest impact on the number of clinic visits related to cold and flu-like symptoms was not the higher number of unvaccinated patients, but the number of vaccinated patients which helped to serve as a protective measure to reduce visits related to cold
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and flu-like symptoms. Therefore, more education about the benefits of the flu vaccine and increasing vaccine accessibility may help reduce the number of patients seen in the RNFC for cold and flu-like symptoms.
Results involving increased hepatitis A & B vaccination rates in a study by Poulos et al. (2008) had similar outcomes. When patients were made aware that the timing to receive a vaccine was appropriate, vaccination rates increased. The important factor of timing,
accessibility, and convenience in the study may have also been the same factor that may have increased vaccination rates in this practice improvement project.
In this practice improvement project, the fewest number of cold and flu-like symptoms were recorded in 2014-2015 when the most vaccines were administered. Conversely, findings also revealed that the most cold and flu-like symptoms resulted in 2013 when the fewest number of flu vaccines were administered. Although there was an increase in unvaccinated patients from 2010-2015, there were an even greater number of patients RNFC for conditions unrelated to cold and flu-like symptoms.
Results from chart reviews indicated that the greatest impact on the number of clinic visits related to cold and flu-like symptoms was not the higher number of unvaccinated patients, but may have been the number of vaccinated patients. The number of flu vaccine recipients may have been a protective measure to reduce clinic visits related to cold and flu-like symptoms. Therefore, more education about the benefits of the flu vaccine and increasing vaccine accessibility may help reduce the number of patients seen in the RNFC for cold and flu-like symptoms.
33 Impact of Smoking, Cough and Flu Vaccine
Cough/sneeze was the most common cold and flu-like symptom in chart reviews from 2011-2015. Smoking may contribute to coughing episodes, which can be caused by COPD, asthma exacerbations, emphysema and bronchitis (CDC, 2014f). One of the most basic needs in the first stage (Physiological) of Maslow’s Theory of Human Motivation is breathing. However, coughing caused by a history of smoking can sometimes prohibit the ease of breathing.
Therefore, more education about the benefits of receiving flu vaccines in the smoking population may help to reduce the cough associated with respiratory illnesses and further complications.
Results also indicated that a majority of patients (69%) seen in the clinic were smokers. Previous studies have shown that current smokers do not get flu vaccines as often as previous smokers and non-smokers (Pearson, Dube, Ford, & Mokdad, 2009). Damage caused to the respiratory tract can increase the risk of respiratory infections caused by smoking (Pearson et al., 2009). Therefore, increased flu vaccination rates in the smoking population may help to reduce the risk of respiratory infections.
Flu Vaccine and Race
African Americans received the most flu vaccinations followed by Caucasians and Hispanics. However, since more African Americans are housed in the shelter, this finding is understandable. Hispanic patients did not receive as many vaccines, but their vaccination rates did increase after flu vaccine clinic implementation. It is unclear, however, if low vaccination rates were due to fewer numbers of people wanting the vaccine, language barriers that may have prevented proper education about flu vaccines, or other factors. If lower vaccination rates were due to language barriers that prevented proper education about flu vaccines, then the need for
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Spanish-speaking volunteers to provide education and administration of flu vaccines for the Hispanic people should be investigated.
Although flu vaccines were available to anyone residing in the shelter, cold and flu-like symptoms may be reduced when a majority of people is vaccinated. This phenomenon, known as herd immunity, can protect people who receive a vaccination in addition to indirectly protect others who were not vaccinated (Smith, 2010). Fifty-one people who received a flu vaccine, but did not have a patient chart to document their race, impacted data that would have given more information on the relationship between race and vaccination rates although the majority of residents of the shelter are African American. Conversations were held with the medical
coordinator about including race on flu documentation slips for potential projects and flu vaccine clinics in the future.
Potential Significance of Age
Despite age ranging from 24 to 67 years for flu vaccine recipients, older patients had the highest uptake of vaccines. There were more people 50 to 59 years of age who received a flu vaccine when compared to any other decade (n=39). People 40 to 49 years of age received the second most flu vaccines (n=29) and people 60 and 69 years of age received the third highest number of flu vaccinations (n=21). People 20 to 29 years of age received the fewest flu vaccines (n=2) and people 30 to 39 years of age received the second lowest (n=10). It is not clear if this might simply be a representation of the demographics in the shelter. Perhaps there are fewer younger people in the shelter on any given night.
Older residents who received a majority of flu vaccines may be explained by the fact that they had more chronic disease for which they wanted to be proactive to maintain optimum health, may have had a longer length of stay in shelters (as compared to younger residents) that
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may increase exposure to illness for which they wanted to reduce, or younger populations may not be as health conscious as older residents to preserve their health. Or, there could have just been a larger amount of older people in the shelter. Although there are benefits when
administering flu vaccines to any age group, focusing on the older population in homeless shelters may yield higher vaccinations rates and reduce contraction and spread of the flu virus through the concept of herd immunity or target efforts to get more of the youth to participate. Focus on Smoking Population
Slightly less than a third of patients included in this project smoked and also received a flu vaccine (29%). Due to this low percentage, one potential goal for a shelter that provides flu vaccines is to vaccinate 100% of residents who are smokers. When people seek the aid of the Community House for shelter, an intake assessment is performed that includes an evaluation of smoking status. Access to this information in patient charts allows the opportunity to identify patients with a smoking history and to educate them about the benefits of receiving a flu vaccine. Cold and flu-like symptoms can be complicated by smoking (Mayo Clinic, 2015). Therefore, focusing on this population for flu vaccine administration may yield fewer complications from the common cold, flu-like symptoms and influenza.
Implications
The availability of an accessible flu vaccine clinic for homeless male residents in a shelter did improve vaccination rates. Shelter-based vaccination programs for this population help to increase vaccination rates when these programs allow more opportunities to provide vaccinations (Story et al., 2014). Therefore, shelter-based vaccination programs should be considered for the following cold and flu seasons to collect more data to assess future trends in vaccination rates.
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Findings indicated a wide range of cold and flu-like symptoms during clinic visits. Although there was no reduction in a specific symptom, data continued to support fewer cold and flu-like symptoms following the implementation of a flu vaccine clinic. Because the flu is spread by respiratory droplets and contaminated hands, education can be provided about the importance of keeping hands as clean as possible. Therefore, the simplistic act of washing hands with soap and water or an alcohol-based hand cleanser can be emphasized to help mitigate the spread of cold and flu-like symptoms (CDC, 2013c).
Piedmont Health Services (PHS) donates flu vaccines to the Community House so
residents can get vaccinated, if they choose. However, when an individual is not a resident of the shelter, he will not be able to receive a vaccine. Although PHS cannot donate an unlimited supply of flu vaccines, having a large enough supply may provide the opportunity to offer flu vaccines to the homeless population outside of the shelter, increase vaccination rates, serve as an important public health initiative and may contribute to better community health.
Limitations
There were several limitations involved with this practice improvement project. The flu vaccines recommended for the 2014-2015 cold and flu season were not the most effective for lowering flu risk due to genetically, mutated viruses already in circulation (CDC, 2015). Therefore, people may have been more reluctant to receive a flu vaccine for this cold and flu season as compared to other seasons, which could have hindered vaccination rates. In addition, the vaccine may not have reduced cold and flu symptoms.
Residents may have received flu vaccines elsewhere and this information might not have been reflected in the medical charts. For example, PCOC administered 125 flu vaccines in 2013 and 95 flu vaccines in 2014 during its one-day event. However, the review of medical charts
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revealed only one patient who received a flu vaccine at this community event. Also, some VA clinics and health departments in the surrounding community offer flu vaccines, but chart reviews did not capture this information. If patients were asked during clinic visits if they had already received a flu vaccine elsewhere, this information could be placed on the intake sheet or elsewhere in the chart to adequately reflect the number of patients who received a vaccine at an offsite location.
Another limitation is that all patients with cold and flu-like symptoms may not have elected to be seen in the RNFC clinic for various reasons. There is a reasonable chance that more people actually had cold and flu-like symptoms in January and February from 2011-2015, but chart reviews only captured patients that signed up for clinic appointments.
Also, challenges were presented when patients did not have medical charts, which made it difficult to obtain demographic data such as smoking status and race. Flu vaccine
documentation slips listed the patient’s date of birth, but no other demographic information Conclusion
The results of this practice improvement project support that an accessible, onsite flu vaccine clinic in a homeless shelter did increase vaccination rates and reduced the number of cold and flu-like symptoms. Efforts need to continue for increasing flu vaccination rates in the homeless population who temporarily rely on shelter. In most years reflected in this project, large numbers of patients seem to be unvaccinated. Smokers need to be at the forefront of flu vaccine initiatives. Future flu vaccine clinics should focus on vaccinating all ages and races, which may help reduce contraction and spread of cold and flu-like symptoms in shelters. Also, targeting smokers for education about the benefits of receiving a flu vaccine may help improve their vaccination rates and reduce respiratory complications caused by a history of smoking.
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APPENDIX A: OCTOBER–DECEMBER _____ PEOPLE WHO RECEIVED FLU VACCINES WHEN NO FLU CLINIC ONSITE
Patient # Vaccine in RNFC (Yes) Vaccine outside RNFC (Yes) Vaccine (No)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
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APPENDIX B: OCTOBER 2014–JANUARY 8, 2015 PEOPLE WHO RECEIVED FLU VACCINES WHEN FLU VACCINE CLINIC ONSITE
Patient # Vaccine in RNFC (Yes) Vaccine outside RNFC (Yes) Vaccine (No)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
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APPENDIX C: JANUARY AND FEBRUARY ____ COLD AND FLU-LIKE SYMPTOMS WHEN NO FLU VACCINE CLINIC ONSITE
Fever/ Cough or Sore Nasal Times Pt. # Chills Myalgia Fatigue Headache Sneeze Throat Congestion Other Seen
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
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APPENDIX D: JANUARY AND FEBRUARY 2015 COLD AND FLU-LIKE SYMPTOMS WHEN FLU VACCINE CLINIC ONSITE
Fever/ Cough or Sore Nasal Times Pt. # Chills Myalgia Fatigue Headache Sneeze Throat Congestion Other Seen
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
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APPENDIX E: DEMOGRAPHICS OCTOBER-DECEMBER _____ WHO RECEIVED FLU VACCINES WHEN NO FLU VACCINE CLINIC ONSITE
Age Race Smoker _________________________________ _____________________________ ____________
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APPENDIX F: DEMOGRAPHICS OCTOBER 2014-JANUARY 8, 2015 WHO RECEIVED FLU VACCINES AT ONSITE FLU VACCINE CLINIC Age Race Smoker __________________________________ ____________________________ ___________
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APPENDIX G: RNFC CLINIS VISITS AND VLU VACCINES PER YEAR
#Jan & Feb 2011 #Flu Vaccine #Cold and Flu-Like #Other Patient
Total Visits Oct-Dec 2010 Patient Visits Visits
#Jan & Feb 2012 #Flu Vaccine #Cold and Flu-Like #Other Patient
Total Visits Oct-Dec 2011 Patient Visits Visits
#Jan & Feb 2013 #Flu Vaccine #Cold and Flu-Like #Other Patient
Total Visits Oct-Dec 2012 Patient Visits Visits
#Jan & Feb 2014 #Flu Vaccine #Cold and Flu-Like #Other Patient
Total Visits Oct-Dec 2013 Patient Visits Visits
Above data prior to flu vaccine clinic ______________________________________________________________________________ #Jan & Feb 2015 #Flu Vaccine #Cold and Flu-Like #Other Patient
Total Visits Oct-Dec 2014 Patient Visits Visits
Above data after implementation of a flu vaccine clinic
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