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faith community/parish nursing, Healthy People 2020, immunizations, influenza, older adults, public health



  1. Pappas-Rogich, Maria


ABSTRACT: An estimated 226,000 hospitalizations and 36,000 deaths from influenza-related causes occur in the United States annually; adults ages 65 and older comprise 90% of flu deaths and 65% of hospitalizations. Older adult immunization rates are far from the Healthy People 2020 goal of 90% coverage. This article explores immunization in the elderly and how faith community/parish nurses can improve immunization rates.


Article Content

Faith community nursing, also known as parish nursing, began as a pilot project in Park Ridge, Illinois, in 1985 through the vision of Reverend Dr. Granger Westberg. It was originally named parish nursing because of its beginnings in the Christian faith, as the term encompasses the type of nursing specialty practice and ministry that reaches within the church and out into the wider community (Patterson & Slutz, 2011). Parish nursing has grown tremendously since its inception and developed into one of the largest types of community health nursing practice. The Christian parish nurse works to integrate faith and healing, focusing on the promotion of health within the context of the values, beliefs, and practices of the church community by providing compassion, respect, and presence-the core of healthcare. Most importantly, parish nursing connects the parishioner to the church as a source of healing and health, and brings the healing presence of Christ, offering spiritual and emotional support to traditional health interventions.

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Given the aging of our society, fragmentation of care, and increasing fiscal constraints, parish nurses who provide health promotion and disease prevention activities in faith communities serve as viable partners with community initiatives (King & Pappas-Rogich, 2011). Vaccination is one of the most important public health interventions. However, older adult rates of vaccination coverage are well below the Healthy People 2020 goal of 90%. The vaccination rate for influenza in 2009 was only 65.6% for adults ages 65 years and older (Centers for Disease Control and Prevention [CDC] (2011a). How can parish nurses be part of the public health collaboration to protect our seniors through immunizations?



New healthcare delivery models and roles have developed in response to rising healthcare costs, difficulties in accessing care, and the needs of an expanding elderly population. Parish nursing is a faith-based model of healthcare delivery that nurtures and supports elderly individuals. Traditionally, the elderly have seen the church as a source of spiritual comfort and socialization. In fact, the older adult population appears to be the primary population for parish nurse service. As far back as 2000, Weis and Schank (2000) described parish nurses' practice with older adults using North American Nursing Diagnosis Association and Nursing Interventions Classifications frameworks. Their study collected data from 19 parish nurses practicing in 22 faith communities of various denominations and their clients. Of the 408 clients in the sample, 71% were older adults between ages 60 and 80. Another study conducted by Matteson, Reilly, and Moseley (2000) found that parish nursing has a valid role among older adults and parish nurses are in an excellent position to give wholistic care.


Five years later Rydholm and Thornquis (2005) investigated quality of life for clients and families, and cost savings using the services of parish nurses. Seventy-five parish nurses contributed charting notes using a format developed by the researchers; a total of 1,061 notes were analyzed. The majority of clients served were women between ages 70 and 89. In another more recent study, McCabe and Somers (2009) examined parish nurses' understanding of the needs of seniors and the barriers that exist in meeting those needs. Thirty-one parish nurses reported they spent 50% to 100% of their time working with seniors. The struggles confronting seniors to maintain access to services, avoid isolation, and adjust to cuts in formal services appeared to be addressed by the parish nurses working with the elderly in McCabe and Somers' study.



Support for programs directed at achieving broad health objectives in local community settings, such as churches, has come from public health agencies, the U.S. Department of Health and Human Services (USDHHS), and the CDC. Every 10 years, the USDHHS leverages scientific insights and lessons learned from the past decade, along with new knowledge of current data, trends, and innovations to promote health. Healthy People 2010 (CDC, 2001) posed 10 leading health indicators with accompanying health challenges, highlighting individual behaviors, physical and social environmental factors, and important health system issues that greatly affect the health of individuals and communities. Healthy People 2020 (CDC, 2009a) moves forward in promoting the health of the nation. Healthy People 2020 calls for community organizations-including religious organizations-to form community health partnerships as well as collaborate with existing and developing community health services. Parish nurses are ideal representatives of their faith communities in these partnerships. As an expansion of home health and public health roles, parish nurse programs use the faith community as a cooperative means for spiritual and sociocultural implementation of health promotion.


King and Pappas-Rogich (2011) conducted a descriptive study of 102 parish nurses with a specific interest in describing interventions used by the nurses that corresponded to Healthy People Health Indicators. Findings indicated the Healthy People practice goal to "Encourage Immunizations for the Prevention of Infectious Diseases" was implemented at least on a yearly basis by 51% of the parish nurses, while 3% of the nurses reported they had not encouraged their parishioners to be immunized.


Older adult immunization rates are modest despite the burden of illness and fatalities associated with vaccine preventable diseases. An understanding of barriers to and facilitators of older adult immunization rates can help parish nurses contribute to the Healthy People 2020 goal of vaccinating 90% or more of older adults and reduce associated mortality and morbidity.



Vaccination is one of the most important and most cost-effective public health interventions for the elderly. Vaccination leads to enormous reductions in morbidity, mortality, disability, and suffering (, 2012). Despite this burden of illness as well as the Advisory Committee on Immunization Practices (ACIP) guidelines, older adult rates of influenza and pneumococcal vaccination coverage are suboptimal and have not improved in the last decade. The nation remains substantially below the Healthy People 2020 goal of 90% coverage for these vaccines.


The annual National Immunization Survey (NIS) is sponsored by the National Center for Immunization and Respiratory Diseases (NCIRD) and directed jointly by NCIRD and the National Center for Health Statistics (NCHS), CDC. The NIS began data collection in April 1994 to monitor childhood immunization coverage. During the summer of 2007, an adult component was added to the NIS called the NIS-Adult. About 7,000 adults ages 18 and older were selected and interviewed via telephone regarding their knowledge, attitudes, and practices related to adult vaccines. Among adults aged 65 and over, only 69% reported receiving their influenza vaccination during the 2006-2007 influenza season and 66% had their pneumococcal vaccination (CDC, 2009b).


The CDC currently estimates that only 5% to 20% of the population receives the influenza vaccine. On average, 226,000 people are hospitalized each year from flu-related complications and 36,000 die. Sixty-five percent of influenza-related hospitalizations are among the elderly. The elderly population carries the highest risk of contracting the influenza virus due to a decrease in the immune system efficiency that occurs with age. The CDC found that adults ages 65 and older comprise 90% of deaths that occur annually from complications related to influenza and pneumonia (CDC, 2011b).


According to the CDC, those over age 64 are at an increased risk for infection and, with few exceptions, should receive an annual influenza immunization and a one-time pneumococcal vaccine. The CDC is now recommending the Fluzone high-dose influenza vaccine to patients ages 65 and older. It is an intradermal vaccine and has four times the amount of antigen compared to the regular influenza vaccine. Fluzone is designed to give older adults a better immune response and better protection against the influenza virus, although long-term studies have yet to be completed and statistical data on outcomes will not be available until 2014 (CDC, 2011b).


Additional vaccines have been proven quite effective in the elderly. Shingles is a disease that causes a painful, blistering rash and is more common and more serious in older adults. About half of the nearly 1 million Americans who get shingles every year are elderly. Just one shingles vaccine reduces the risk of shingles and long-term pain after shingles in adults 60 and older. One shot of Tdap vaccine reduces the risk of getting the potentially deadly infections of tetanus, diphtheria, and pertussis. Pertussis can be a serious, even fatal disease in infants. Grandparents can be ill with pertussis for months and can pass the infection to babies too young to be vaccinated. Tetanus is a severe, painful infection, and most of the deaths from tetanus are among older adults. A list of recommended vaccinations for older adults can be found in Table 1. A full explanation of vaccines and downloadable schedule can be found at

Table 1: Vaccines Re... - Click to enlarge in new windowTable 1: Vaccines Recommended for the Elderly


Parish nurses who appreciate why elders do not get vaccinated can more effectively focus their efforts to increase immunization rates. According to the CDC (2010a) and Johnson, Nichol, and Lipczynski (2008), common misconceptions that can contribute to low immunization rates in seniors generally fall into categories listed in Table 2 and discussed below.

Table 2: Common Misc... - Click to enlarge in new windowTable 2: Common Misconceptions Among the Elderly About Vaccinations

Public opinions about vaccination include varied and deep-seated beliefs, a result of the two, sometimes divergent goals of protecting individual liberties and safeguarding the public's health. Religious objections to vaccines are based generally on (1) the ethical dilemmas associated with using human tissue cells to create vaccines, and (2) beliefs that the body is sacred, should not receive certain chemicals or blood or tissues from animals, and should be healed by God or natural means (The College of Physicians of Philadelphia, 2011). Researchers have found that individuals who exercise religious exemptions are at a greater risk of contracting infections, which put themselves and their communities at risk (Feikin et al., 2000). Parish nurses, in their role as public health advocates, may struggle to balance the ethics of protecting individual beliefs and the community's health (Blum & Talib, 2006).


Scripture verses that have served as touch points for religious exemption from vaccination include, "If you make the Most High your harm will befall you... (Psalm 91:9-11, NIV), "The prayer offered in faith will make the sick person well; the Lord will raise them up...(James 5:15-16, NIV), and others (Romans 12:1; 1 Corinthians 2:5). These are important and true words of God and we must respond to those who ask about these verses in relation to healthcare with grace, humility, and respect. It may be helpful to note that while God gives us these Scriptures, we cannot impose our wishes or presume upon God. Jesus gives a model of asking "Yet not as I will, but as you will" to his Father God (Matthew 26:39). God may choose to heal us through prayer and medicine.


Other issues related to lack of vaccination are lack of healthcare provider recommendations, time constraints on providers, and ineffective reminder systems. Furthermore, the responsibility for senior immunization has not been definitively assigned by public and private health systems, resulting in fewer and uncoordinated programmatic efforts (Kimmel, Burns, Wolfe, & Zimmerman, 2007). The cumulative effect is that many older adults at high risk for vaccine-preventable diseases remain unvaccinated.



Recognizing that immunization rates for influenza and pneumococcal vaccines among the elderly, especially minority elderly, are below desired levels, Zimmerman et al. (2003) studied a variety of patients and healthcare facilities in greater Pittsburgh, PA, and sampled from four strata: (1) inner-city neighborhood health centers, (2) clinics in Veterans Administration facilities, (3) a rural practice network, and (4) urban/suburban healthcare practices to determine factors that explain most missed immunizations. They found that an increase in older adult immunization rates requires individualized interventions that include an assessment of client knowledge, attitudes, beliefs, and practices regarding immunization. Their recommendations urge healthcare providers to give clear and intentional recommendations to clients to be vaccinated and patient educational programs that emphasize vaccine indications and efficacy in a culturally competent manner.


Nichol (2006) concurs that a healthcare provider's recommendation is one of the strongest predictors of whether an individual will be vaccinated. Most people will be immunized if a healthcare provider (HCP) recommends vaccination-even those who have negative attitudes toward immunization. Although the majority of older adults visit an HCP two or more times per year, urgent concerns tend to dominate office visits (Johnson et al., 2008), especially given the chronic comorbidities requiring regular medical attention in the elderly population. Parish nurses may be the only healthcare provider many older adults see on a frequent and regular basis for support and counseling. Clear and intentional recommendations of required vaccines by the parish nurse can strongly impact immunization rates.


Older adults may be unaware of the need for vaccines thus parish nurse efforts need to be focused on educating parishioners about the risks and benefits of immunization in easy-to-understand and culturally sensitive language. Older parishioners can be asked about immunization status at regular client encounters and given appropriate patient education materials. Many congregations publish a weekly bulletin or monthly newsletter that may be the ideal forum in which parish nurses can place timely health related educational materials, including up-to-date immunization recommendations.


It is important to educate faith community members about what is influenza illness as misconceptions abound. Influenza is a serious respiratory illness that is easily spread by coughing, sneezing, and inadequate hand washing and can lead to severe complications, even death. The classic symptoms of influenza are sudden onset of fever and chills, dry cough, runny nose, body aches, headache, and sore throat (CDC, 2011b). Influenza is much more serious than a "common cold" virus. A helpful and free toolkit for faith communities to help prevent the spread of infectious diseases and promote immunization is available from Reilly et al. (2011).


A common fear among older adults is that if they receive the influenza vaccine, they will get the virus and become ill with influenza. The influenza vaccine is prepared from killed viruses that are inactive and cannot cause influenza (CDC, 2011c). Educate elders that it is only a coincidence that people experience a cold or respiratory infection after being vaccinated. In fact, almost all people who receive influenza vaccine have no serious complications (CDC, 2011b).


Although serious adverse events due to vaccination are rare, media attention increases public awareness of adverse vaccine events and may fuel older consumers' fear of vaccine safety and efficacy. In February 2010, the CDC's ACIP voted in favor of universal influenza vaccination in the United States to protect as many people as possible (CDC, 2010b). Parish nurses should consider receiving the flu vaccine themselves, and encourage and refer at-risk family members of older adults to be vaccinated. This provides a good role model for preventive healthcare as well as increasing "herd immunity," which reduces the likelihood of spreading the virus by limiting the older person's chance of contact with an infected person (Schnirring, 2008).


Other strategies for improving vaccination rates include educating older adults that Medicare covers flu and pneumonia vaccines with no copays or deductibles. Medicaid coverage and reimbursement for adult vaccines vary significantly from state to state, and parish nurses should be aware of their state's policies. Targeting adults ages 65 and older for vaccinations may require offering earlier daytime hours as many seniors prefer not to drive or travel at night. Guide individuals and families to community resources and coordinate with other community agencies to provide seasonal flu and pneumonia shots and other recommended vaccines for older adults. Nurses also may organize vaccine clinics on-site at church or arrange for transportation to service sites. These interventions support the Healthy People finding that nontraditional settings can be more convenient and accessible places to obtain immunizations (Zimmerman et al., 2003). Table 3 offers ideas for increasing vaccination rates among the elderly.

Table 3: Recommendat... - Click to enlarge in new windowTable 3: Recommendations for Increasing Vaccination Rates Among Older Adults


Divergent cultural perspectives and opinions toward vaccination, including religious objections, signal the need for continued communication and collaboration between parish nurses, other healthcare personnel, and the faith community regarding acceptable and effective immunization policies. To respect individuals' beliefs and address varied concerns, all 50 U.S. states allow child vaccination exemptions for medical contraindications; 48 states allow religious exemptions; and 20 states allow exemptions for philosophical reasons (Malone & Hinman, 2007). As vaccinations for the community-dwelling older adult are voluntary, no formal exemption need be made. The responsibilities of the parish nurse are to provide education in support of vaccination as well as the risks, to answer questions and provide guidance but appreciate that ultimately immunization is the client's choice. As a patient advocate, the parish nurse respects individual autonomy and remains nonjudgmental of individual choice.


The practice of Health Ministries has been in existence since early Christian times. Christ charged his followers with the mission of tending to the whole person. In his teaching, healing, and preaching, Jesus set the example for his apostles and for us to follow: "Jesus went through all the towns and villages, teaching in their synagogues, proclaiming the good news of the kingdom and healing every disease and sickness" (Matthew 9:35, NIV).


The church as a social influence model, using indigenous sources of spiritual and social support, can exert positive influence on the health and well-being of our elders. The establishment and maintenance of policies and procedures for immunizations based on the CDC standards is essential, and parish nurses can aspire to meet or exceed national goals for immunizations for those elders entrusted to our care.


Web Resources




* Immunization Action Coalition (IAC)-


* Immunization Schedules/Information






* Infection Control and Emergency Preparedness Toolkit for the Faith Community-supplemental digital content at


* Take 3 Actions to Prevent the Flu-




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