RUNNING HEAD Birth Dose of Hepatitis B

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RUNNING HEAD: Birth Dose of Hepatitis B

                        Promoting the Birth Dose of Hepatitis B
                             Pacific Lutheran University
                           Candis LeBaron & Natasha Wills
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                                     Windshield Assessment

       Kitsap County is composed of Bremerton, Silverdale, Poulsbo, Port Orchard and

Bainbridge Island, with a population of 244,800. Silverdale has a large shopping area, including

a shopping mall. There are many ferry systems throughout the county, which connect residents to

the greater Seattle Area. The main ferry system runs from Bremerton to Seattle, but there are

also ferries from Kingston to Edmonds, Southworth to West Seattle, and Bainbridge Island to

Seattle. Houses throughout Bremerton and Port Orchard are in respectable condition. There are

many newer houses throughout Port Orchard, and in Bremerton and Port Orchard there are older

houses, but they are in great shape. Kitsap County and Tacoma are divided by the Tacoma

Narrows Bridge with Gig Harbor, which is considered Pierce County, in the middle.

       There are two military bases, Submarine Base Bangor and Puget Sound Naval Shipyard.

The latter consists of the US Navy ships. The Base Bangor in Silverdale houses US Marines.

Puget Sound Naval Shipyard is government run, providing many civilian government jobs for

Kitsap County residents. This county consists of a younger population; this may be due to the

high military population. With the US Navy being in Bremerton, this increases population and

strengthens the economy of Kitsap County.


   Washington State defines poverty as having an income less than or equal to $19,806. In 2005,

eight percent of Kitsap County was living in poverty, while within Washington State there was

an eleven percent poverty rate. In 2007, Kitsap County had 96 percent of their civilian adults

currently employed, even with a graduation rate of 81 percent (CDC, 2008).
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       Within Kitsap County, there is one trauma level three hospital, a Birthing Center with a

Stork Express for prenatal education, and two OB/GYN clinics. This does not include the Naval

Hospital or Group Health. Within those two clinics there are obstetricians and nurse practitioners.

There are 117 primary care physicians and nine percent of them are pediatricians. The

population to provider ratio for total insurance coverage, low income and Medicare populations

(Schueler, V., Berthon, C., Olexa, L., Hopkins, L., Metcalf, H., 2004)..

       Five percent of women in Kitsap County received no or late prenatal care from 2002-

2004. Within the same time frame, there was a 40 percent Medicaid reimbursement for deliveries.

With further studying, they found that 84 percent of Kitsap County, ages 18 and older, had some

form of insurance coverage. By 2006 there was an increase to 75 percent of women beginning

prenatal care within their first trimester (Kitsap County Health District, 2008).

       The Center of Disease Control reported that in 2007 there were a total of 72 cases of

Chronic Hepatitis B in Washington State and two cases in Kitsap County (CDC, 2008). Harrison

Birth Center had reported that 1715 babies were born from January 1, 2008 – October 15, 2008.

Of the 1715 babies born, 1573 babies had received the birth dose of Hepatitis B and nine babies

received the Hepatitis B Immunoglobulin. This left 0.8 percent of the newborns in Kitsap County

unprotected from Hepatitis B.

                                       Community Strengths

        Residents of Kitsap County verbalize a sense of security and genuinely care for their

properties. The ferry systems give the community adequate access to many Seattle Metro areas.

The police stations are placed in conveniently accessible locations, in the middle of the town

(Bremerton, Silverdale and Port Orchard). There are a lot of grocery, clothing and other stores

for shopping in convenient locations throughout Kitsap County. This county is especially nice as
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it is private, almost secluded and separate from the larger cities, Tacoma and Seattle. There are

plenty of public and private schools offered throughout the county (Washington State

Department of Health, 2006).

        The Kitsap County Health District has a clinic for the people in the community, which

provides immunization administration as well as Hepatitis C and HIV screening. Also, within

the Health District there are nurse epidemiologists and a nurse practitioner. Kitsap County Health

District reports that there are less motor vehicle related deaths in Kitsap County (9.5%) than in

Washington State (11.3%). In addition, there was a decreased rate of drug related deaths in

Kitsap County (11.2%), with a rate of 14.2% in Washington State.

                                       Community Weaknesses

        There are over 700 people who are homeless within Kitsap County. The rates of

Chlamydia are extremely high, with 456 cases already reported between January-August of this

year. Kitsap County also has an 11.5 % alcohol related death rate, compared to 9.7 percent rate

in Washington State.

        Kitsap County has a new bridge that was built next to the Tacoma Narrows Bridge to

relieve traffic. Unfortunately, there is now a toll bridge fee of four dollars to get off of the

peninsula; this can become expensive for frequenters of the other side. There is a Good to Go

pass, which helps to cut down on crossing costs. Though a bridge toll is a weakness, it isn’t life

threatening, whereas decreased hospital access may be.

        There is a minimum drive of 30 minutes to get to a higher level trauma hospital, unless

you are air lifted. Referrals for specialty surgeons, clinics and physicians are located across the

bridge, which potentially poses financial or geographical difficulty to those needing care.
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                                       Health Related Issues

       The physician to population ratio is also very low within Kitsap County. Women in

Kitsap County tend to receive late or no prenatal care compared to women in Washington State.

In addition, Janet from the Kitsap County Health District stated that statistics have shown that

from 2007 to 2008, there has been a steady declination in the birth dose administration.

                                      Assessment Limitations

       Limitations to the assessment included there being no access for communication with the

women who refused their newborns receiving the Hepatitis B vaccines at the time of their

decision. Thus, the ability to identify the true reason as to why they refused to have their babies

become vaccinated was limited. Another option to help with this conundrum was to find data that

might support a reason for the decline. Again, this data was inaccessible and not necessarily

identified as a causal relationship. Information regarding whether there are any known cases of

Hepatitis B positive infants due to transmission from mom during delivery was another

important question that was unavailable. Had this extra information been available, it is believed

that the promotion of the birth dose would have been more “real” to the pregnant women.

                                          Systems Theory

       Having explored Kitsap County as a whole, it was apparent that their systems theory was

an open system.
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                                 Promotion of Hepatitis B
                                      Birth Dose.

                                            Kitsap County
                                            Moms-to-be &
            Input                             neonates
  OB Staff members,                Knowledge                                     Educated moms-
    Kitsap County                                                                to-be, immunized
   Health District,                                                                  neonates,
   education and                            Throughput
       research                                 Brochures & power point          Hepatitis B rates,
                                   Communication between                          communication
                                     OBs & Moms-to-be



       The issue with the community involved a lack of education of moms-to-be regarding the

Hepatitis B birth dose as well as the possible transmission to the baby during birth. There seemed

to be some hesitation from moms concerning their newborn babies receiving the vaccination

after birth. This hesitation has often been attributed to fear of the unknown and safety of the

vaccination. It is possible that moms think that their babies will not be at risk as long as the

mothers don’t have the disease. This misconception that it is only contracted from the mother

may lead to the mother, putting off allowing their baby to obtain the vaccination within 12 hours

from birth.

       In Kitsap County, there were only two reported cases of Chronic Hepatitis, thus

presenting less of a transmission risk to the babies that have not received the birth dose of
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Hepatitis B (CDC, 2008). The medical community was very close and interacted well together.

Members of the medical community were willing to learn more information from the Health

District and us (PLU nursing students) regarding the importance of promoting the birth dose.

       The project of promoting the birth dose of Hepatitis B was chosen for us, and for that

reason there isn’t a true rationale for prioritization. The Health District felt there was a concern

that moms-to-be were not getting enough information before delivery to make the decision of

allowing their babies to receive the birth dose. It was important to the Kitsap County Health

District to implement this project, as this would be beneficial to their community of only 85%

having some sort of health insurance.

The following nursing diagnosis was recognized:

       Risk of Hepatitis B transmission among newborn babies of Kitsap County as evidenced

       by 152 newborns not receiving the birth dose of Hepatitis B vaccinations.

       A Healthy People 2010 objective that directly related to this issue was Section 14-2:

Reduce chronic Hepatitis B virus infections in infants and young children (perinatal infections).

Healthy People 2010 found in 1995 that there were 1,682 cases of chronic hepatitis B virus

infections in children under the age of two years. Their 2010 objective is to have a 76%

improvement, meaning only 400 cases of chronic Hepatitis B virus in children under age two

years (Healthy People 2010, 2000).

       Another Healthy People 2010 objective that related was the objective to eliminate health

disparities. With this project, we would be preventing infectious disease through education and

promotion of immunization and increasing the knowledge of pregnant women. There are 28

focus areas within Healthy People 2010, four of which help give rationale for promotion of the

birth dose of Hepatitis B. They are immunization and infectious disease, maternal, infant and
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child health, education and community based programs and sexually transmitted disease

(Healthy People 2010, 2000).

        The core function of community health applied to the Kitsap County community was

assurance. According to Stanhope & Lancaster (pg 258), the core function of assurance promises

“members of the community that they will have access to needed health services…that quality

health services are effective and easily accessible…and that research is conducted and the

resulting knowledge is applied to developing innovative solutions to health problems in the

community.” An intervention needed to be planned that would help to assure the community that

a steady declination of newborns in Kitsap County receiving the birth dose of Hepatitis B

vaccine was recognized and that improving those numbers to increase protection of newborns

was a priority.

        In order to address this problem, a plan needed to be decided on and then implemented as

some sort of project which would provide educational literature to pregnant women about

Hepatitis B and the importance of the birth-dose vaccine. This project would be aimed at

elimination of the occurrence of disease, a form of primary prevention. Distribution of this

information to the two county OBs and The Stork Express would be an effective way to reach

pregnant women in Kitsap County, since it would be impossible to meet with and educate all

pregnant women in Kitsap County. It was also decided that the created educational literature

should be presented to caregivers at each site and the importance of the literature being given to

moms clearly stressed. To begin, short and long-term goals and objectives were established for

the project.

        Long Term Goals:
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      Increase the number of newborns receiving the Hepatitis B vaccination within the first 12

       hours of birth.

      Decrease the number of chronic Hepatitis B cases among children less than 2 years of age.

Short term goal:

      Pregnant women in Kitsap County will receive education about the birth dose of the

       Hepatitis B vaccination.

       In order to achieve such goals, objectives were created which set a timeframe to work

with and that were measurable. The objectives set were as follows:

      Pregnant women in Kitsap County will receive literature regarding Hepatitis B birth dose

       from providers by December 15, 2008.

      Newborns receiving the birth dose of Hepatitis B vaccine will increase by 10% by

       December 15, 2009.


       The first step in implementation of the project was to create some form of educational

literature to offer to providers. Many forms of literature about Hepatitis B and Hep B

vaccinations from organizations around the country were researched. Only one pamphlet was

found which provided most of the information that was needed to share with pregnant women,

and it happened to be the one made by the Washington State Department of Health!

       That pamphlet was very useful, and it was decided that it would be part of the literature to

provide to moms-to-be. However, a decision was made to distribute it with an additional

information sheet, which would have to be created by project members. This additional sheet

took one day to construct. It was a one-page, question-answer format, which provided

information vital in promoting the birth dose of Hepatitis B to pregnant women and was not
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already covered in the pamphlet. Since information in our analysis showed that possible reasons

for mothers not permitting the birth dose within the first twelve hours was due to lack of

knowledge, or fear about the vaccine, educational information about the safety of the vaccine

was included. Once finished, it was looked over for discrepancies by a handful of nurses at the

health department, and it was officially approved by Janet and Lynne, the project advisors. (see

appendix for printout of additional sheet).

        Once the educational literature was prepared, the three local OB clinics needed to be

contacted in order to verify that they would meet to discuss including the Hepatitis B birth dose

literature in their prenatal education packets. Setting up a meeting with local providers was most

often difficult. It was this way because the contacts would not initially return calls made or

messages left. Communication was established with Dr. Zappata’s office after 2 weeks of

leaving messages. Once in communication with the Doctor’s Clinic, their manager informed the

group that they send all of their pregnant clients to the Stork Express for prenatal education. This

changed the initial plan, now having only two sites at which to educate providers and distribute

the literature.

        The Stork Express was the most elusive of the three places originally contacted. After

three weeks of leaving messages with different recommended contacts, it was decided by the

project mentors, Janet and Lynne, that prompt delivery of the literature was more important than

delaying the delivery of the literature. The providers had indicated that they would be willing to

distribute the literature, but it apparent that a meeting to explain the importance of the literature

would be not be set up with either clinic, even though it was considered beneficial.

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                In order to evaluate the Hepatitis B birth dose project, the project goals and

objectives must be looked at from a formative and summative perspective. When concerning a

formative review, short term goals and objectives had to be considered. The short term goal

stated that moms-to-be in Kitsap County would receive education about the birth dose of the

Hepatitis B vaccine. This short term goal was supported by short term objectives, which were to

make sure pamphlets were distributed by December 15, 2008. Thus, the short term goal was met,

as providers immediately began including the literature in their prenatal education programs.

        This project has just recently been implemented, so a certain passage of time will be

needed to evaluate the effectiveness of endeavors made and the attainment of the long term goal.

Although the long term goals cannot be evaluated from a summative perspective, it will not be

difficult to do, when the time comes. If there is an increase in the number of newborns who

receive the Hepatitis B vaccination within the first 12 hours of birth and a decrease in the number

of chronic Hepatitis B cases among children less than 2 years of age, then the established goals

will have been met. The objective stating that there being a 10% increase of newborns that

receive the birth dose of Hepatitis B vaccine by December 15, 2009 is an accurate way to form a

summative evaluation of the long-term goals. After that date, data collected on that information

will hopefully reveal that the project is effective.


        In retrospect, this project was an enjoyable success, despite some of the many setbacks

related to lack of response from Kitsap County Providers. The plan did not significantly change

during the course of the semester, with the exception of the decision to just deliver the pamphlets

and abort meeting to present a power point to the providers. Those on site at the OB clinics who
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       In the future, it would be prudent for students working on similar projects to be more

assertive toward the beginning of the semester, stopping in to provider’s offices and delivering

pamphlets early, instead of waiting too long for a return phone call. This would help to ensure

efficient use of time and resources to complete objectives. Of course, this should be considered

as long as it is done in a professional manner and with respect to the providers in mind. The

Kitsap County Health District was an excellent resource for this project, and it is recommended

that students continue to utilize the talents from all departments necessary within the KCHD to

successfully complete future projects, as was done with this Hepatitis B birth dose project.
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CDC, (2008). Centers of Disease Control and Prevention. Hepatitis B Vaccination. Retrieved on
  October 28, 2008 from Web site:

Healthy People 2010, (2000). Healthy People. Retrieved on October 24, 2008 from Web site:

Kitsap County Health District, (2008). Kitsap County Health. Epidemiology Retrieved on
    October 24, 2008 from Web site:

Schueler, V., Berthon, C., Olexa, L., Hopkins, L., Metcalf, H. (2004). Access to Primary Health
   Care Providers in Kitsap County. Retrieved on October 24, 2008 from Web site:

Washington State Department of Health, (2006). Hepatitis B, Acute. Notifiable Conditions:
  Hepatitis B. Retrieved October 24, 2008 from Web site: