Immunisation Excellence Seminar

transcript

Improving Immunisation

23 April 2015ASB Arena

Text questions to:021-dr-gray021-37-4729

Total Population Māori

Rachel Webber

Senior Advisor, Under Fives Programme

rachel_webber@moh.govt.nz

Health targets

• 95% of 8 month olds fully immunised for age

• Performance measures

• 95% of 2 year olds fully immunised for age

• 90% of 4 year olds in 2015/16 (95% in 2016/17)

Jun 2009Ethnicity gap 11% pointsDep gap 5% points

Dec 2014Ethnicity gap 2% pointsNo dep gap

8 month target announced Jun 2012- 85% by end Jun 2013- 90% by end Jun 2014- 95% by end Dec 2014

PCV7 introduced to schedule in 2008; PCV10 in 2011

2006 2007 2008 2009 2010 2011 2012 2013

Rate (per 100,000 population) of invasive pneumococcal disease by age, over time

Institute of Environmental Science and Research Ltd (ESR). Invasive pneumococcal disease in New Zealand, 2013. Porirua: ESR; 2014.

Vaccination is a pro-equity intervention

ESR IPD report 2013 (provisional)

Rate per 100 000 population of invasive pneumococcal disease by

quintiles of the 2013 NZ Deprivation Index and year, 2009-2013

1 2 3 4 5

2013 New Zealand deprivation index quintile

2009 2010 2011 2012 2013

Why 95%?

• High immunisation rates protect not only the individual

but, for most vaccines, also the community by reducing

spread of the disease to vulnerable people.

• “Herd immunity”

• Measles is one of the most infectious diseases.

• coverage of 95% is needed for herd immunity

It’s about stopping children dying

Whooping cough (Pertussis)

Whooping cough is common in New Zealand.

• We have an outbreak of the disease every 3–5 years.

The most recent outbreak began in August 2011 and is

still ongoing.

Since the outbreak began, more than 11,500 cases of

whooping cough have been reported to mid July 2014.

• In 2012 alone, there were 5793 reported cases and two

infant deaths

“A whooping cough epidemic sweeping the country has claimed the life of a 6-week-old Christchurch baby”

The coroner ruled the baby’s death in November 2012 could have been prevented if more people had been vaccinated.

Regional status

Comparison of PHOs: Eastern Bays Primary Health Alliance

Comparison of PHOs: Western Bay of Plenty PHO

Regional differences in decline rates

Decline + opt-off rate for immunisation at age 8 months for quarter ending Dec 2014

Why do people decline?

“Rejecters”

• Opposed to most or all child immunisation

“Nurturers”

• Not opposed to immunisation but think children are at

low risk

“Fearfuls”

• Immunisation experience distressing

“Vulnerables”

• Face barriers to accessing services

“Unwell”

• Don’t immunise due to child’s ill health

Questions?

Supporting parents to make a positive choice for vaccination

Dr Pat Tuohy – National Immunisation Champion

Ministry of Health

A decline is an opportunity to have a conversation about immunisation

• Find out what is behind the decision and engage in a dialogue with the parent

• Acknowledge their fears and concerns and‘decisional conflict’

• Respectfully re-interpret any factual misconceptions

• Respect their decision, but offer to contact them when the situation changes

Trust me I’m a Doctor!

• Trust has to be earned and given - it can’t be demanded

• Earn trust by being open and respectful

• Trust is hard earned and easily lost

Key points

• NZ parents have an increased degree of trust and acceptance of vaccination and most parents are willing to have their children immunised

• Despite this, many have residual anxiety about the vaccination process

• The attitude of the GP and practice nurse is a crucial factor

• There are a range of enablers and barriers which need a ‘whole of system’ approach to address

Regional differences in decline rates

Decline + opt-off rate for immunisation at age 8 months for quarter ending Dec 2014

Why do parents not immunise or immunise late?

There are many possibilities:

• Do they understand the information?

• Are they are conflicted or confused?

• Are they visiting ‘hard to use’ practices?

• Do we listen to them?

• Do they trust us?

Intention to immunise by ethnicity

Source: Growing Up in New Zealand Study Report 2 (2012). Morton et al

Intention to immunise by deprivation

Source: Growing Up in New Zealand Study Report 2 (2012). Morton et al

Declines in the WBOP

11% vaccine safety

own research

homeopathy

natural approach

side effects

allergies

bad experience

family members have reacted

horror stories

does not believe

wants to delay

contraindication

not provided

no reason given

reaction to previous

conflicting advice

Data supplied by: Diane Newland, Immunisation Coordinator, Western Bay of Plenty

Source: Audience Research: Delayers of Infant Immunisation 2013

Identify Target populations

Parents’ attitudes and experiences of immunising infants

• Parents have a strong desire to protect their children from serious illness and disease, and most generally support immunisation.

• Immunisation is a significant event for new parents, and mothers value partner and family/whānau support.

• At a rational level, parents generally have confidence in the safety of vaccines, but at an emotional level, they still have fears about potential side effects of vaccines.

• Parents fear the immunisation experience.

• Parents find the immunisation environment in GP clinics disempowering.

Source: Audience Research: Delayers of Infant Immunisation 2013

Achieving the immunisation target95 percent of eight-month-olds fully immunised by December 2014

The Ministry of Health has developed a four-point action plan: Enrol, Engage, Promote, and Monitor to assist with achieving the immunisation target.

Addressing Inequity

There is a widely held view that addressing inequity is complex and time-consuming and must involve whole of system social change.

Our experience shows that taking a Quality improvement approach can address inequity over a short time scale

Using validated methods, such as the IHI Triple aim, gave us confidence that we could make a difference through:

• planning for equity

• ensuring timely and accurate reporting of progress.

• monitoring our outcomes

• adjusting our interventions

Support from other programmes

A Northland mother interviewed for a recent NZ Doctor article shows the unique character of the B4SC. She says one of the positives to come out of it was the decision to go ahead with a vaccine that she had been unsure of.

“We had a good chat about vaccinating with the nurse and decided to go ahead with one of the vaccines that we weren’t going to do. The nurse presented the information to me and was factual and nice, instead of being forceful, whereas before I’ve felt like I was being drilled … I think it’s in the best interest of your children to (have the check). It’s free and it’s worth it. There’s no reason not to do it.”

Supporting parents to decide

Informal discussion

• Family

• Friends

• Health professionals

Personal research

• Internet

• Pamphlets

• Books

Types and levels of evidence

Decision aids

If we are to engage effectively with parents, we must replace one way information delivery with dialogue.

The discussion has to acknowledge the social processes around immunisation decisions.

Questions?

Healthy Communities – Mauriora!Healthy Communities – Mauriora!

Lakes DHB 8 month immunisation

Pip KingPortfolio Manager

Planning and Funding Lakes DHB

Healthy Communities – Mauriora!

Our population?

About 1500 live births per year

48% Maori

52% other

54% live in deciles 7 to 10

Trends in immunisation coverage

How we got here?

1. Implemented good leadership

2. Examined the systems and processes

3. Worked hard on the final 10%

Key points of change over time

Improving leadership

Leadership accountability and planning

Immunisation action group

Met weekly

Accountable to the GM and CE

Single immunisation team

Improving systems and processes

Pathway from pregnancy and opportunities

for intervention

Precalls, recalls and follow ups

Clinic level data

Monitoring, auditing and feedback

Working with the final 10%

Multi Disciplinary Team

Declines

Missed Opportunities

Feedback

Phone people

Questions?

Te Manu Toroa & Nga Mataapuna Oranga

Strategies to ImproveImmunisation

Ngā Mātāpono Me Ngā UaraWhanaungatangaWe will endeavour to be welcoming, embracing, considerate and show respect towards everyone.

KotahitangaWe will maintain unity and purpose in all that we do.

ManaakitangaWe will show respect, support and care in everything we do.

Tikanga/KawaWe will provide leadership to guide all behaviour and action within the organisation.

WairuatangaWe will provide and acknowledge the spiritual wellbeing of individuals.

Tangata WhenuaWe will respect and be considerate of Tangata Whenua customs and beliefs.

Ngākau PonoWe will be loyal and committed to our clients needs to ensure our clients live a healthy lifestyle.-

GP ClinicsWaitaha Health Centre Tauranga Moana City

2000 6000

Te Akau Hauora2500

Pirirakau Hauora1200

Te Manu Toroa & Nga Mataapuna Oranga

Maori 84%

Asian 4%

Pacific Island 3%

Enrolled Population - 11700

Maori84%

Pacific Island

Asian4%

Other9%

Immunisation Screening from April 2014 – March 2015

Waitaha Health Centre

Tga Moana City Clinic

Te Akau Hauora

Pirirakau Hauora

Identified Problems, Clarified and Redefined Processes

• Coding Errors

• Immunisation Schedules

• Transient Patients

Whanau Ora Team Approach

• Key Influencers

• Regular focus meetings

• Key tasks identified and ownership allocated

Keys to Success

• Understanding the process

• Regimented and disciplined whanau ora approach

• Regular meetings with clear action points

• Clear goals and great team work

Whakatauki

‘My success should not be bestowed onto me alone, as it was not individual success but success

of a collective’

Some of our Imms Team!

Questions?

Hard to

reach or

hard to

use?Tim Corbett

Director of Thinking

DeepLimited

Making it easier for

whanau to immunise

Statement of disclosure

This work was funded by GlaxoSmithKline NZ Ltd

TAPS NZ/VAC/0010a/12

What barriers do Maori have…….

(victim blame approach)

What barriers does General Practice create for Maori

(‘customer’ view)

Wanted to look from another angle….

Gap analysis

Maori health

Health literacy

Gen Praccapacity

Audience research

Workshop &

Interviews

Social marketing

Analysed from a range of contributing factors

Reach…….WELCOME…....follow-up

Key areas for action

Comfort

• Imms for Maori

• Whanau/‘nannie’ comms

• ‘Whanau friendly’

Welcome

• First impression

• Receptionist THE one• Pronunciation

• PMS tag

• Prof development

• Customer service

• Waiting and consult room

Follow-up

• Thanks

• Mum positive

• In a Maori frame

Contact details:

Tim Corbetttim@deeplimited.com021648136www.deeplimited.com

Questions?

Improving Immunisation

23 April 2015ASB Arena

Immunisation Excellence Seminar

Health & Medicine