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Improving Immunisation 23 April 2015 ASB Arena
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Improving Immunisation
23 April 2015ASB Arena
Text questions to:021-dr-gray021-37-4729
Total Population Māori
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
0
20
40
60
80
100
120
2006 2007 2008 2009 2010 2011 2012 2013
Rat
e p
er 1
00
,00
0
Year
Rate (per 100,000 population) of invasive pneumococcal disease by age, over time
<2y
<5y
5-64y
>65y
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
0
5
10
15
20
25
30
1 2 3 4 5
Ra
te p
er
100 0
00 p
op
ula
tio
n
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
Regional differences in decline rates
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
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?
Text questions to:021-dr-gray021-37-4729
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
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
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
4333%
1511%
129%
118%
86%
75%
65%
54%
54%
43%
43%
32%
32%
22%
22%
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?
Text questions to:021-dr-gray021-37-4729
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
Healthy Communities – Mauriora!
Trends in immunisation coverage
Healthy Communities – Mauriora!
How we got here?
1. Implemented good leadership
2. Examined the systems and processes
3. Worked hard on the final 10%
Healthy Communities – Mauriora!
Key points of change over time
Healthy Communities – Mauriora!
Improving leadership
Leadership accountability and planning
Immunisation action group
Met weekly
Accountable to the GM and CE
Single immunisation team
Healthy Communities – Mauriora!
Improving systems and processes
Pathway from pregnancy and opportunities
for intervention
Precalls, recalls and follow ups
Clinic level data
Monitoring, auditing and feedback
Healthy Communities – Mauriora!
Working with the final 10%
Multi Disciplinary Team
Declines
Missed Opportunities
Feedback
Phone people
Questions?
Text questions to:021-dr-gray021-37-4729
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
3%
Asian4%
Other9%
Immunisation Screening from April 2014 – March 2015
0
20
40
60
80
100
120
Ap
r-1
4
May
-14
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
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?
Text questions to:021-dr-gray021-37-4729
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
CRM
Gen Praccapacity
Audience research
Workshop &
Interviews
Social marketing
Analysed from a range of contributing factors
Reach…….WELCOME…....follow-up
Key areas for action
Comfort
Reach
• 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
Questions?
Text questions to:021-dr-gray021-37-4729
Improving Immunisation
23 April 2015ASB Arena
