Slides from the Māori Health Excellence seminar focused at improving attainment of the immunisation Health Target.

1. Improving Immunisation
23 April 2015
ASB Arena

2. Text questions to:
021-dr-gray
021-37-4729

3. Total Population Māori

5. Rachel Webber
Senior Advisor, Under Fives Programme
rachel_webber@moh.govt.nz

6. 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)

7. Jun 2009
Ethnicity gap 11% points
Dep gap 5% points
Dec 2014
Ethnicity gap 2% points
No dep gap
8 month target
announced Jun 2012
- 85% by end Jun 2013
- 90% by end Jun 2014
- 95% by end Dec 2014

8. PCV7 introduced to schedule in 2008; PCV10 in 2011
0
20
40
60
80
100
120
2006 2007 2008 2009 2010 2011 2012 2013
Rateper100,000
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.

9. 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
Rateper100000population
2013 New Zealand deprivation index quintile
2009 2010 2011 2012 2013

10. 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

11. It’s about stopping
children dying

12. 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.

13. • 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.

14. Regional status

15. Comparison of PHOs: Eastern Bays Primary Health Alliance

16. Comparison of PHOs: Western Bay of Plenty PHO

17. Regional differences in decline rates

18. 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

19. 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

20. “Vulnerables”
• Face barriers to accessing services
“Unwell”
• Don’t immunise due to child’s ill health

21. Questions?
Text questions to:
021-dr-gray
021-37-4729

22. Supporting parents to make a positive
choice for vaccination
Dr Pat Tuohy – National Immunisation Champion
Ministry of Health

23. 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

24. 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

25. 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

26. 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

27. 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?

28. Intention to immunise by ethnicity
Source: Growing Up in New Zealand Study Report 2 (2012). Morton et al

29. Intention to immunise by deprivation
Source: Growing Up in New Zealand Study Report 2 (2012). Morton et al

30. Declines in the WBOP
43
33%
15
11%
12
9%
11
8%
8
6%
7
5%
6
5%
5
4%
5
4%
4
3%
4
3%
3
2%
3
2%
2
2%
2
2%
1
1% 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

31. Source: Audience Research: Delayers of Infant Immunisation 2013
Identify Target populations

33. 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

34. Achieving the immunisation target
95 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.

35. 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

36. 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.”

37. 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.

38. Questions?
Text questions to:
021-dr-gray
021-37-4729

39. Healthy Communities – Mauriora!Healthy Communities – Mauriora!
Lakes DHB
8 month immunisation
Pip King
Portfolio Manager
Planning and Funding
Lakes DHB

40. Healthy Communities – Mauriora!
Our population?
 About 1500 live births per year
 48% Maori
 52% other
 54% live in deciles 7 to 10

41. Healthy Communities – Mauriora!
Trends in immunisation coverage

42. Healthy Communities – Mauriora!
How we got here?
1. Implemented good leadership
2. Examined the systems and processes
3. Worked hard on the final 10%

43. Healthy Communities – Mauriora!
Key points of change over time

44. Healthy Communities – Mauriora!
Improving leadership
 Leadership accountability and planning
 Immunisation action group
 Met weekly
 Accountable to the GM and CE
 Single immunisation team

45. 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

46. Healthy Communities – Mauriora!
Working with the final 10%
 Multi Disciplinary Team
 Declines
 Missed Opportunities
 Feedback
 Phone people

47. Questions?
Text questions to:
021-dr-gray
021-37-4729

48. Te Manu Toroa &
Nga Mataapuna Oranga
Strategies to Improve
Immunisation

49. Ngā Mātāpono Me Ngā Uara
Whanaungatanga
We will endeavour to be welcoming, embracing, considerate and show respect
towards everyone.
Kotahitanga
We will maintain unity and purpose in all that we do.
Manaakitanga
We will show respect, support and care in everything we do.
Tikanga/Kawa
We will provide leadership to guide all behaviour and action within the
organisation.
Wairuatanga
We will provide and acknowledge the spiritual wellbeing of individuals.
Tangata Whenua
We will respect and be considerate of Tangata Whenua customs and beliefs.
Ngākau Pono
We will be loyal and committed to our clients needs to ensure our clients live a
healthy lifestyle.-

50. GP Clinics
Waitaha Health Centre Tauranga Moana City
2000 6000
Te Akau Hauora
2500
Pirirakau Hauora
1200

51. Te Manu Toroa &
Nga Mataapuna Oranga
Maori 84%
Asian 4%
Pacific Island 3%
Enrolled Population - 11700
Maori
84%
Pacific
Island
3%
Asian
4%
Other
9%

52. Immunisation Screening from
April 2014 – March 2015
0
20
40
60
80
100
120
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Waitaha Health Centre
Tga Moana City Clinic
Te Akau Hauora
Pirirakau Hauora

53. Identified Problems, Clarified
and Redefined Processes
• Coding Errors
• Immunisation Schedules
• Transient Patients

54. Whanau Ora Team Approach
• Key Influencers
• Regular focus meetings
• Key tasks identified and
ownership allocated

55. Keys to Success
• Understanding the process
• Regimented and disciplined whanau ora
approach
• Regular meetings with clear action points
• Clear goals and great team work

56. Whakatauki
‘My success should not be
bestowed onto me alone, as it was
not individual success but success
of a collective’

57. Some of our Imms Team!

58. Questions?
Text questions to:
021-dr-gray
021-37-4729

59. 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

60. What barriers do Maori
have…….
(victim blame approach)
What barriers does General
Practice create for Maori
(‘customer’ view)
Wanted to look from another angle….

61. Gap
analysis
Maori
health
Health
literacy
CRM
Gen Prac
capacity
Audience
research
Workshop
&
Interviews
Social
marketing
Analysed from a range of contributing factors

62. Reach…….WELCOME…....follow-up

63. 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

64. Contact details:
Tim Corbett
tim@deeplimited.com
021648136
www.deeplimited.com

65. Questions?
Text questions to:
021-dr-gray
021-37-4729

66. Improving Immunisation
23 April 2015
ASB Arena