Strategies to reduce inequalities
in child health: Perspectives from
Aotearoa/NZ
Annual Health Services Research
Meeting
Seattle, 25th June 2006
Dr Sue Crengle
Overview
• Briefly describe two examples of ethnic
health disparities and strategies to
address these
• Identify general principles necessary for
achieving desired outcome
• SIDS prevention
• Meningococcal vaccination
SIDS mortality rates per 1000 live births
by ethnicity 1980- 1986 (Source NZHIS 2005)
Rate per 1000 live births
12
10
8
Mäori
Other
Total
6
4
2
0
1986
1984
1982
1980
SIDS case control study
• 1987-1990 nation-wide case-control study
• Number of ‘unmodifiable’ factors
• Four ‘modifiable’ risk factors for SIDS
–
–
–
–
Prone sleeping position
Maternal smoking
Not breast feeding
Infant bed sharing
Mitchell EA, Scragg R et al NZ Med J 1991;104:71-6
Mitchell EA, Taylor BJ et al J Paediatr Child Health 1992; 29(Suppl 1):S3-8
Scragg R, Mitchell E et al BMJ 1993; 307: 1312-1218
SIDS reduction campaign
• Campaign to reduce these risk factors
came out 1991/2
• Campaign to reduce these risk factors
failed Mäori
SIDS mortality rates per 1000 live births
by ethnicity 1980- 1994 (Source NZHIS 2005)
Rate per 1000 live births
12
10
8
Mäori
6
Other
Total
4
2
0
1994
1992
1990
1988
1986
1984
1982
1980
Key messages didn’t reach
Mäori
• Inappropriate and ineffective messages for
Mäori community
• Inappropriate dissemination methods
• No provision of culturally acceptable
alternatives esp. with bed sharing
SIDS prevention
• 1994…
– Mäori SIDS prevention team funded
– Spent time listening and talking to community
• 1996
– developed Mäori appropriate education /
prevention
• Sites
• Messages
• Staff
SIDS prevention
• 1996
– developed Mäori appropriate education /
prevention
• Sites
• Messages
• Staff
Mäori SIDS prevention
• 1996 – developed Mäori appropriate
– Family assistance
• Workers who go to SIDS death - work with family
in short and sometimes longer term.
– Work with coroners and others in sector to
ensure safe and appropriate interactions
between agencies and families
SIDS mortality rates per 1000 live births
by ethnicity 1980-99
(Source NZHIS 2003)
12
10
8
6
4
2
0
1998 prov
1997
Total
1996
1994
1993
Euro/Other
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
Maori
NZ meningococcal vaccine
programme
• My role of previous permanent advisor Māori
• Sub-serotype specific Men B epidemic since
1991
• Three strands to delivery
– Under 5 years – GP based delivery
– 5 – 18 (at school) – school based delivery
– Young people not at school – GP based delivery
• MoH role
• DHBs role
NZ meningococcal vaccine
programme
• ‘General’ population programme
– Some Māori ‘add ons’
• ‘communication’ strategy
– Media, stakeholders, providers
• Use of Māori providers already delivering immunisation
outreach (no increase in these services)
• General population programmes usually
increase inequalities e.g. SIDS prevention
NZ meningococcal vaccine
programme
• Māori advice largely unheeded until serious
inequalities in coverage apparent (c. early 2005)
– Further Māori media strategy
– Increase outreach services
• Accompanying discourses
– ‘There are problems with the data’
– ‘Māori families are ‘low and slow’ to vaccinate their
children’
• School based programme in CMDHB – Māori highest
consent rate but lowest coverage
National coverage dose 1 and 3 at 23 april 2006 by age and ethnicity
120
100
80
Mäori
% 60
Pacific
40
Other
20
0
6w-4y
5-17y
18-19y
6w-4y
5-17y
18-19y
dose 1
dose 1
dose 1
dose 3
dose 3
dose 3
Age and dose
Doing it right…
• Te Whānau ā Apanui health service
• 1 doctor, 2 nurses, 1 receptionist
• ~ 2000 registered patients
– ~160 under 5 y olds
• 92% Māori
• HIGHLY deprived / low SE area
• Rural
– ~ 2 ½ hours by road to nearest hospital
• LARGE catchment area
• 100% coverage of < 5 year olds
– Dose 1 and 2 over approx three weeks
– Dose 3 over four to five weeks
How?
• Communication
– Formal at sites in community several months before
programme
– With patients via newsletter
– Informal communication with whānau in community
• Appropriate service
– Careful planning of approach
– Sites of delivery
• At all clinics
• At kohanga reo
• At home (planned and “drive-by’s”)
kohanga reo - Māori language
child care centres
Hapū -
How??
• Practice systems to foster efficient
implementation
• Staff
• Positive reinforcement for children
• They also ‘took over’ the school programme and
had similar results
Re-learning what we
know…
• ‘General’ programmes do NOT reduce
disparities
• Programme designed for those
experiencing disparities works for all
– Multiple points
• Consultation, communication, service delivery etc
• ‘80% of $ for last 20%’
– Maybe not if programme design approp