Overview
Strategies to reduce inequalities
in child health: Perspectives from
Aotearoa/NZ
• Briefly describe two examples of ethnic
health disparities and strategies to
address these
• Identify general principles necessary for
achieving desired outcome
Annual Health Services Research
Meeting
Seattle, 25th June 2006
Dr Sue Crengle
• SIDS prevention
• Meningococcal vaccination
SIDS mortality rates per 1000 live births
by ethnicity 1980- 1986 (Source NZHIS 2005)
SIDS case control study
• 1987-1990 nation-wide case-control study
• Number of ‘unmodifiable’ factors
R a te p e r 1 0 0 0 liv e b irth s
12
10
• Four ‘modifiable’ risk factors for SIDS
8
–
–
–
–
Mäori
Other
Total
6
4
2
Prone sleeping position
Maternal smoking
Not breast feeding
Infant bed sharing
0
1986
1984
1982
1980
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 mortality rates per 1000 live births
by ethnicity 1980- 1994 (Source NZHIS 2005)
SIDS reduction campaign
12
Rate per 1000 live births
• Campaign to reduce these risk factors
came out 1991/2
• Campaign to reduce these risk factors
failed Mäori
10
8
Mäori
6
Other
Total
4
2
0
1994
1992
1990
1988
1986
1984
1982
1980
1
SIDS prevention
Key messages didn’t reach
Mäori
• Inappropriate and ineffective messages for
Mäori community
• 1994…
– Mäori SIDS prevention team funded
– Spent time listening and talking to community
• 1996
• Inappropriate dissemination methods
– developed Mäori appropriate education /
prevention
• No provision of culturally acceptable
alternatives esp. with bed sharing
• Sites
• Messages
• Staff
SIDS prevention
Mäori SIDS prevention
• 1996
• 1996 – developed Mäori appropriate
– developed Mäori appropriate education /
prevention
– Family assistance
• Workers who go to SIDS death - work with family
in short and sometimes longer term.
• Sites
• Messages
• Staff
– Work with coroners and others in sector to
ensure safe and appropriate interactions
between agencies and families
NZ meningococcal vaccine
programme
SIDS mortality rates per 1000 live births
by ethnicity 1980-99
(Source NZHIS 2003)
• My role of previous permanent advisor Māori
• Sub-serotype specific Men B epidemic since
1991
• Three strands to delivery
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
– 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
2
NZ meningococcal vaccine
programme
• ‘General’ population programme
NZ meningococcal vaccine
programme
• Māori advice largely unheeded until serious
inequalities in coverage apparent (c. early 2005)
– Some Māori ‘add ons’
• ‘communication’ strategy
– Further Māori media strategy
– Increase outreach services
– Media, stakeholders, providers
• Use of Māori providers already delivering immunisation
outreach (no increase in these services)
• Accompanying discourses
– ‘There are problems with the data’
– ‘Māori families are ‘low and slow’ to vaccinate their
children’
• General population programmes usually
increase inequalities e.g. SIDS prevention
• School based programme in CMDHB – Māori highest
consent rate but lowest coverage
Doing it right…
National coverage dose 1 and 3 at 23 april 2006 by age and ethnicity
• Te Whānau ā Apanui health service
• 1 doctor, 2 nurses, 1 receptionist
• ~ 2000 registered patients
120
100
– ~160 under 5 y olds
80
Mäori
% 60
Pacific
40
Other
• 92% Māori
• HIGHLY deprived / low SE area
• Rural
– ~ 2 ½ hours by road to nearest hospital
20
• LARGE catchment area
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
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
• 100% coverage of < 5 year olds
– Dose 1 and 2 over approx three weeks
– Dose 3 over four to five weeks
How??
• Practice systems to foster efficient
implementation
• Staff
• Positive reinforcement for children
• They also ‘took over’ the school programme and
had similar results
• At all clinics
• At kohanga reo
• At home (planned and “drive-by’s”)
kohanga reo - Māori language
child care centres
Hapū tribal subgroup
3
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
4