Strategies to reduce inequalities in child health:

Perspectives from Aotearoa/NZ

Annual Health Services Research Meeting

Seattle, 25th June 2006Dr 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)

0

2

4

6

8

10

12

1980

1982

1984

1986

Rat

e pe

r 100

0 liv

e bi

rths

MäoriOther

Total

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)

0

2

4

6

8

10

12

19

80

19

82

19

84

19

86

19

88

19

90

19

92

19

94

Ra

te p

er

10

00

liv

e b

irth

s

Mäori

Other

Total

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)

0

2

4

6

8

10

12

19

80

19

81

19

82

19

83

19

84

19

85

19

86

19

87

19

88

19

89

19

90

19

91

19

92

19

93

19

94

19

96

19

97

19

98

pro

v

Maori Euro/Other Total

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

0

20

40

60

80

100

120

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

%

Mäori

Pacific

Other

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

kohanga reo - Māori language child care centres Hapū - tribal subgroup

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”)

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