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