Disparities in Childrens Health Care Getting to Solutions II

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) 12 Rate per 1000 live births 10 8 6 4 2 0 1980 1982 1984 1986 Mäori Other 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) 12 Rate per 1000 live births 10 8 6 4 2 0 Mäori Other Total 1980 1982 1984 1986 1988 1990 1992 1994 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 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1996 1997 1998 prov 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 120 100 80 % 60 40 20 0 6w-4y dose 1 5-17y dose 1 18-19y dose 1 6w-4y dose 3 5-17y dose 3 18-19y dose 3 Mäori Pacific Other 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