1. Strategies to reduce inequalities in child health: Perspectives from Aotearoa/NZ Annual Health Services Research Meeting Seattle, 25 th June 2006 Dr Sue Crengle

2. 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

3. SIDS mortality rates per 1000 live births by ethnicity 1980- 1986 (Source NZHIS 2005)

4. 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

5. SIDS reduction campaign Campaign to reduce these risk factors came out 1991/2 Campaign to reduce these risk factors failed Mäori

6. SIDS mortality rates per 1000 live births by ethnicity 1980- 1994 (Source NZHIS 2005)

7. Key messages didnt reach Mäori Inappropriate and ineffective messages for Mäori community Inappropriate dissemination methods No provision of culturally acceptable alternatives esp. with bed sharing

8. SIDS prevention 1994… –Mäori SIDS prevention team funded –Spent time listening and talking to community 1996 –developed Mäori appropriate education / prevention Sites Messages Staff

9. SIDS prevention 1996 –developed Mäori appropriate education / prevention Sites Messages Staff

10. 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

11. SIDS mortality rates per 1000 live births by ethnicity 1980-99 (Source NZHIS 2003)

12. 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

13. 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

14. 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

16. 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

17. 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-bys)

18. How?? Practice systems to foster efficient implementation Staff Positive reinforcement for children They also took over the school programme and had similar results

19. 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