Evaluation of Meningococcal B Immunisation National Roll-out
Final Report
Prepared for Ministry of Health November 2006
CONTENTS EXECUTIVE SUMMARY ...... 6 1. BACKGROUND TO EPIDEMIC AND THE MVS...... 14 2. EVALUATION OVERVIEW ...... 16 3. SUMMARY OF COVERAGE AND IMPACT...... 18 OVERALL PROGRAMME COVERAGE ...... 18 COVERAGE COHORTS ...... 19 Current age...... 19 Initial cohort ...... 19 Age at first dose ...... 20 COVERAGE BY DHB S ...... 21 ADJUSTMENTS FOR PRIMARY CARE ETHNICITY CODING ...... 22 Methods...... 22 Adjustment models ...... 23 Impact on coverage estimates...... 23 IMPACT OF THE PROGRAMME ...... 25 KEY LESSONS AND RECOMMENDATIONS ...... 27 4. DESCRIPTION OF PROGRAMME IMPLEMENTATION...... 28 CONTRACT WITH DHB S ...... 29 NATIONAL VACCINE PURCHASE AND SAFETY MONITORING ...... 29 COLD CHAIN STRENGTHENED ...... 29 COMMUNICATIONS STRATEGY...... 30 DELIVERED BY GENERAL PRACTICE AND PUBLIC HEALTH NURSES ...... 30 NIR AND SBVS...... 30 OUTREACH SERVICES ...... 30 CATCH -UP CLINICS ...... 31 ADDITIONAL ACTIVITIES ...... 31 ROLLOUT DATES ...... 31 5. VACCINE DISTRIBUTION AND ALLOCATION ...... 33 KEY LESSONS AND RECOMMENDATIONS ...... 34 6. SAFETY MONITORING DATA SUMMARY...... 35 7. SETTING UP THE PROGRAMME ...... 36 RELATIONSHIP MANAGERS WORKED WELL ...... 36 GOOD WORKING RELATIONSHIPS AT DHB / PROVIDER LEVEL ...... 36 A WELL RUN PROGRAMME ...... 37 SOME RESOURCE CONSTRAINTS ...... 37 MATERIALS AND COMMUNICATIONS EFFECTIVE ...... 38 NATIONAL ADVISORY GROUP PERSPECTIVE ...... 39 KEY LESSONS AND RECOMMENDATIONS ...... 39 8. COMMUNICATIONS AND MEDIA...... 41 IMPACT OF COMMUNICATIONS ...... 42 FEEDBACK FROM EXTERNAL MEDIA INFORMANTS ...... 43 ANALYSIS OF MEDIA COVERAGE ...... 44 KEY LESSONS AND RECOMMENDATIONS ...... 47 9. COMMUNITY AWARENESS RAISING...... 48 NATIONAL AWARENESS RAISING ...... 48 LOCAL AWARENESS RAISING ...... 49 TRAINING AND SETTING UP ...... 49 CAR STRATEGIES ...... 49 WHAT WORKED WELL ...... 51 HOW COULD CAR BE IMPROVED ? ...... 51
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KEY LESSONS AND RECOMMENDATIONS ...... 52 10. UNDER 5S...... 53 COVERAGE ...... 53 PATTERNS AND PHASES OF VACCINATION UPTAKE ...... 54 NATIONAL IMMUNISATION REGISTER ...... 55 GIVING THE VACCINE IN PRACTICES ...... 56 REFERRING TO OUTREACH ...... 57 SECOND AND THIRD DOSES ...... 58 REASONS FOR NOT VACCINATING ...... 59 DHB COMMUNICATION WITH PRACTICES VIA PHOS...... 60 KEY LESSONS AND RECOMMENDATIONS ...... 60 11. SCHOOL AGED CHILDREN ...... 62 THE SCHOOLS -BASED VACCINATION SYSTEM ...... 63 GIVING THE VACCINE IN SCHOOLS ...... 64 Consenting ...... 64 Giving the vaccine...... 65 CATCH -UP CLINICS ...... 66 SECOND AND THIRD DOSES ...... 66 REASONS FOR NOT VACCINATING ...... 67 VACCINATION COVERAGE BY AGE FOR SCHOOL CHILDREN ...... 67 KEY LESSONS AND RECOMMENDATIONS ...... 69 12. 18-19 YR OLDS ...... 71 REASONS FOR NON -IMMUNISATION ...... 72 KEY LESSONS AND RECOMMENDATIONS ...... 73 13. OUTREACH SERVICES ...... 75 OUTREACH DATA ...... 75 REFERRING TO OUTREACH FROM PRIMARY CARE ...... 76 WHAT PROPORTION OF REFERRED CHILDREN WERE VACCINATED? ...... 76 WHAT WORKED IN COMMUNITY CLINIC AND MOBILE VACCINATION SERVICES ?...... 78 COST OF OUTREACH ...... 81 KEY LESSONS AND RECOMMENDATIONS ...... 81 14. 4TH DOSE ...... 83 15. HAS THE PROGRAMME ACHIEVED ITS COVERAGE OBJECTIVES ...... 84
THIS SECTION REPORTS ACHIEVED PROGRAMME COVERAGE AGAINST TARGETS AND EXAMINES DELIVERY OF VACCINATIONS TO THESE GROUPS ...... 84 ACHIEVED COVERAGE AGAINST TARGETS ...... 84 VIEWS ABOUT THE PROGRAMME FROM NRAG ...... 85 COVERAGE BY DEPRIVATION ...... 86 COVERAGE BY ETHNICITY CONTROLLING FOR DEPRIVATION ...... 86 DELIVERY TO MAORI ...... 89 Coverage...... 89 Maori uptake of MeNZB TM ...... 89 Understanding Maori coverage ...... 91 A view from the community...... 93 National Advisory Group perspectives on Maori coverage...... 94 DELIVERY TO PACIFIC ...... 96 Understanding Pacific coverage...... 96 16. OTHER FACTORS INFLUENCING PROGRAMME SUCCESS ...... 98 NATIONAL PLANNING AND COMMUNICATIONS ...... 98 DHB CHARACTERISTICS ...... 99 School decline rates predict overall coverage ...... 100 Coverage weakly related to time a DHB has been vaccinating ...... 100 Overall Coverage not related to DHB size ...... 100
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Other DHB characteristics ...... 101 INCREASE DELIVERY OF DOSE 2 AND DOSE 3 ...... 101 CHARACTERISE GOOD INTENDERS AND ADDRESS ANY ACCESS BARRIERS ...... 102 17. DISCUSSION OF THE VALIDITY OF THE PROGRAMME LOGIC ...... 104 18. KEY LESSONS AND RECOMMENDATIONS ...... 109 Analysis of coverage data ...... 109 Vaccine control and distribution...... 109 Setting up the Programme...... 109 Communications and media...... 110 Community Awareness Raising...... 110 Under 5s...... 111 School aged children...... 112 18 – 19 year olds...... 113 Outreach ...... 114 Other considerations...... 115 CONCLUSION ...... 116 GLOSSARY ...... 117 APPENDICES ...... 118 CAR SURVEY ...... 118 GP SURVEY ...... 123 PHO SURVEY ...... 123 PHN SURVEY ...... 140 OUTREACH SURVEY ...... 140 DHB SURVEY ...... 152 CATI <5 S ...... 160 HH SURVEY ...... 175
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Figures
Figure 1 Incidence of Meningococcal disease 1990-2004 ...... 14 Figure 2 Coverage rates by DHB at 30 June 2006 ...... 21 Figure 3 Impact of adjusting for ethnicity miscoding ...... 25 Figure 4 Impact of Programme in Northern Region (Phase 1 and Phase 2) ...... 26 Figure 5 Impact of Programme excluding Northern Region (Phase 3)...... 26 Figure 6 Total clippings and number of negative clippings 1/1/2004 – 30/6/2005 .... 44 Figure 7 Clippings versus key Programme events in 2004 ...... 45 Figure 8 Media exposures versus uptake for Waikato ...... 46 Figure 9 Under 5 dose 3 vaccination uptake by DHB ...... 54 Figure 10 Under 5 decline in coverage between dose 1 and dose 3...... 58 Figure 11 5-17 dose 3 vaccination uptake by DHB...... 62 Figure 12 Coverage versus decline rates ...... 65 Figure 13 Coverage by age in years for children aged 5 -17 ...... 68 Figure 14 Coverage by age in years for Maori children aged 5 -17...... 68 Figure 15 18-19 dose 3 vaccination uptake by DHB...... 71 Figure 16 Average Cost per Reported OIS Vaccination by DHB...... 81 Figure 17 Coverage by Deprivation for initial cohort...... 86 Figure 18 Coverage by deprivation by ethnicity for 6w – 5 yr olds ...... 87 Figure 19 Coverage by deprivation by ethnicity for 5-17 yr olds...... 88 Figure 20 Coverage by deprivation by ethnicity for 18-19 yr olds...... 88 Figure 21 Dose 1 uptake for children aged 0-4, all DHBs ...... 90 Figure 22 Associations with DHB coverage...... 99 Figure 23 Revised Programme Logic ...... 108
Tables
Table 1 MeNZB TM vaccination coverage rates by age and ethnicity...... 18 Table 2 Vaccination coverage by age, ethnicity, current age. initial cohort ...... 19 Table 3 Revised coverage figures after ethnicity adjustment – Model 1...... 24 Table 4 Revised coverage figures after ethnicity adjustment – Model 2...... 24 Table 5 Programme development timeline ...... 28 Table 6 Programme start dates by DHB...... 32 Table 7 Summary of Indicators for the communications programme ...... 42 Table 8 Major themes and discourse in print media...... 45 Table 9 Coverage for under 5s, dose 1 and dose 3, with ethnicity adjustment...... 53 Table 10 Under 5 vaccination uptake phases...... 54 Table 11 Clinicians views on reasons for declining...... 59 Table 12 Clinicians concerns about giving MeNZB at 6 weeks...... 59 Table 13 Coverage for 5 – 17 yr olds dose 1 and dose 3 ...... 62 Table 14 Coverage for 18-19 yrs olds (no adjustment) ...... 71 Table 15 Northland Outreach referrals for dose 1...... 77 Table 16 Achieved coverage versus targets...... 84 Table 17 Coverage for different groups showing effect of adjustment, by ethnicity.. 89 Table 18 Predictors of vaccination completion...... 92 Table 19 Practice characteristics by % Maori patients...... 93
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Executive Summary
Background
New Zealand is experiencing an epidemic of group B meningococcal disease. The epidemic started in 1991. As case numbers increased a control and prevention plan was developed and implemented. When case numbers continued to increase a decision was made to develop a vaccine for the New Zealand strain of group B Neisseria meningitidis that was responsible for 75% of cases. This report evaluates the implementation of the National Meningococcal B Immunisation Programme (the Programme) that aimed to vaccinate 90% of the children and young people aged under 20 years old with 3 doses of the vaccine between July 2004 and June 2006. The Programme was delivered by District Health Boards (DHB) through their Public Health Nurse (PHN) workforce, which delivered vaccinations to school children, and through primary health care providers who delivered vaccinations to all other eligible people.
The evaluation is based on data from coverage reports supplied by the Ministry of Health from the National Immunisation Register (NIR), independent analyses of NIR data, case studies in particular DHBs, focus groups with Ministry of Health staff and other key stakeholders, and a series of surveys of DHB project managers, general practices, PHNs and organisations providing awareness raising or outreach immunisation services. Two surveys of vaccination clients were conducted: a telephone survey to explore vaccination issues for 250 children under 5 yrs old and a household survey of 500 households.
Coverage
1. By the 30 th June 2006 80% of children and young people aged under 20 years old had received three doses of MeNZB TM . Table E1 shows coverage by age, ethnicity and number of doses.
2. Coverage rates may be calculated for the initial cohort of children and young people that were eligible for vaccination at the time the Programme commenced, allowing for the different start dates in each DHB. Table E2 shows these coverage rates by age and ethnicity, for dose 3.
3. A comparison of ethnicity coding on PHO registers with ethnicity coding on school consent forms showed that primary care significantly under-codes Maori ethnicity. An adjustment for primary care under-coding of Maori ethnicity raises the number of Maori immunised in primary care. The effect of this adjustment on estimated coverage rates is shown in Table E3.
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Table E1 Vaccination coverage by age, ethnicity and dose, current age
n Dose 1 Dose 2 Dose 3 Current age 6w-4y 278402 247,232 89% 231,606 83% 210,294 76% 5-17y 786270 708,436 90% 695,515 89% 673,827 86% 18-19y 121680 76,571 63% 71,305 59% 65,073 54% Total 6w-19y 1186352 1,032,239 87% 998,426 84% 949,194 80% Ethnicity 6w-4y Maori 74716 55,682 75% 50,023 67% 42,718 57% Pacific 28759 27,450 95% 25,621 89% 23,023 80% Other 174927 164,100 94% 155,962 89% 144,553 83% 5-17y Maori 182350 162,585 89% 157,690 87% 149,925 82% Pacific 66540 68,991 104% 67,495 101% 64,394 97% Other 537380 476,860 89% 470,330 88% 459,508 86% 18-19y Maori 22590 11,958 53% 10,249 45% 8,542 38% Pacific 8350 6,214 74% 5,680 68% 4,973 60% Other 90740 58,399 64% 55,376 61% 51,558 57%
Table E2 Vaccination coverage by age, ethnicity, initial cohort
Ethnicity Age group Maori Pacific Other All 6w-4y 64% 90% 91% 84% 5y-17y 79% 90% 84% 83% 18y-19y 20% 29% 38% 34% All (6w-19y) 70% 85% 80% 78%
Table E3 Impact of ethnicity adjustment on coverage estimates
Dose 1 Dose 3 6w-4yr population NIR 1 % adjusted % NIR Adjusted Maori 74716 54659 73% 65486 88% 41632 56% 49739 67% Pacific 28759 26994 94% 27847 97% 22517 78% 23818 83% Other 174927 161728 92% 150048 86% 141869 81% 132461 76% 1NIR = National Immunisation Register
Impact
4. Because of the staggered roll-out there is a delay before the overall impact of the Programme can be measured. According to analyses reported by the Ministry of Health, there is preliminary evidence that the MeNZB TM vaccine is working and having an impact on the number of cases of epidemic strain meningococcal disease among children aged under 20 years.
5. These analyses also suggest that the vaccine appears to be providing a good level of protection to those people who are fully immunised. The Ministry of Health reports that a
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poisson regression model that can separate the effects of the vaccine from the effects of the natural progression of the epidemic, shows a five-fold reduction in disease rates among fully vaccinated New Zealanders. The model estimates vaccine effectiveness at 80%.
Setting up
6. The Programme was delivered by DHBs through a variation in their funding contracts. DHBs contracted for service delivery with providers within their areas. Each DHB had a Project Manager and a Project Sponsor, often a General Manager (GM). National coordination was provided by the Meningococcal Vaccination Strategy (MVS) team within the Ministry of Health. The specificity of the service agreement and oversight exercised by the Ministry over DHB implementation of the Programme was much tighter than with other service contracts.
7. The MVS team contracted 5 “relationship managers” to work closely with groups of DHBs to ensure DHBs were undertaking the necessary preparatory work, and to improve communication and sharing of useful experience. DHBs and Ministry staff considered this arrangement had worked very well.
8. Vaccine was purchased nationally from an international supplier, and licensing issues handled centrally.
9. Prior to the distribution of the vaccine a major effort was made to ensure general practices had adequate cold storage and vaccine management systems, with immunisation coordinators visiting individual practices. Funding was available for improving poorly functioning refrigerators. A contractor was appointed for vaccine distribution.
10. The vaccine management and distribution processes used in the Programme were highly effective and would form a solid basis for any future vaccination programme. By the end of June 2006 the difference between National Immunisation Register (NIR) doses recorded and vaccine allocated was only 1.6%. This is a spectacular result when compared with typical wastage rates of around 15%.
11. Throughout the Programme, an Independent Safety Monitoring Board (ISMB) established by the Health Research Council has reviewed MeNZB TM safety monitoring data. The members are international experts in vaccines, paediatrics and epidemiology. Following its final meeting the ISMB advised that they “found no evidence for any concern arising from the safety data generated from the monitoring of the MeNZBTM vaccine programme”.
12. The Programme was implemented with a staggered roll-out to allow a programme of adverse event surveillance to be implemented, so that high disease incidence areas were targeted first and to accommodate the requirements and availability of the NIR.
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Implementation
13. A comprehensive media strategy was developed nationally including testing of messages and tracking research. A wide variety of media were employed including TV, radio, print and bus shelters. Video materials were available for schools, and a range of leaflets and posters were available for distribution. This strategy was very successful in raising awareness of meningococcal disease and of the Programme.
14. To supplement national media activities DHBs were also required to contract for local Community Awareness Raising (CAR). This was planned to be delivered before the vaccination started in a given DHB, and was targeted to Maori, Pacific and low income areas. The impact of CAR was difficult to assess in a high intensity national media campaign. DHBs were pleased with the services provided. In case study DHBs, some practices reported increased vaccination requests after CAR activities.
15. Of the 42 CAR providers identified by DHBs, 23 provided responses to a questionnaire about their experiences. Providers were diverse, including PHOs, Marae Committees, Maori and Pacific Community Trusts, the Maori Women’s Welfare League and in house DHB provision. A third of respondents reported dedicating resources specifically to Maori CAR, with a quarter having resource specifically for Pacific CAR. Eighty percent of CAR providers said that staff received specific training, and they rated this training highly (3.9/5). Providers were slightly less satisfied with the time they had to set up their CAR services (3.3/5). CAR providers were generally happy with the liaison they had with DHBs, PHOs, and primary care (all 3.7/5).
16. The National Rollout Advisory Group considered that Maori visibility in the public profile of the Programme could have been greater. DHB Programme Managers advised contracting with some Maori providers took longer than expected. In any future vaccination campaign sufficient time should be allowed for consultation with Maori, at both a local and national level. Maori key influencers should be engaged early in campaign development. Maori clinical champions should be engaged and have a high profile.
Under 5s
17. The Programme was the first test of the National Immunisation Register. The NIR is a centrally held database of immunisation records. Practice Management Systems (PMS) were updated so they could upload immunisation data to the NIR. Despite initial teething difficulties the NIR is now integrated into general practice clinical and business processes. The level of national reporting now available on immunisation coverage far exceeds what was available previously. However, the feedback of data to practices still requires some fine tuning.
18. All practices used practice registers to identify children eligible for immunisation. Practices typically employed three attempts to invite a client to an immunisation, either by letter or phone call. Alerts were also attached to the patient record in the PMS to facilitate
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opportunistic immunisation and encourage communication with caregivers when they attended for other reasons.
19. The practice survey showed that practically all (91%) practices gave immunisations for “drop ins” i.e. without an appointment, with 87% feeling that this was an effective method of vaccination. Twenty-two percent of those surveyed operated a “drop-in clinic” at special times, where children are seen without appointments. Twenty-eight percent felt this was an effective method of vaccination. Seventy-four percent of practices operated a vaccination clinic for which parents had to make an appointment. Of these practices, 72% felt this was effective.
20. Practices estimated that the decline rate for MeNZB TM vaccination for children under 5 was 8%, compared with 5% for other childhood vaccinations.
21. While workloads were high, compounded by a heavy flu season, practices generally coped well. There were no significant problems administering the vaccine.
22. DHBs also contracted Outreach Immunisation Services (OIS). When general practices had identified that a child was not responding to invitations to be vaccinated they referred the child to an OIS provider. The OIS would contact the child and encourage the family to get them vaccinated, providing information, facilitating appointments, providing transport, or rarely, administering vaccinations in the home.
23. The average number of referrals per practice was 13. Forty percent of practices did not report refering to Outreach Immunisation Services.
School age children
24. The school programme was supported by the Schools Based Vaccination System (SBVS). This was a separate database that was pre-loaded with the names of all school children. All children were given consent forms that were completed at home and returned to school. Data from the SBVS were loaded into the NIR regularly so that the NIR maintained a complete record of all immunisations that were given.
25. The schools immunisation campaign was a major logistical exercise that was successfully implemented. High coverage levels were achieved, 86% overall, and 96% for Pacific children. It was thought that high coverage rates were achieved because schools have a captive audience and the infrastructure to support 100% coverage, for example class by class attendance at the immunisation venue.
26. Even though considerable work was done to design an easy-to-use consent form it was generally regarded as too complicated. Approximately one quarter were not completed correctly and a lot of nurse time was used completing these. Forms should be as simple as possible, and not appear complex. A significant field test of forms for any future vaccination project is recommended.
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27. Managing the volume of consents was a challenging task. Some consent forms were not able to be located when required. Consideration could be given to scanning consents and using electronic systems (mobile computers) for recording information.
28. Some parents did not have enough information. The use of school information evenings is a sensible way to provide this, with expert advice available, and has the added benefit of contributing to community awareness raising.
29. Most people are happy to have their children immunised at school. The average decline rate was 8.5%. Only a very small proportion of these people preferred their GP to give the vaccination.
30. Nine percent of children are absent on any single day. Catch-up clinics are thus an essential part of any schools based vaccination strategy.
31. The SBVS IT infrastructure has enhanced the capacity of PHNs to deliver vaccinations. It is now fully functional and should be used for other vaccination programmes. Consideration should be given to methods for maintaining the knowledge and skills of the people who used this system.
18-19 yr olds
32. The lowest coverage rates achieved were those for young people aged 18-19, 54%, based on current age. For the children eligible for vaccination when the Programme commenced the coverage was 34%. It was planned that vaccinating young people aged less than 20 but who were not attending school, would be undertaken by primary care, predominantly general practices, but also including clinics at educational institutions and workplace clinics. The highest dose 3 coverage rate was achieved in Otago DHB with a large student population, and some recent well-publicised cases of meningococcal disease.
33. There was a general feeling from many providers and managers that not enough planning and resources had been devoted to developing strategies for vaccinating the 18-19 year old group.
Outreach
34. One of the key strategies for immunising the hard to reach was the funding of Outreach Immunisation Services (“OIS”) for MeNZB TM . Outreach services are already funded by the National Immunisation Programme for the delivery of the immunisations on the childhood immunisation schedule. As suggested in the Ministry guidelines to DHBs, MeNZB TM Outreach services built on existing capacity rather than establishing new services. Because of the explicit prioritisation of Maori and Pacific children, MeNZB TM OIS contracts were often awarded to existing Maori OIS providers.
35. The data available on Outreach service provision was very variable and limits an assessment of impact. Much better reporting can be reasonably expected, even of newly
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established organisations, and should be required in any future vaccination programme that includes outreach provision.
36. DHB reports suggest that around 30,000 or 1% of the 3 million vaccinations were given by Outreach. This represents 4.5% of the vaccinations given to children under 5. Other data sources (Provider survey results, GP referral numbers and PHO estimates) suggest smaller numbers.
37. The variable reporting suggests building some functionality into the NIR for supporting the registering and tracking of outreach referrals. This could also improve the referral rate to OIS from general practice. This could be easily done with a “referral to outreach” immunisation claim. These “claims” could then be collated and referred to the appropriate outreach provider, or regional coordination service.
38. To assist outreach providers manage referrals within their organisations a free web based application could be developed and provided to any group that wanted to use it. This would automatically provide remote access to client management tools (checking status, recording an immunisation given) through a mobile internet connection. This application could link directly to the NIR.
39. Outreach vaccination is expensive, approximately $240 per vaccination given. The role of Outreach Immunisation as a stand-alone service could be examined in the context of the emerging need for a generic home health visitor.
4th dose
40. Final data from the clinical trials demonstrated that following dose 3, 53% of infants (enrolled aged 6 to 10 weeks) developed a four-fold rise in bactericidal antibody titres. Additional data showed that a fourth dose, administered at 10 months of age, raised this percentage to 82%. A fourth MeNZB TM dose was licensed in January 2006 for all infants who received their first dose before they were 6 months old, and primary care providers were asked to administer this vaccination to eligible children.
Has the programme reached its objectives?
41. This evaluation is concerned with the extent to which the Programme achieved its coverage objectives. The overall goal of the Meningococcal Vaccine Strategy is the control of the meningococcal disease epidemic in New Zealand with a target of reduction of at least 70% cases of the New Zealand strain of group B meningococcal disease in under 20 year olds. Whether this is likely to have been achieved will only become clear when analyses of disease rates have been undertaken, adjusting for the likely natural course of the epidemic. According to analyses reported by the Ministry of Health, there are early signs of a significant reduction in case numbers.
42. Target coverage rates of 90% were only achieved for Pacific children aged 5-17. The targets set were, rightly, very ambitious, and this result is a significant achievement.
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43. Maori vaccination coverage did not reach the same levels as “Other”. Coverage of children aged 5-17 was 4% lower; for children aged 6w-4y was 9% lower (26% lower before adjustment for ethnicity under-coding of Maori in primary care); and for Maori young people aged 18-19 was 19% lower (no adjustment undertaken).
44. Because of the current distribution of meningococcal disease the likely impact of the achieved coverage rates will be to reduce the burden of disease on the targeted groups, and contribute to an overall reduction in inequalities.
Other factors influencing coverage
45. An analysis of associations between DHB characteristics and coverage showed that within a DHB, school decline rates predicted overall coverage. Coverage was only weakly related to time a DHB has been vaccinating and overall coverage was not related to DHB size. There was a negative relationship between overall coverage and the number of Maori in a DHB, as expected based on known lower dose 3 coverage for Maori, in children aged 5-17 and 18-19. However the percentage of Maori in a DHB is positively associated with Maori coverage.
Conclusion
46. Overall the Meningococcal B Immunisation Programme has been implemented very successfully, and is a tribute to the Meningococcal Vaccination Strategy team, and the large numbers of other health workers who have contributed to its success. In the historical context of low vaccination rates in New Zealand and high levels of anti- immunisation activity, it has achieved a good result. The final coverage rates of 80% (78% of the “initial cohort”) are likely to increase slightly as the Programme has been extended from the original June 30 until December 2006 for children 5-19 years and until 2009 for children less than 5 years old. The major disappointment of the Programme was the lower coverage achieved for Maori despite the strong emphasis throughout the Programme on achieving high coverage rates for Maori.
47. Key components have been put in place for future vaccination programmes, in particular vaccine management procedures, the NIR, and an expanded range of outreach immunisation services. Most valuable is probably the experience of numerous individuals in the health sector who have been directly involved in delivering the Programme. In the event of the requirement for another mass vaccination campaign, for example for pandemic influenza, the country is better placed than it has ever been to deliver vaccinations.
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1. Background to epidemic and the MVS
New Zealand is now in the 17 th year of a group B meningococcal disease epidemic. The epidemic started in 1991, and in 1995, as case numbers continued to increase, a national plan for the control and prevention of meningococcal disease was developed. The measures adopted included increased surveillance with the delivery of prophylactic antibiotics to case contacts, public awareness campaigns about hygiene and early diagnosis, and encouraging GPs to administer parenteral antibiotics to suspect cases.
Figure 1 Incidence of Meningococcal disease 1990-2004
Meningococcal case strains (typed) 1990-2004
500 Group C Vaccine Trials 450 Started Group B, other
400 Group B - epidemic strain below the line denotes pre - epidemic levels 350 Vaccine Rollout 300
250
200
150
100
50
0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Year
(Source: Meningococcal disease in New Zealand 1991-2004 ESR May 2005) Although these measures were undoubtedly effective, the incidence of disease remained high and, following a meeting with the World Health Organisation in 1998, a decision was made to develop a vaccine for the New Zealand strain of group B Neisseria meningitidis that was responsible for most of the cases (consistently around 75%). The vaccine was subsequently developed by the Chiron Corporation and the Norwegian Institute of Public Health. Vaccine trials were conducted in New Zealand in 2002. These concluded that, using a three dose schedule, the vaccine was safe and likely to be effective, and a decision was made to administer the vaccine to all children and young people aged less than 20 years old. The Meningococcal B Immunisation Programme is the largest vaccination programme undertaken in New Zealand.
While all New Zealanders are at risk of developing meningococcal disease those most at risk are Maori and Pacific children and children living in deprived areas. These are also the children who historically have been least likely to be reached by immunisation programmes. The Meningococcal B Immunisation Programme aimed to reduce past disparities in immunisation coverage and achieve an equal level of protection and coverage for all. The
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goals and objectives for the Programme were designed to ensure this is achieved by focusing attention, effort, and resources on reaching those most at risk. The goal of the Programme was to implement an effective national immunisation programme for the New Zealand epidemic strain of group B meningococcal disease that reduces inequalities for Maori and Pacific people and achieves 90% coverage for all under 20 year olds.
Primary Objectives
Coverage of Maori 0-19 year olds Coverage of Pacific 0-19 year olds Coverage of children under 5 year olds Coverage of 0-19 year olds living in NZDep 9 and 10 areas
Targets
90% of Maori under 5 year olds fully vaccinated 90% of Maori at school fully vaccinated 90% of Maori out of school fully vaccinated 90% of Pacific under 5 year olds fully vaccinated 90% of Pacific at school fully vaccinated 90% of Pacific out of school fully vaccinated 90% children under 5 year olds fully vaccinated 90% 0-19 year olds living in NZDep 9 and 10 areas fully vaccinated
Secondary Objective
Coverage of non- Maori non-Pacific 0-19 year olds
Targets
90% of non- Maori non-Pacific at school fully vaccinated 90% of non- Maori non-Pacific out of school fully vaccinated
The role of this evaluation is to assess how well these objectives were achieved. The overall goal of the Meningococcal Vaccine Strategy as a whole is the control of the meningococcal disease epidemic in New Zealand with a target of reduction of at least 70% cases of the New Zealand strain of group B meningococcal disease in under 20 year olds. Establishing whether the Programme has achieved this goal is not within the scope of this evaluation, and is the subject of a separate piece of research.
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2. Evaluation overview
This report presents an evaluation of the national roll-out of the Meningococcal B Immunisation Programme. The evaluation commenced in February 2005 and follows an evaluation of the initial roll-out that covered the period July 2004 to January 2005 1 (the “initial roll-out evaluation”).
The objectives of the evaluation are to:
describe the Programme, including the context in which it has been implemented, the main delivery strategies employed, any problems that arose during delivery, and any changes made as a result
describe the approaches different providers are taking in different settings, identify what works well, and key lessons that can be learned to improve current Programme delivery – especially to Maori and Pacific peoples, children under five and children from low income families
identify the key lessons that have been learned from Programme implementation to assist subsequent immunisation programmes and agree on a method to convey these to the respective groups affected, such as the Ministry of Health, District Health Boards, (DHBs) Primary Health Organisations (PHOs) and General Practices
determine whether the Programme has met its objective to implement an effective national immunisation programme for the New Zealand epidemic strain of group B meningococcal disease that reduces inequalities for Maori and Pacific people and achieves 90% coverage for all under 20 year olds.
identify and analyse the factors that explain the degree to which the Programme has met or failed to meet its objective, and to explain any variations between different areas and different population groups as far as it possible, and identify ways that this can be rectified and the difficulties avoided in any future phases of the implementation
test the validity of the Programme logic
disseminate the key findings of the Evaluation in a way that is accessible for DHBs and other organisations interested in the results of the Evaluation.
To meet these objectives a wide variety of qualitative and quantitative research approaches have been utilised. The evaluation is based upon an analysis of data from:
four case studies based in three specific DHBs involving interviews with families and representatives from the DHB, and PHOs and other stakeholders. Two focussed on the primary care programme and two on the schools based programme. A fifth case study examined outreach and community clinics in the four Northern DHBs.
1 Evaluation of Initial Roll-out of Meningococcal B Immunisation Programme - Overview Report. 2005, Phoenix Research.
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a survey of immunisation providers (GPs, PHNs, Outreach and Community Awareness Raising providers)
a survey of practices’ views and concerns regarding implementing a fourth dose
a telephone survey of clients of the Programme completed in September 2005
a household survey conducted in April 2006
ongoing analyses of routine data collected by the National Immunisation Register
A document review, including DHB reports and Project Implementation Plans
an analysis of media coverage of the Programme and related issues.
a series of interviews with DHB relationship managers, external media stakeholders and members of the National Roll-out Advisory Group
An additional survey was completed to explore any issues practices had with implementing the fourth dose of MeNZB.
Additional data sources include:
Tracking Research
Evaluation of the initial roll-out
Safety monitoring data
A study of the NIR accuracy and completeness
An earlier report summarised findings from the process stage of the evaluation, based predominantly on national data reports and the first three cases studies. This final evaluation report draws on data from all the above sources, and is a stand-alone document.
Meningococcal B Immunisation Evaluation Final Report p 17 CBG Health Research November 2006
3. Summary of coverage and impact
Overall Programme coverage
Data extracted from the National Immunisation Register, supplied by the Ministry of Health, shows that by the 30 June 2006 the Programme had delivered three doses of vaccine to 80.0% of the target age group, Over a million children received the first dose of vaccine (87.0%). Coverage for school aged children (5-17 years old) was 85.7% and for children aged 6 weeks to 4 years it was 75.5%. These figures are based on the age of the child at the beginning of the next month (i.e. July 2006).
The table below shows coverage figures by different age groups and ethnicities, using current age.
Table 1 MeNZB TM vaccination coverage rates by age and ethnicity n dose 1 dose 2 dose 3 Current age 1 6w-11m 49552 43,175 87% 33,944 69% 23,039 47% 1-4y 228850 204,057 89% 197,662 86% 187,255 82% 6w-4y 278402 247,232 89% 231,606 83% 210,294 76% 5-17y 786270 708,436 90% 695,515 89% 673,827 86% 18-19y 121680 76,571 63% 71,305 59% 65,073 54% Total 2 6w-19y 1186352 1,032,239 87% 998,426 84% 949,194 80% 6w-11m Ethnicity Maori 13676 10,467 77% 7,705 56% 4,698 34% Pacific 5259 4,618 88% 3,530 67% 2,396 46% Other 30617 28,090 92% 22,709 74% 15,945 52% 1-4y Maori 61040 45,215 74% 42,318 69% 38,020 62% Pacific 23500 22,832 97% 22,091 94% 20,627 88% Other 144310 136,010 94% 133,253 92% 128,608 89% 6w-4y Maori 74716 55,682 75% 50,023 67% 42,718 57% Pacific 28759 27,450 95% 25,621 89% 23,023 80% Other 174927 164,100 94% 155,962 89% 144,553 83% 5-17y Maori 182350 162,585 89% 157,690 87% 149,925 82% Pacific 66540 68,991 104% 67,495 101% 64,394 97% Other 537380 476,860 89% 470,330 88% 459,508 86% 18-19y Maori 22590 11,958 53% 10,249 45% 8,542 38% Pacific 8350 6,214 74% 5,680 68% 4,973 60% Other 90740 58,399 64% 55,376 61% 51,558 57% NZDep 9-10 6w-4y 69471 65,635 95% 60,298 87% 53,197 77% NZDep 1-10 2 6w-4y 275685 247,232 90% 231,606 84% 210,294 76% 1 Defined by child’s age at beginning of next month (i.e. 1 July 2006) . 2 Estimated populations are based on projections from StatsNZ. Total (NZDep 1-10) population differs from the Total (Ethnicity) as they are calculated differently by StatsNZ.
Meningococcal B Immunisation Evaluation Final Report p 18 CBG Health Research November 2006
Coverage cohorts
Programme reporting was complicated by the fact that coverage reports have to apply to a specified cohort (group) of children, and this cohort can be defined in different ways.
Current age The previous table reported coverage for the cohort of children that would be eligible for immunisation on the 1st of July 2006. This cohort has been called the “current age” cohort. Coverage figures for the current age cohort report the percentage of children that are in the eligible age group that have been immunised at the time of reporting. Thus a current age coverage report produced on a given day reports the number of children in the eligible age group that have received vaccinations up to that day.
Because a baby who has just become eligible for vaccination cannot have had all three vaccinations, the maximum possible three dose coverage is less than 100% of the number of eligible children. Because vaccination eligibility starts at six weeks old and the shortest period of time for all three vaccinations to be given to babies is 15 weeks, it is not logically possible for children under 21 weeks old to have completed the three dose vaccination schedule.
Taking this into account, adjusted targets for 6w-11m olds have been calculated. Achieving 90% coverage for those eligible by age in the 6w-11m population is equivalent to 75% for dose 2 and 60% for dose 3. The adjusted targets for 6w-4y are 90% dose 1, 88% dose 2, 84% dose 3.
Initial cohort For the purposes of reporting on the performance of providers in delivering vaccinations to the cohort of children eligible for vaccination when the Programme started, the “initial cohort” may be preferred. This cohort is defined as the group of children eligible for vaccination at the date the Programme commenced. The birth dates used to define this cohort will vary from DHB to DHB. The birth dates used to define these cohorts also vary according to whether a child received their first immunisation at school or in primary health care, as the dates for starting these vaccination campaigns were different in each DHB.
The following table shows these coverage rates by age and ethnicity, for dose 3.
Table 2 Vaccination coverage by age, ethnicity, current age. initial cohort Ethnicity Age group Maori Pacific Other All 6w-4y 63.5% 89.5% 91.2% 83.6% 5y-17y 78.6% 90.5% 84.1% 83.4% 18y-19y 19.7% 29.2% 37.6% 33.7% All (6w-19y) 69.8% 85.3% 80.4% 78.3%
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The overall coverage for the initial cohort was 78.3%. The coverage figures in this table are different from those in the current age cohort because:
1. Babies born after the Programme commenced appear in the current age cohort but not in the initial cohort
2. Young people that turn 20 after the Programme commenced appear in the initial cohort but not in the current age cohort
3. As children and young people age they become eligible for vaccination by different provider types (primary care and schools-based vaccinations), with different effectiveness at giving vaccinations.
As an illustration of these effects, many of the young people aged 18-19 in the current age cohort will have received vaccinations at school. However, none of the young people in the initial cohort will have received vaccinations at school. As schools delivered vaccinations to young people aged 16-17 at a higher rate than primary care delivered vaccinations to young people aged 18-19, the 18-19 current age cohort has higher vaccination rates than the 18-19 initial cohort, 54% compared to 34%.
The initial cohort has been used in this evaluation when plotting DHB coverage figures against time since commencement of the Programme, and for analyses of coverage by ethnicity by deprivation.
Age at first dose A third possible method of defining the cohort of children for which to report coverage is to define eligibility on the basis of the age of children when they received their first dose. This method is not used in this report.
Meningococcal B Immunisation Evaluation Final Report p 20 CBG Health Research November 2006
Coverage by DHBs
The range of coverages achieved by each DHB for children the current age cohort (for each dose) is shown in the following graph. DHBs are listed in the order that they started delivering the programme. DHBs have been delivering the Programme for different periods of time. The highest coverage rates were achieved in Counties Manukau where vaccinations have been delivered for 102 weeks. Nelson Marlborough has been delivering vaccinations for 53 weeks.
Figure 2 Coverage rates by DHB at 30 June 2006
Coverage by DHB by dose, data up to 30th June 2006
50% 60% 70% 80% 90% 100%
National
Counties Manukau
Waitemata
Auckland
Northland
Waikato
Lakes
Bay of Plenty
Tairawhiti
Taranaki
Hawkes Bay
Whanganui
Mid Central
Hutt Valley
Capital and Coast
Wairarapa
Otago
Southland
South Canterbury
Canterbury
West Coast
Nelson Marlborough
Dose 1 Dose 2 Dose 3
Meningococcal B Immunisation Evaluation Final Report p 21 CBG Health Research November 2006
Adjustments for primary care ethnicity coding
When early results from Phase 2 of the Programme suggested very low uptake of vaccinations for Maori aged under 5 in Waitemata DHB (and others) the possibility that Maori were not enrolled in primary care was considered. An examination of the pooled registers from Waitemata PHOs however showed that 101% of the estimated population was enrolled in a PHO. Analysis for the entire country showed that 99.3% of children aged under 5 were enrolled in a PHO. Even if all the un-enrolled children were Maori it was not mathematically possible for this to explain low vaccination rates.
An examination of the ethnicity composition of submitted registers against known DHB population structure revealed that it was highly likely that Maori were being misclassified as being of Pacific, or Other ethnicity.
As low vaccination rates for Maori aged under 5 continued as the Programme rolled out nationally it became important to the assessment of the effectiveness of Programme that this ethnicity misclassification was quantified.
Methods Ethnicity data for the Programme was collected in two different ways:
For children at school it was collected via a consent form completed by parents. The ethnicity question was asked in the same way as the census and a person could nominate up to six ethnicities (although only 3 were recorded on the NIR).
For children under 5 (and out of school) it was uploaded from practice management systems. For a variety of reasons, often only one ethnicity is recorded on these systems 2
Data were also available from the PHO registers for all children and young people enrolled in a PHO in New Zealand. These data are taken from practice registers. The registers included the ethnicity recorded for each child.
The ethnicity recorded for a MeNZB TM vaccination on the NIR was compared to the ethnicity recorded in these PHO population registers for the same child (using NHI numbers to match children).
It was found that for children aged less than 5 years old ethnicity was much the same in the two places. However for children aged between 5 years and 15 years (i.e. where the ethnicity on the NIR vaccination record had come from the school record) there were significant differences. Children were much less likely to be classified as Maori in the PHO record, indicating under-coding of Maori ethnicity in practice data. Pacific ethnicity also appeared to be slightly under-coded.
2 An internal paper completed by a Ministry analyst identified that multiple ethnicities were 10 times more frequent on the census than on PHO registers
Meningococcal B Immunisation Evaluation Final Report p 22 CBG Health Research November 2006
Under the assumption that the ethnicity data on the schools consent from were correct, the primary care ethnicity data were adjusted by the extent of ethnicity misclassification in each DHB. When supplied with
the total number of immunisations given for children aged 6w-4yr (by year) the number of immunisations given for children aged 6w-4yr classified as Maori the number of immunisations given for children aged 6w-4yr classified as Pacific these adjustments could be applied to estimate the number of Maori and Pacific children that received an immunisation, and the remaining children were then classified as “Other”.
Adjustment models Two models were used to estimate the extent of ethnicity misclassification in the 6w-4yr group, and to adjust for it. The modelling was undertaken by the Public Health Intelligence section of the Ministry of Health.
Both models used the differences between ethnicity recorded for 5-15 year olds on the NIR, and the PHO records for the same children, as a basis for estimating ethnicity misclassifications for 0-4 year olds
Model 1: This considered age as a covariate and calculated adjustment percentages to apply to each individual year of age for children under 5, by ethnicity and DHB.
Model 2: This was a simpler model that did not adjust for variations in the misclassification patterns by year of age that exist within the 5-15 data. Instead 5-15 children were treated as one age-group. This model calculated a single 0-4 adjustment percentage to apply to each ethnicity and DHB
This second model resulted in higher estimates of under-coding.
Impact on coverage estimates When the above procedure was applied it appeared that, compared to the data on school vaccination consent forms, primary care coding nationally 3 underestimates the number of patients aged 6w-4 that are Maori by about 19% in model 1 and 29% in model 2. The following two tables (Table 3 and Table 4) table show the impact of these adjustments on the overall coverage rate by ethnicity. In both tables the adjusted figures show Maori dose 1
3 National adjustments are calculated by applying the DHB adjustments to the data and then summarising it.
Meningococcal B Immunisation Evaluation Final Report p 23 CBG Health Research November 2006
coverage for children 6w-4y was actually higher than coverage for “Other”. In model 1 the dose 3 adjusted figures show Maori coverage is still 9% less than coverage for “Other”; in model 2 the dose 3 adjusted coverage for Maori is 4% higher than for “Other”.
Table 3 Revised coverage figures after ethnicity adjustment – Model 1
dose 1 dose 3 6w-4yr population NIR % adjusted % NIR Adjusted Maori 74716 54659 73% 65486 88% 41632 56% 49739 67% Pacific 28759 26994 94% 27847 97% 22517 78% 23818 83% Other 174927 161728 92% 150048 86% 141869 81% 132461 76% ALL Maori 279656 228959 82% 239786 86% 199697 71% 207804 74% Pacific 103649 102070 98% 102923 99% 91658 88% 92959 90% Other 803047 696361 87% 684681 85% 651822 81% 642414 80% 6w-17yr Maori 257066 217081 84% 227908 89% 191263 74% 199370 78% Pacific 95299 95875 101% 96728 101% 86722 91% 88023 92% Other 712307 638128 90% 626448 88% 600596 84% 591188 83% Note: Data as at 30 June 2006
Table 4 Revised coverage figures after ethnicity adjustment – Model 2
dose 1 dose 3 6w-4yr population NIR % adjusted % NIR Adjusted Maori 74716 54659 73% 73,247 98% 41632 56% 55652 74% Pacific 28759 26994 94% 32,841 114% 22517 78% 27541 96% Other 174927 161728 92% 137293.5 78% 141869 81% 122825 70% ALL Maori 279656 228959 82% 247546.8 89% 199697 71% 213716.6 76% Pacific 103649 102070 98% 107916.8 104% 91658 88% 96681.97 93% Other 803047 696361 87% 671926.5 84% 651822 81% 632778.5 79% 6w-17yr Maori 257066 217081 84% 235668.8 92% 191263 74% 205282.6 80% Pacific 95299 95875 101% 101721.8 107% 86722 91% 91745.97 96% Other 712307 638128 90% 613693.5 86% 600596 84% 581552.5 82% Note: Data as at 30 June 2006
The more conservative adjusters from Model 1 have been used in the remainder of this report. While the logic of the adjustment process seems sound, some of the results of Model 2 seem implausible, for example dose 1 Pacific coverage of 114%. However Model 2 does predict total numbers of Maori and Pacific children that closely match the known ethnicity distributions of DHB census data. Further work is required to examine this issue more closely; it has potential implications for the analysis of primary care data in many different areas.
Meningococcal B Immunisation Evaluation Final Report p 24 CBG Health Research November 2006
The following graph shows the impact of adjusting for these differences on national coverage rates for 6w-4yr olds, using Model 1. The estimated coverage for Maori aged 6w-4yr increases from 56% to 67%.
Figure 3 Impact of adjusting for ethnicity miscoding
Impact of adjustment for probable ethnicity miscoding (data to 30 June 2006)
100%
90%
80%
70%
60%
50% % coverage % 40%
30%
20%
10%
0% Maori Pacific Other Maori Pacific Other
DOSE 1 DOSE 3
NIR coverage figures Adjusted NIR coverage figures
Impact of the Programme
Because of the staggered roll-out there is a delay before the overall impact of the programme can be measured. According to analyses reported by the Ministry of Health, there is preliminary evidence that the MeNZB TM vaccine is working and having an impact on the number of cases of epidemic strain meningococcal disease among children aged under 20 years. The vaccine appears to be providing a good level of protection to those people who are fully immunised. Those people who are not immunised remain at greater risk of contracting the epidemic strain of meningococcal disease than those immunised.
The major challenge in assessing the impact of the vaccine is estimating what the likely course of the epidemic would have been without the mass vaccination campaign. The Ministry of Health reports that a poisson regression model that can separate the effects of the vaccine from the effects of the natural progression of the epidemic, shows a five-fold reduction in disease rates among fully vaccinated New Zealanders. The model estimates vaccine effectiveness at 80%.
The data for the Northern region is shown in the following graph of cases per month.
Meningococcal B Immunisation Evaluation Final Report p 25 CBG Health Research November 2006
Figure 4 Impact of Programme in Northern Region (Phase 1 and Phase 2)
Number of cases of epidemic strain meningococcal disease vs % dose 3 coverage for all individuals aged 6 weeks to 19 years in Northern Region 18 90%
16 80%
14 Start of 70% vaccination campaign 12 60%
10 50%
8 40%
Number Number of cases 50%
83% dose % dose 3 coverage 6 dose 3 3 coverage 30% coverage
4 20%
2 10%
0 0% Jul Jul Jul Jul Apr Apr Apr Apr Apr Oct Oct Oct Oct Jan Jun Jan Jun Jan Jun Jan Jun Jan Feb Mar Feb Mar Feb Mar Feb Mar Feb Mar Aug Sep Nov Aug Sep Nov Aug Sep Nov Aug Sep Nov Dec Dec Dec Dec May May May May May 2002 2003 2004 2005 2006
Unvaccinated/partially vaccinated Fully vaccinated % dose 3 coverage
The same data for all regions except the Northern region is presented in the next graph:
Figure 5 Impact of Programme excluding Northern Region (Phase 3)
Number of cases of epidemic strain meningococcal disease vs % dose 3 coverage for all individuals aged 6 weeks to 19 years in New Zealand excluding the Northern Region 30 90%
80% 25 70%
20 60%
50%
15 Start of vaccination 40% campaign 50% dose 3
Number Number of cases coverage % % dose 3 coverage 10 30% 77% dose 3 coverage 20% 5 10%
0 0% Jul Jul Jul Jul Apr Apr Apr Apr Apr Oct Oct Oct Oct Jan Jun Jan Jun Jan Jun Jan Jan Jun Feb Mar Feb Mar Feb Mar Feb Mar Feb Mar Aug Sep Nov Dec Aug Sep Nov Dec Aug Sep Nov Dec Aug Sep Nov Dec May May May May May 2002 2003 2004 2005 2006
Unvaccinated/partially vaccinated Fully vaccinated % dose 3 coverage
Meningococcal B Immunisation Evaluation Final Report p 26 CBG Health Research November 2006
Key lessons and recommendations
This section has presented a summary of coverage and impact; specific lessons and recommendations appear in later sections in relation to different components of the Programme. However, this section has highlighted the importance of understanding extent of ethnicity under-coding in primary care, and further work on this is strongly recommended.
R1 Further research should be undertaken to understand the extent of ethnicity under-coding in primary care.
Meningococcal B Immunisation Evaluation Final Report p 27 CBG Health Research November 2006
4. Description of Programme implementation
The following table presents a summary of the key events in the development and implementation of the MeNZB TM vaccination programme.
Table 5 Programme development timeline Date Event 1991 New Zealand’s group B meningococcal disease epidemic begins 1992 The Institute of Environmental Science and Research (ESR) defines strain of bacterium causing the epidemic 1997 March NZ government approves an initial $6 million towards prevention of meningococcal disease August Auckland Healthcare Services undertakes feasibility study of a New Zealand vaccine clinical trial 1998 September MoH meets with vaccine manufacturers and national and international advisors at the WHO to begin developing a strain-specific vaccine for NZ 2000 January Findings of a three year research project into risk factors of meningococcal disease; research influences government policy including health, education and housing Oct-Dec Delegations from vaccine manufacturers visit NZ December Requests for proposals sent to four collaborations of vaccine manufacturers 2001 Worst year of the epidemic to date – 650 cases and 26 deaths January New health sector structures come into being February Chiron Corporation, working with the Norwegian Institute of Public Health, selected as preferred providers Key policy document confirmed “Meningococcal Disease in NZ – Proposed Epidemic Control Strategy using Meningococcal B:4:P1.7b,4 Outer Membrane Vesicle Vaccine.” Leader of MVS appointed July MOH and Chiron Corporation sign a contract to develop a vaccine July Meningococcal Management Team formed December Cabinet decision on funding meningococcal programme 2002 January Health Minister Annette King announces funding of $100 million plus towards the MVS project. April Funding of $200 million over five years allocated to the MVS May Phase 1 clinical trial begins in Auckland- undertaken by University of Auckland; 75 adults involved October Phase 2 clinical trials begins; 600 children aged 8-12 years are involved in the first trial of this phase November Total number of deaths since the epidemic began reaches 200 December MoH announces delay to the expected launch of the proposed nationwide immunisation programme due to additional time needed to upscale the vaccine to produce the large volumes required. 2003 Disease rate 14.4 cases /100,000 540 cases, 13 deaths February Clinical trials involving 320 toddlers aged 16-24 months begins March Rollout options paper prepared for consultation groups (4 options) April Second consultation paper, with 3 more options and recommendation for NTS/STN; approval for under 16 month olds unlikely at start of roll out May Clinical trials involving 320 infants aged 6-8 months begins June Total number of cases since the epidemic began reaches 5000 June Paper advises MMT of preferred option All Together, North to South and South to North August Results of clinical trials of adults announced at Paediatric Society of NZ Annual Conference; results indicate the vaccine is safe and produces protective antibodies.
Meningococcal B Immunisation Evaluation Final Report p 28 CBG Health Research November 2006
October Vaccine upscale failure; prospect of more than100,000 doses First meeting National Rollout Advisory Group/s 2004 January PHOs come into existence January First shipment of MeNZB TM arrives – 200-250,000 doses January Clinical trials involving about 400 infants aged 6-10 weeks begin March Results of clinical trials of toddlers aged 16-24 months announced at the WHO/UNICEF Workshop on the expanded programme on Immunisation in the Pacific in Auckland; results continue to be encouraging. March Second shipment of MeNZB TM arrives March School immunisation database ready April Meningococcal Strategy published in NZMJ – Response to an Epidemic May Tentative date for first school-based immunisation June NZ Doctor article criticises likely waste of vaccine July Start 6mths-4 yrs and under 20 out of school in CM DHB July 7 Minister of Health announces provisional licensure of MENZB July 8 Licensure of vaccine gazetted July 18 NIR goes live in CM DHB July 19 Primary care and school based campaign commences. First vaccination of under-5 by GP in CM DHB 2006 January 4th dose added to MeNZBTM schedule for children who received their first dose before they were six months old
Contract with DHBs
The Programme was delivered by DHBs through a variation in their funding contracts. DHBs contracted for service delivery with providers within their areas. Each DHB had a Project Manager and a Project Sponsor, often at General Manager level. National coordination was provided by the Meningococcal Vaccination Strategy (MVS) team within the Ministry of Health. The MVS team contracted 5 “relationship managers” to work closely with groups of DHBs to ensure DHBs were undertaking the necessary preparatory work, and to improve communication and sharing of useful experience.
National vaccine purchase and safety monitoring
Vaccine was purchased nationally from an international supplier, and licensing issues handled centrally. An Independent Safety Monitoring Board was established to monitor any reactions to the vaccine from a number of sentinel GP practice sites, Emergency Departments and hospital discharge data.
Cold chain strengthened
Prior to the distribution of the vaccine a major effort was made to ensure general practices had adequate cold storage and vaccine management systems, with immunisation coordinators visiting individual practices. Funding was available for improving poorly functioning refrigerators. A contractor was appointed for vaccine distribution.
Meningococcal B Immunisation Evaluation Final Report p 29 CBG Health Research November 2006
Communications strategy
A comprehensive media strategy was developed nationally including testing of messages and tracking research. A wide variety of media were employed including TV, radio, print and bus shelters. Video materials were available for schools, and a range of leaflets and posters were available for distribution. To supplement these national media activities DHBs were also required to contract for local Community Awareness Raising (CAR). This was planned to be delivered before the vaccination started in a given DHB, and was targeted to Maori, Pacific people and people living in low income areas.
Delivered by General Practice and Public Health Nurses
The vaccination was delivered to school children by Public Health Nurses. Children under 5 and older youth no longer at school were vaccinated by general practices. DHBs worked with PHOs and practices in their areas to ensure that providers received information about the Programme and patient educational materials, produced nationally.
NIR and SBVS
The Programme was the first test of the National Immunisation Register (NIR). The NIR is a centrally held database of immunisation records. Practice Management Systems (PMS) were updated so they could upload immunisation data to the NIR. Each PMS also has it s own system of recording immunisations, monitoring rates and producing recalls. The school programme was supported by the Schools Based Vaccination System. This was a separate database that was pre-loaded with the names of all school children. All children were given consent forms that were completed at home and returned to school. These data were loaded onto the SBVS which was then used, along with a manual record on the physical consent form, to record immunisations as they were given. Data from the SBVS were loaded into the NIR regularly so that the NIR maintained a complete record of all immunisations that were given.
Data reported directly from the SBVS showed the coverage achieved in relation to school rolls. Reports from the NIR were based on age groups. As young people can leave school before they turn 17, the NIR reports for the 5-17 age group are only an approximate measure of the coverage of school aged children.
Outreach Services
DHBs were also required to contract Outreach Immunisation Services (OIS). When general practices had identified that a child was not responding to invitations to be vaccinated they referred the child to an OIS provider. The OIS would contact the child and encourage the family to get them vaccinated, providing information, facilitating appointments, providing transport, or rarely, administering vaccinations in the home. DHBs also contracted for other Outreach services to reach children not referred from general practice.
Meningococcal B Immunisation Evaluation Final Report p 30 CBG Health Research November 2006
Catch-up clinics
To deliver vaccinations to school children who did not receive them initially, or who missed their second or third vaccinations, DHBs were required to incorporate a range of catch-up clinics into their school immunisation delivery. Public Health Nurses returned at least once to each school after each vaccination was given to vaccinate children that had been initially missed. Additional catch up clinics were held at advertised community venues.
Additional activities
DHBs and PHOs could access regular (weekly) feedback on their vaccination coverage from the NIR throughout the Programme. The Ministry collated reports of coverage by DHB and sent them to DHBs each week. Some DHBs sent regular summary feedback to PHOs and practices.
In response to the observed vaccination rates, and the pattern of uptake, DHBs also instituted their own additional activities during the later stages of the Programme, including for example targeted advertising or the provision of mobile community clinics.
Rollout dates
A number of factors influenced the final rollout of the Programme. Vaccine was limited. When the roll-out was planned it was estimated that vaccine could be supplied at around 250,000 doses per month, provided there were no problems with production. Some regions had high rates of meningococcal disease and were natural first candidates for vaccinations. In addition, the National Immunisation Register was being progressively implemented, and it was important that this key Programme infrastructure was in place before vaccination commenced.
These considerations justified a staggered roll-out of the MeNZB™ by disease risk down the North Island and then from the bottom of the South Island.
The roll-out of the Programme had three “phases”. Phase 1 was the implementation of the Programme in Counties Manukau DHB and some adjacent census area units in Auckland DHB. This was followed by Phase 2 in Auckland, Waitemata and Northland. Phase 3 was the national rollout in the remaining DHBs. The key commencement dates for the Meningococcal Vaccine Strategy roll-out are shown in the following timeline. The immunisation campaign finished on 30 June 2006, The MeNZB TM vaccine remains available to children aged over 5 until the end of 2006. For children under 5 it remains available until 2009 or until disease rates indicate vaccinating can end sooner.
Meningococcal B Immunisation Evaluation Final Report p 31 CBG Health Research November 2006
Table 6 Programme start dates by DHB DHB Primary care Schools Phase 1 Counties Manukau and “eastern corridor” of Auckland DHB 19-Jul-04 2-Aug-04 Phase 2 Auckland 8-Nov-04 Waitemata 1-Nov-04 Northland 22-Nov-04 Phase 3 Auckland 21-Mar-05 Waitemata 17-Mar-05 Northland 2-May-05 Waikato 1-Feb-05 21-Mar-05 Lakes 7-Feb-05 2-May-05 BOP 7-Feb-05 2-May-05 Tairawhiti 14-Feb-05 4-Apr-05 Taranaki 21-Feb-05 9-May-05 Hawkes Bay 21-Mar-05 4-Apr-05 Whanganui 4-Apr-05 9-May-05 Mid Central 18-Apr-05 9-May-05 Hutt 2-May-05 16-May-05 Capital Coast 2-May-05 16-May-05 Wairarapa 23-May-05 16-May-05 Southland 6-Jun-05 30-May-05 Otago 30-May-05 30-May-05 Canterbury 27-Jun-05 6-Jun-05 South Canterbury 13-Jun-05 6-Jun-05 West Coast 20-Jun-05 13-Jun-05 Nelson Marlborough 4-Jul-05 13-Jun-05
Meningococcal B Immunisation Evaluation Final Report p 32 CBG Health Research November 2006
5. Vaccine distribution and allocation
This section is based on information from a paper supplied by the Ministry of Health.
Management and vaccine supply distribution has been a key success of the programme and the logistical experience will be invaluable in future immunisation programmes.
In previous immunisation programmes there has been wastage of around 15% and as much as 25% of vaccine 4.
For this programme vaccine supplies were limited due to MeNZB TM being made specifically for the NZ strain
The programme allowed for vaccine wastage of only 5% - higher wastage was believed to be unacceptable due to cost, and impact of children not being able to receive the vaccine
Main causes of wastage are delivery failures, provider wastage, fridge failures and expired vaccine
Vaccine orders had to be 6 months ahead of expected delivery
The Ministry also had to balance vaccine ordering, so that stocks did not run out, but also that vaccine did not expire
In the two years prior to the commencement of the Programme, the National Immunisation Programme (NIP), which deals with all immunisations, undertook a Cold Chain Accreditation project. Practices received up to $3000 to assist with achieving accreditation, which was often spent on a new fridge. To achieve accreditation practices had to demonstrate proper storage and use of vaccines, such as monitoring fridge temperatures and keeping vaccines stocks current. The successful implementation of this earlier project helped reduce wastage from spoilage.
Key strategies used to deliver vaccine were:
Forecasting based on having a six month reserve throughout the staggered roll-out
Vaccine allocated to DHBs based on census population projections with the Ministry undertaking to ensure there would be sufficient vaccine in the country for each DHB to complete the course before they were able to start the course
A real time inventory and vaccine allocation monitoring system was introduced
Providers allocated vaccine based on PHO enrolments
Daily vaccine delivery available but deliveries limited to one per day per delivery address
4 Heffernan, H. (2000). Vaccine wastage costs in New Zealand 1995 - 1999: A report prepared for the Ministry of Health, Project C59.
Meningococcal B Immunisation Evaluation Final Report p 33 CBG Health Research November 2006
Programme education and training emphasised that providers should not stock pile but only hold one week’s vaccine at a time
Orders only accepted and deliveries made a week before the programme commenced in a DHB area
Suspected over-ordering queried quickly and directly with practices
Total vaccine allocated monitored against vaccinations recorded on the NIR
Outcomes
As the end of the national programme (late June) the difference between NIR doses recorded and vaccine allocated was only 1.6%. This is a spectacular result when compared with typical wastage rates of 15%.
Key lessons and recommendations
R2 Tight inventory control, strict inventory reporting and systematic vaccine allocation are effective vaccine management strategies. The vaccine management and distribution processes for used the Programme were highly effective and would form a solid basis for any future immunisation programme.
Meningococcal B Immunisation Evaluation Final Report p 34 CBG Health Research November 2006
6. Safety monitoring data summary
This evaluation does not include an assessment of the safety of the MeNZB TM vaccination, however, throughout the MVS Programme, an Independent Safety Monitoring Board (ISMB) established by the Health Research Council has reviewed MeNZB TM safety monitoring data. The members are international experts in vaccines, paediatrics and epidemiology. The ISMB provides independent advice on the safety of the MeNZB TM immunisation.
Following its final meeting the ISMB advised that they “found no evidence for any concern arising from the safety data generated from the Monitoring of the MeNZB TM vaccine programme”. The ISMB also commented that the Ministry and its Meningococcal Vaccine Strategy Data Management Group had conceived and executed an outstanding program of sensitive and objective safety monitoring for the implementation of the MeNZB TM programme. It is planned that a description of the safety monitoring programme and its findings will be submitted for publication in peer reviewed journals.
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7. Setting up the Programme
The MeNZB TM Immunisation Programme was delivered through a variation in the Crown Funding Arrangement (CFA) with each DHB. Each DHB was required to submit a Project Implementation Plan (PIP) which described how the Programme would be delivered in their area. These were required three months before the Programme was due to start in each DHB, and needed to be approved by the Ministry before the Programme could start in an area. Each DHB employed a Project Manager for the Programme and designated a Sponsor for the Programme, often at GM level, and frequently a Maori or Pacific GM.
The MVS team supplied DHBs with a large amount of background material including resource materials, templates, guidelines and contracting specifications that were considerably more directive than many other previous contracts. DHBs in the case studies and in the responses to survey questions, reported that the material was helpful, although the Ministry reported that it was apparent that nationally some DHBs had not fully appreciated the extent to which the specifications would be enforced.
The effect of tight specification of what was required was some uniformity across DHBs in the services that were funded, and the rates at which they were funded. Nevertheless there was considerable scope for local variation particularly in the way in which outreach and community awareness services were delivered, discussed later.
Relationship managers worked well
From the Ministry’s perspective one of the key successes of the programme, after some initial scepticism from some DHBs, was the system of relationship managers, with 5 designated people responsible for Ministry / DHB communication for groups of DHBs. This system provided a reliable, timely and sensitive communications infrastructure that was seen as having been critical to the successful implementation of the Programme.
“Initially the DHBs were wary of this (the relationship managers), we were much more in their face than they have been used to. But the relationship has grown and matured and they are happy with it now.”
Good working relationships at DHB / Provider level
In spite of significant time pressure DHBs and providers in case studies reported generally good working relationships. Most DHBs maintained direct communication with practices, but all worked closely with local PHOs. In 3 cases DHBs had no direct contact with practices, using PHOs as the channel for communications. These DHBs recorded the lowest and third lowest coverage for 6w-4y (the third DHB in this group recorded the seven lowest).
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PHOs in case studies and in survey responses were pleased at being involved in early planning. In the case studies some providers thought that planning for the Programme had strengthened relationships between OIS providers and primary care.
There was some concern from PHOs at an apparent lack of coordination in some community awareness raising activities.
A well run Programme
The survey of DHB project managers confirmed the views that were expressed in the case studies. In unprompted free form text questions, 70% of programme managers listed management / planning and information / communications as successful features of the Programme.
The MVS team at the Ministry were pleased with the Programme’s planning, monitoring and reporting. When interviewed in July 2005 the MVS staff reported that the Programme was on schedule and within budget.
The Programme Director considered that the quality of contracting was critical to the success of the programme, because contracts determine what services are to be delivered and how service delivery can be managed. The MVS team learned that high quality contract development requires the best legal advice available and skilled negotiation teams, and the whole process requires sufficient time for all parties to share requirements and agree on solutions.
PHO satisfaction with the liaison with their DHB was more variable. PHOs were asked to rate this liaison on a five point scale. A quarter of PHOs rated liaison as only “reasonable” or worse, suggesting any future vaccination campaign should require DHBs and PHOs to agree upon the form and content of relevant communications.
Some resource constraints
Providers frequently reported difficulties operating in tight timeframes. In one case timetables were brought forward two months at short notice and providers felt unprepared for programme delivery. At the other end of the immunisation delivery cycle outreach providers reported some concern that they might not have enough time to achieve expected outcomes because of slower than expected uptake.
Providers also reported some difficulties accessing funding. Typically these occurred when a DHB was still negotiating over contents of contracts, while the roll-out of the programme was proceeding according to the schedule. Some providers delayed service delivery until funding was secured, with the result that services were not delivered at the optimal time.
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For the DHBs the Programme was only one of a large number of projects that are current at any one time, comprising a reasonably small fraction of their total workload. For PHOs and providers the Programme was a very major undertaking, and consuming significant resources and raising workforce capacity issues. In the face of the many other new demands on practices at this time, for example, implementing CarePlus, Service to Improve Access (SIA) projects, new funding schedules and the influenza season, some practices reported extreme work pressure.
However, PHO representatives reported in case studies that the programme appeared to have been within the current capacity of most general practices.
“In general practice, it was viewed as a bit of a mountain, in terms of workload. The reality, to date, is that it has been manageable.”
Concerns about short timeframes and access to funding were also raised in survey responses from PHOs, GPs and PHNs. Providers also commented on the difficulty delivering the Programme at the same time as influenza was prevalent.
Materials and communications effective
In the early stages of the Programme there were some significant shortcomings in the distribution of communication materials, with material arriving late or at the wrong destinations. In some cases practices received materials the day before launch. It is possible that the lack of materials, in particular the detailed 16 page booklet, allowed space for anti- immunisation activities to go unchallenged. In response, the Ministry implemented a new management process for materials and strengthened communications with DHBs.
Given this history it is notable that there were no major problems reported in the three case study DHBs. Information resources provided as part of the Programme were regarded by DHB representatives as very successful in educating both health professionals and the public about Meningococcal B. PHO representatives remarked that they had had good feedback from the practices about materials, especially the larger information booklet.
The video that was used in schools (not produced by the Ministry, but an Australian one) was reported to be very effective in motivating children to want vaccination. There were reports from parents of non-immunised children in one case study that it was too frightening.
DHB representatives in one case study praised the Ministry for the quality and timeliness of the refutation of anti-immunisation material. It was viewed that the Ministry team had a good grasp of the misconceptions that may have been created by anti-MeNZB TM lobbyists and supplied providers with sufficient information to counter the arguments and misinformation that were being utilised.
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“There are a few emails flying around the schools, but the Ministry has done well getting information to the professionals.”
National Advisory Group perspective
NRAG representatives drew the following lessons from the campaign:
There is still wide variation in DHB and PHO capacity to support and implement primary health campaigns of this nature. Some DHBs will choose to ignore national principles and design strategies which reflect their own goals.
Assess the capacity and capability of DHBs to implement the project with the aim of providing support where necessary.
Find methods for giving national directives to DHBs, which are non-negotiable and require immediate implementation without variation to the specifications.
Use established systems and avoid, wherever possible, creating new ones for the purposes of one campaign.
Exploit the opportunity to build workforce capacity and capability by considering how best to make long-term gains.
Appoint advisory groups that contain well-known experts who can commit to the work and who are articulate and strategic thinkers.
Have an issues register that outlines problems considered by the advisory group and detailing their closure at the end of the meeting.
Ensure that the all advice received from the advisory group is acknowledged with a report on the actions taken.
Consider paying advisors for all the time involved in the work.
Key lessons and recommendations
DHBs can successfully manage establishing the infrastructure for the delivery a major mass vaccination campaign that uses Public Health Nurses for school based delivery and existing primary care providers for children aged under 5. Other more centrally driven or devolved delivery mechanisms could have been employed, but the DHB approach has worked well.
R3 DHBs could be used to coordinate and manage the delivery of a similar vaccination campaign in the future.
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Tight specification of contracting requirements between DHBs and local providers helped DHB meet national requirements for equity and effectiveness.
R4 The Ministry should consider using tight contracting with DHBs in any future vaccination campaign.
Relationship managers were an important reason for successful implementation. Relationship managers facilitated communications between DHBs and the Ministry of Health and also provided a useful way to share information regionally.
R5 The Ministry should consider using a system of “relationship managers” responsible for managing the Ministry / DHB interface for groups of DHBs within the same region in any future vaccination campaign.
The three DHBs that did not communicate directly with practices had low vaccination rates.
R6 Direct communication between DHBs and practices may be more effective than PHO mediated communication in any future vaccination campaign.
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8. Communications and media
The communications and media strategy was critical to the success of the Programme. To achieve the desired coverage figures (90%), the Programme had to appeal to all New Zealanders and have wide acceptance throughout the target groups. The Programme was complex and the vaccine itself was new, which, it was recognised, would raise a range of questions regarding safety and effectiveness. The use of primary care and schools based delivery models each had different communications requirements. There were issues surrounding the licensing of the vaccine, and there was potential political sensitivity about targeting Maori and Pacific children, even though they had the highest rates of meningococcal disease.
In recognition of these factors the key communications strategy was a high intensity campaign, with multiple exposures over extended periods of time using as many different media as possible. To increase acceptance in the target communities, advertising was tailored to these groups, using well known public personalities appropriate to specific ethnic and age groups.
The communications team identified three major phases – celebrity endorsement, the use of Family Health Diary to reach more mainstream audiences and “survivor” stories, where people with exposure to meningococcal disease shared their experiences. The communications strategy aimed to remain flexible as it was inevitable that new angles would develop as the Programme rolled out, and these would need to be closely managed.
For example, as a result of the slower than expected uptake of vaccination by Maori aged under 5, and interim evaluation feedback, Maori communications were strengthened. Maori clinicians were engaged, a Te Reo spokesperson was appointed and a new series of targeted advertisements were commissioned.
It was important to coordinate messages across multiple delivery methods, and this required a significant degree of central direction and control, with consistent messages and branding. The use of templates that could be used by DHBs to present locality-specific messages was helpful in maintaining national consistency. TV, although very expensive, was considered to be very powerful in setting the media agenda.
For the communications team, and many people associated with the Programme, one of the most frustrating aspects of the Programme was the disproportionate attention given to anti- immunisation campaigners. Although numerically tiny they were able to attract a large amount of coverage. The professional desire of journalists to present both sides of an argument, and possibly the commercial driver of a controversy being good for sales, meant that Programme spokespeople could potentially have been in the position of publicly engaging in some absurd debates e.g. immunisation weakens the immune system, the government wants to support the pharmaceutical industry. After reviewing international experience a deliberate decision was taken to only engage with anti-immunisation activists when it suited the specific
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objectives of the Programme. At the end of the Programme the communications team suggested a number of features that might be considered for future campaigns:
Tighter linkage between advertising and vaccination opportunities Use more print advertising, especially advertorials Capitalise on local knowledge for distribution Funding DHBs for communication, allowing them more scope for commissioning or delivering locally relevant activities, within national guidelines, and for employing additional communications staff. Impact of communications
Ongoing assessment of the impact of Programme communications was provided by two tracking surveys 5. Following a baseline survey, further surveys were conducted 14 weeks after the launch of the campaign in South Auckland (November 2004) and Northland (February 2005), and a final national telephone survey was undertaken in November 2005, of parents or caregivers under 20. Table 5 summarises the results of these surveys. It should be noted that some questions were asked slightly differently in follow-up surveys, so results are only indicative.
Table 7 Summary of Indicators for the communications programme South Topic Explanation Baseline Auckland Northland NZ 1. Awareness % that without prompting named 23% 52% 40% meningococcal disease as “a disease of major concern to New Zealanders” … as above but prompted 74% 100% 100% Awareness of Programme 98% 2. Seriousness % that believe meningococcal 89% 62% 59% disease is “a serious disease” 3. Personal % that believe they or their family 47% 36% 36% Relevance were at risk of getting meningococcal disease (somewhat) 4. Informedness % that believe they were well 35% 47% 51% informed about meningococcal disease (a lot of info) 5. Vaccine % that were aware of the - 89% 71% availability availability of a vaccine 6. Vaccine as a % who identified vaccination as ‘a 10% 94% 83% 90%* form of best way to prevent catching prevention meningococcal disease’ 7. Likelihood to % that reported they were likely to 72% 73% 65% 88%** vaccinate vaccinate themselves or their family against meningococcal disease *asked as “children should be immunised against”; **said were immunised or had begun immunisation
In the national telephone survey:
5 The Meningococcal B Vaccine Strategy. The Evaluation of the Communications campaign: Overview Report - Final. BRC 2006. Wellington.
Meningococcal B Immunisation Evaluation Final Report p 42 CBG Health Research November 2006
All (100%) claimed that they were aware of meningococcal disease Almost all (98%) were aware of the immunisation programme 88% stated that they considered children should be immunised against meningococcal disease The main sources of information concerning the vaccination programme reflected the communication media used by the Ministry of Health These results indicate a very high level awareness regarding meningococcal disease and the MeNZB TM vaccine in the community.
Feedback from external media informants
To obtain an external perspective on the communications associated with the Programme interviews were conducted with independent media informants, typically journalists and reporters who had covered the Programme and had had significant exposure to it.
Participants suggested that in any future campaign:
All Ministry public representatives have communications training in the presentation of complex information in an adversarial environment.
Provide an information/briefing session, with the option to obtain highly detailed information if required.
Advance preparation for the most likely controversies. In particular, have available detailed descriptions of administrative processes for any medicines / products, background material on efficacy of the product, and registration details.
Provide access to independent specialists and advisors.
Be certain that regional and national information sources are aligned
Design the website as a crucial communication tool that will be accessed by the media and general public
Given the experience of this programme, participants felt that future campaigns should also plan in advance how to respond in the media in the event of a disease occurrence at any stage in the process.
Generally the points raised were recognised early on in Ministry planning and incorporated into the strategy. The fact that reporters still felt there was not enough information or access to experts suggests that they needed more information about who to contact, or where to find specific information.
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Analysis of media coverage
The Immunisation Advisory Centre (IMAC) undertook an analysis of media activity related to MeNZB TM and agreed to provide access to this work for this evaluation. The analysis was conducted by an experienced qualitative researcher working with IMAC and samples of material were analysed by two independent researchers.
All print media from January 2004 to June 2005 were entered into a database chronologically, including information about publication type, article type, author, both publication and region of publication, size of article and date of publication. Techniques for analysis were developed from literature on discourse analysis and framing. Systematic qualitative document analysis was used to sort and understand dominant themes that emerged from the media articles. All print media was systematically sorted and coded based on emerging themes. From this ‘emergent coding’, specific themes were identified.
The chart below plots total media mentions and the number of negative mentions.
Figure 6 Total clippings and number of negative clippings 1/1/2004 – 30/6/2005
180
160
140 National roll-out starts Start of Programme in 120 Counties Manukau
100 Roll-out to wider Auckland 80
60
40
20
0 1 4 7 3 3 6 9 5 10 13 16 19 22 25 28 31 34 37 40 4 46 49 52 12 1 18 21 24 Total Clippings Anti Clippings
The x-axis is weeks since 1 Jan 2004. The y axis is total clippings per week. The following chart relates MeNZB TM events for 2004, but the above graph does show that whenever there is any anti-MeNZB TM activity there is much more positive media activity. In the second quarter of 2005 there was an increase in anti-MeNZB TM activity, with TV appearances by anti-
Meningococcal B Immunisation Evaluation Final Report p 44 CBG Health Research November 2006
MeNZB TM lobbyists. It is not possible to unequivocally attribute cause and effect, but this anti- MeNZB TM activity appears to have precipitated a steady increase in positive media.
Print clippings in 2004 can be related to key events in the Programme. There were several major events that occurred during 2004 that appeared to be reflected in the media. The first was the high profile case of Charlotte Cleverley-Bisman, a 6 month old baby with meningococcal septicaemia. A few days later a further case received front page attention, another baby of the same age called Junior. One week later licensure of the vaccine was announced. Demand for the vaccine was high. There were celebratory media releases following the first 100,000 and 250,000 doses. The only other major media event was high coverage of a promotional poster showing a Cook Island woman which was deemed to be culturally insensitive. Figure 7 plots media exposures in 2004 against specific events.
Figure 7 Clippings versus key Programme events in 2004
Total M edia Clippings 2004
14 0
12 0
Licensure 10 0
8 0 First ¼ million doses 6 0
4 0 First Culturally unsafe Junior 100,000 poster doses 2 0 Charlotte
0
1 2 3 4 5 6 7 8 9 0 2 4 5 7 9 1 3 5 8 0 2 4 7 9 1 3 4 6 8 0 2 1 11 1 13 1 1 16 1 18 1 20 2 22 2 24 2 26 27 2 29 3 31 3 33 3 35 36 3 38 3 40 4 42 4 4 45 4 47 4 49 5 51 5
Neutral Posit ive Ant i
The themes and discourses for the national media are described in the following tables. The data is for major themes / discourses only.
Table 8 Major themes and discourse in print media
Theme Count % Informative 2333 70.5% Vaccine benefits outweigh risks [+/-] 282 8.5% Vaccinations are safe/not safe [+/-] 208 6.3% Vaccination promotion 197 6.0% Vaccine effective/not effective [+/-] 126 3.8% Withholding information/conspiracy 100 3.0% State intervention vs. personal choice 53 1.6% Natural is best 10 0.3%
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Discourse Count % nil discourse 1754 53.2% Scientific discourse (e.g. 'studies have shown…') [+/-] 312 9.5% Fear (e.g. Killer Epidemic on its Way) 314 9.5% Celebratory (e.g.:Vaccine Success!) 232 7.0% Urgency (e.g: Parents Demand Vaccine Now) 177 5.4% Sadness/tragedy 164 5.0% Anger (e.g.: Vaccine Deniers are Nuts) 153 4.6% Belief 74 2.2% Paranoia[suspicion] (e.g.: They just want your Money) 63 1.9% Control/persuasion (e.g.: Vaccination Should be Compulsory) 52 1.6% This analysis shows that most Programme related media were neutral and informative. The great majority of print media conveyed information about programme activity. Fifteen percent of clippings however dealt with risk / benefit and safety issues. The discourse was usually neutral or scientific; the next most common discourse was “fear.”
Because media exposures were classified by area, an attempt was made to assess the impact of the print media exposures on local vaccine uptake, in two case study DHBs (Waikato and Tairawhiti). The following figure shows this analysis for Waikato. The dose 1 uptake rates for children aged 6w-4y and 5y-17y have been overlaid on a graph of number of media exposures in each week.
The Waikato data seems to offer a good test of this hypothesis. The initial media activity is associated with the commencement of the Programme in the Waikato. There is a flurry of activity in week 29-37, but there is no obvious change in immunisation delivery, at a time when coverage was 70% (final coverage 76%). On the other hand positive stories in week 19- 21 appear to be followed by small increase in vaccinations.
Figure 8 Media exposures versus uptake for Waikato
Waikato media versus coverage
35 0.12
Vaccinations 30 Pro 0.1 Anti 25 0.08
20 0.06 15
Media items 0.04
10 in coverage Increase
0.02 5
0 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Weeks in 2005
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Key lessons and recommendations
The communications strategy was successful in achieving its goal of high intensity coverage.
This consisted of planned releases about programme development and implementation but also included high profile MeNZB TM cases. These were powerful media opportunities.
Even negative coverage appeared to be followed by a positive response, further increasing exposure for the Programme.
R7 The Ministry communications team advised that in future programmes they would:
• Encourage tighter linkage between advertising and vaccination opportunities
• Use more print advertising, especially advertorials
• Capitalise on local knowledge for distribution
• Consider funding DHBs for communication
Despite a large amount of information being made available, journalists still suggested improving accessibility of spokespeople, and making more information available on the website.
R8 Provide access to as much information as possible, through spokespeople with high availability, briefings and a comprehensive web site.
By far the most common theme of print stories was informational (eg advising vaccination was about to start), distantly followed by discussions of risk and benefits of the vaccine itself and safety of the vaccine. The discourse was most often judged to be neutral, followed by “scientific” and “fear”
There may be some weak evidence of local media activity encouraging vaccination, but the evidence available is difficult to interpret.
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9. Community awareness raising
Successful delivery of the Programme required communities to be supportive of the Programme and for people to be well informed about and receptive to offers of immunisation. Community Awareness Raising (CAR) could be considered as having two broad goals. The first was establishing visible “champions” (or “key influencers”) that could advocate for the Programme within their communities, and other strategies designed to increase community receptivity and knowledge about the Programme. The second was a more individually oriented approach, involving a range of activities to encourage individuals to vaccinate.
A structured Community Awareness Raising component was incorporated into the Programme from the beginning. Each DHB was required to submit detailed plans for Community Awareness Raising activities targeting Maori, Pacific and youth not attending school. DHBs were required to have contracts with providers for:
Engaging the support of leaders, role models and trusted “influencers” as recognised advocates or “champions” for the Programme.
Promoting the Programme generally in a range of settings
Holding education sessions with small groups
Door knocking
Working with local media
These plans were included in Project Implementation Plans that had to be signed off by the Ministry before funding was released to DHBs.
National awareness raising
A comprehensive media strategy was implemented at the Ministry level, involving the provision of educational and promotional materials in multiple languages, specification of key messages, national TV and print advertising. While it was expected that local awareness raising activities would be aligned with the messages in national campaigns, for example using the same branding (logos and colours) and key phrases, it was explicitly recognised that each area would need to adopt awareness raising strategies most suited to their populations.
“The national awareness raising has been pivotal for Maori PHO strategies in ensuring the most at-risk were told and can be targeted by our resources.”
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Local awareness raising
DHBs generally contracted awareness raising activities to existing Maori and Pacific organisations, recognising the access these groups already had to the MeNZB TM immunisation target groups.
Of the 42 CAR providers identified by DHBs, 23 provided responses to a questionnaire about their experiences. Providers were diverse, including PHOs, Marae Committees, Maori and Pacific Community Trusts, the Maori Women’s Welfare League and in house DHB provision. A third of respondents dedicated resources specifically to Maori CAR with a quarter having resource specifically for Pacific CAR.
Training and setting up
Eighty percent of CAR providers said that staff received specific training, and they rated this training highly (3.9/5). Providers were slightly less satisfied with the time they had to set up their CAR services (3.3/5). Some questionnaire respondents mentioned the lack of setup time as the thing they were least satisfied with in their service delivery. CAR providers were generally happy with the liaison they had with DHBs, PHOs, and primary care (all 3.7/5), although in a small number of cases the free form responses to questionnaires sometimes revealed high levels of frustration with DHBs, with one provider suggesting direct contracting with the Ministry may have been more effective in their area.
CAR strategies
A wide range of strategies were employed. In the case study DHBs initial activity was typically to meet with key leaders and influencers in the Maori and Pacific communities. Once these people had been briefed and communications channels established the most common activity was the attendance at scheduled community events, sometimes coupled with a “whanau ora” activity, with a stall and distribution of materials.
Local media opportunities were exploited including appearances on Maori and Pacific radio stations. Reports from the case study DHBs indicated that these services were delivered as contracted with 80% achievement on required Key Performance Indicators.
In focus groups, CAR representatives felt that awareness raising at community events had been highly successful. They felt that people were willing to receive information but that people did not expect to be confronted with having to decide whether to have the vaccination. However, for older harder-to-reach youth it was sometimes acceptable to make such an offer. The CAR team explained that these youth are often disconnected from health services and therefore, they are usually more accepting of easy access options.
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“It is important with youth awareness raising to offer the vaccine there and then, because they will not come back tomorrow. If you make it easy, they do it.”
Providers of CAR considered that repeated exposures were necessary to keep awareness levels high.
“We are having whanau ora days – every time there is an activity, there is an influx and then it wanes off – so you need activities, almost every week that capture people’s imagination.”
PHO and practice representatives reported favourably on the activities of community awareness raisers. Managers expressed admiration for the innovative ideas for awareness providers, such as the activities for family days. They also appreciated the apparent willingness of CAR staff to go the extra mile for Meningococcal B, frequently completing Meningococcal B activities in their own time.
Practices reported that local events/activities aimed to at families directly resulted in increased demand for the vaccination.
“We definitely see an influx after the events.”
One DHB communication representative perceived that their DHB effectively refuted anti- immunisation propaganda by using positive immunisation stories in the local media. They reported that they invited lobbyists to be present at public gatherings where a public health physician also presented facts about the successful use of meningococcal B vaccinations. It was advised that this has proved to be a successful strategy to objectively challenge some of the material used by the anti-immunisation lobbyists to create doubts about the vaccine. However there is an alternative view within the national MVS team that same caution needs to be taken as public engagement can also increase credibility of anti-immunisation activists.
Overall the material collected for the case studies suggests that the CAR that was contracted for has been successfully delivered, although this assessment was sometimes difficult in the absence of good reporting.
In interviews reflecting on the entire Programme, the Ministry MVS team thought that in the future they would advise that more time be allowed for planning and consultation, and that more resources, direction and training be devoted to any community awareness raising aspect of public health programmes. Some locally produced materials were not particularly effective, and a mechanism for reviewing these before distribution could be helpful. They felt that early consideration should be given to mechanisms for linking awareness-raising to the required action.
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What worked well
DHB programme managers rated the delivery of CAR services highly (4.5/5) but were less certain about the impact of CAR (3.8/5). There was strong support for the importance of using CAR individuals that had established links with specific communities, including youth, and for delivering targeted CAR activities to specific groups, rather than, for example generic advertising such as blanket leaflet drops, static stalls at community events or radio advertising. The materials provided by the Ministry were rated highly. One provider specifically mentioned a wallet size card as an effective idea for youth in particular.
In terms of raising community awareness, to create an environment receptive to vaccination, CAR providers rated talking to key-influencers such as kaumatua as highly effective. For motivating people to vaccinate, one-on-one communication was the most effective, even if delivered at a community event such as a “whanau ora” day.
Two-thirds of PHOs provided some CAR themselves. Once again respondents mentioned face-to-face and community meetings CAR as being things that worked well; leaflets, posters and radio advertising were not so effective.
Although it happened somewhat later in the process, one DHB project manager made the observation that information sent to every parent as part of the informed consent process for schools based immunisation was probably the single most effective form of raising awareness within their community. Having every family with school aged children exposed to the immunisation would have had an enormous impact on overall awareness.
The importance of schools as community awareness raisers was shown in a BRC Marketing and Social Research (“BRC”) National Tracking Survey in which respondents were asked to identify their main source of information:
Schools / playcentres / kindergartens 41% GPs 23% News media including television 20% Newspapers 16% In this survey schools also scored well as the most influential source of information (28%), with GPs or primary health care at 22%. GPs were the most trusted source for information (90%) in the baseline survey (prior to the Programme commencement).
The lack of data on the types and numbers of CAR activities undertaken by CAR providers was mentioned as a concern by some DHBs.
How could CAR be improved?
The commonest way in which programme managers thought CAR could be improved was by linking CAR with vaccinations, if possible delivering vaccinations immediately after awareness
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raising. The desirability of aligning CAR with vaccination was also mentioned by some PHOs. There was a small group of DHBs who thought that CAR should have been done earlier in the programme; these were DHBs where materials arrived very close to immunisation start dates. One programme manager felt that the MoH had not considered the needs of 18-19 yr olds adequately in designing materials for CAR, and that this was an area for improvement.
PHO immunisation coordinators felt CAR could have been improved by more funding and consultation, some lamenting the fact that PHOs were not funded directly for CAR, but that they had to tender for it from DHBs. Some PHOs felt the CAR achieved was pretty good for the resources available.
Key lessons and recommendations
It is difficult to assess the impact of specific CAR activities over and above the effect of the intensive national advertising campaign.
Some primary care providers reported influxes of children for vaccination after CAR community events. DHB project managers were less certain of its overall value. Some DHBs reported very poor results from non-targeted CAR for example leaflets, radio advertising, general door knocking.
On the other hand, targeted CAR with specific Maori or Pacific communities, for example at kohanga reo or “whanau ora” days, with opportunities for one-on-one engagement, was considered effective by CAR providers, PHOs and some DHBs.
R9 CAR activities that involve direct engagement with small groups and individuals are likely be the most effective, and should be preferred over other local activities.
In all cases CAR works best when delivered by people with established links with the targeted community.
R10 CAR should be delivered by individuals known to the target community.
Many CAR providers emphasised that CAR should be linked with vaccination if possible.
R11 Individually oriented CAR should be linked with an immediate opportunity to vaccinate whenever possible. In practice this might mean starting CAR when vaccinations start.
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10. Under 5s
Children aged under 5 were vaccinated by primary care providers. They received a standard immunisation payment and PHOs were eligible for incentive payments once targets of 80% and 90% were achieved. It was well appreciated before the Programme started, based on existing immunisation uptake, that achieving 90% immunisation targets in primary care would be challenging 6. To maximise the chance that target rates would be achieved PIPs had to include plans for local community awareness raising and outreach immunisation services. The resources devoted to national advertising were also significant, and TV, radio and print campaigns were implemented with high visibility.
In addition to known difficulties that MeNZB TM vaccination would face there were additional logistical concerns. An effective cold chain for vaccine supply needed to be established and IT infrastructure needed to be in place to support reporting and monitoring.
Coverage
The overall coverage achieved for children under 5 by 30 June 2006 was 74%. The breakdown of this figure by ethnicity is shown below. A second set of columns shows the effect of applying an adjustment for the impact of ethnicity under coding, as described in section 3.
Table 9 Coverage for under 5s, dose 1 and dose 3, with ethnicity adjustment Dose 1 Dose 3 6w-4yr population NIR adjusted NIR Adjusted Maori 74716 54659 73% 65486 88% 41632 56% 49739 67% Pacific 28759 26994 94% 27847 97% 22517 78% 23818 83% Other 174927 161728 92% 150048 86% 141869 81% 132461 76% ALL 278402 243381 87% 243381 87% 206018 74% 206018 74% Note: Data as at 30 June 2006
The following graph shows the proportion of the initial cohort, the group of children that were eligible for vaccination when the Programme started in each DHB, that had been given three doses, plotted by week since vaccinations started.
6 By 31 July 2006, 45% of PHOs had achieved 80% coverage and received this incentive payment; only 2.5% achieved 90% coverage
Meningococcal B Immunisation Evaluation Final Report p 53 CBG Health Research November 2006
Figure 9 Under 5 dose 3 vaccination uptake by DHB
Patterns and phases of vaccination uptake
The shape of the curves is similar for each DHB, with a rapid uptake phase as children became eligible for their third vaccination twelve weeks after the Programme started, and attend for vaccination as scheduled, followed by a second phase of slower vaccination completion. The final phase, reached at around 40 weeks after the Programme commenced shows the slow following-up of the hard-to-reach, represented by the long tail of near parallel lines on the right of the plots, where vaccinations are being delivered at a slow constant rate. The following table summarises these uptake phases:
Table 10 Under 5 vaccination uptake phases Phase Level Reached Average Time Range taken 1 50% 8 weeks 3-13 2 70% 21 weeks 10-43 3 75% 40 weeks 24-73 The DHBs with the three lowest rates had fallen behind others by week 20, that is, 8 weeks after third doses started to be given
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National Immunisation Register
The NIR was implemented at the same time as the Programme. Case studies revealed initial implementation problems regarding uploading results from practices and in some areas the local DHB NIR teams were unable to produce reports. Some providers reported that NIR access has been unavailable much more often than expected.
It was feared by some provider representatives that the difficulties with uploading data to the NIR might reduce practitioner engagement with the NIR as a whole. This was not confirmed in a survey of practices, nor by an audit of NIR completeness in CM DHB. The audit, commissioned by the Ministry in March 2005, and conducted in 30 randomly selected practices in CM DHB, found that completeness of data capture was 95% in primary care (and over 90% in school-aged children).
The set up of the NIR system in the practices themselves was regarded by PHO representatives in case studies as a successful part of the Programme. PHO representatives reported that the problems that had been anticipated, such as delays in PMS updates, did not eventuate. The train-the-trainer approach that provided on site training to each practice was also noted as a key success. PHO representatives felt that the close alignment of the roll-out of the NIR with the Programme had provided purpose, emphasis, focus, and motivation for practices to establish the NIR system.
“In this region, it [NIR and MeNZB Programme] was all integrated. Meningococcal B has been a great lead off for the NIR. It has made the process easier because you could focus on Meningococcal B.”
It was reported that, at times, there have been differences in the timing and precise content of messages coming from the Ministry NIR team and the MVS team.
“The communications about the two projects [NIR and MeNZB Programme] coming from above (the Ministry) - there seemed to be no collaboration and/or alignment at that level.”
The effective operation of the NIR meant that coverage reporting for the Programme could be delivered at a level of detail and timeliness not seen before in New Zealand. Weekly reports were set up to provide coverage progress data from the NIR to PHOs and DHBs. The Ministry collated weekly coverage reports by DHB and distributed these to DHB project managers. This was a very important aspect of the Programme, conveying immediate feedback to the sector on Programme implementation, identifying areas of low uptake by area, ethnicity, deprivation and age group.
The quality of the national and DHB level reporting built confidence in the Programme and generally reinforced the perception of the Programme as well managed. However, reports from the NIR at the PHO / practice level were not so useful. Many PHOs and practices said
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that the reports they received from the NIR were not helpful at all, and in fact created work as resources were used to reconcile the numbers in NIR reports with practice registers. As the NIR reports did not include practice denominators it was not possible to use them to reconcile PHO level immunisation rates with the pooled data from practices’ internal systems. Nevertheless in the survey of 250 randomly selected practices 72% were able to enter data into the NIR at the start of the Campaign, rising to 95.5% by October 2005; 84.1% were able use the NIR to check immunisation status, with 73.6% actually using it to do so. 91% of practices reported that the electronic claiming system was working.
Giving the vaccine in practices
All 250 practices surveyed recalled patients for MeNZB TM vaccination. 96% used letters to recall patients, with an average of 2 letters sent per patient, and 94% phoned patients, making an average of 2 calls per patient. Over a third of practices tried to contact patients after hours and at weekends. Other recall methods used included practice-sponsored local advertising and specific home visiting. Seventy eight practices mentioned other methods of contacting patients; 45% mentioned opportunistic vaccination. Some practices ran extensive waiting room displays, including running a supplied 5 minute DVD. Fridge magnets were very popular and felt to be effective reminders for some families.
The PHO representatives in the case studies felt that the primary care providers that were achieving high immunisation rates had designated clinics to complete MeNZB TM vaccinations, some with appointment times and some on a drop in basis. All reported that they could and would accommodate families who elected to walk in.
“You have to be able to deal with those that just walk in without an appointment – sometimes they will have to wait. We find that they are prepared to wait.”
The practice survey showed that practically all (91%) practices gave immunisations for “drop ins” i.e. without an appointment, with 87% feeling this is an effective method of vaccination. 22% of those surveyed operated a “drop in clinic” at special times, where children are seen without appointments. 28.2% felt this was an effective method of vaccination. 74% of practices operated a vaccination clinic that parents had to make appointments at. Of these practices, 72% felt this was effective.
Case study participants claimed that MeNZB TM immunisation imposed a large extra workload on practices and facilities were often stretched in terms of space and staff. Some PHOs had developed a vaccinator pool to offset expected workforce capacity issues which was successfully implemented.
“We started by recruiting nurses who had the additional capacity to offer to other practices. We got the 40”
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In the practice survey, respondents estimated that implementing the Programme required an average of 17 hours per week nurse time, 13 hours admin and 11 GP hours (the average practice has 3 GPs) Sixty two percent of practices actually employed at least some extra staff.
It was notable that there were no reported problems with administering the vaccine or with maintaining supplies. National data showed that vaccine wastage was extremely low at around 1.6% in comparison with typical rates of 15-20%. The cold chain was effectively maintained using chilly bins, and vaccine supplies were reliably delivered. One of the significant effects of the Programme was the establishment of reliable refrigeration and fridge temperature monitoring in general practice, which will have improved storage and management systems for of all vaccines.
Referring to outreach
Outreach Immunisation Services (OIS) were a key component of the Programme. When a practice was unsuccessful in contacting a patient, typically after three attempts they were expected to refer to Outreach. The organisation and delivery of Outreach is described in a later section.
In the practice survey, practices reported that they made an average of 13 referrals to Outreach (range 0 – 287). As the 250 practices in the survey were randomly selected from 1267 active practices this represents nearly 17,000 referrals nationally, for an estimated population of 280,000 children 6w – 4yrs, although the potential “referable” population would have been larger as new children joined practices. Forty four percent of practices made no referrals to Outreach. Practices were asked if there were any barriers to using Outreach. Thirteen percent of practices gave specific reasons for not using Outreach. These included the paper work involved in a referral and possible implications for practice funding.
Although Outreach services were expected to provide feedback to referrers 14% of the practices that did use outreach did not know whether any of the children referred to outreach had received immunisation. Practices estimated that 40% of the children referred to outreach received MeNZB TM immunisation.
The coordination of Outreach referrals was often through the PHO, and some DHBs ran centralised Outreach coordination services. PHOs were sometimes Outreach providers (although there was an expectation that whenever appropriate existing services would be utilised to deliver Outreach). PHO survey respondents estimated that about a third of referrals might have been avoided if practices had checked (or been able to check) the NIR to see if an immunisation had been given elsewhere.
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Second and Third doses
There was a significant reduction in coverage for doses 2 and 3. The difference between first dose and third dose coverage rates was greatest for Maori.
Figure 10 Under 5 decline in coverage between dose 1 and dose 3
Decrease in coverage between dose 1 and dose 3
100%
90%
80%
70% Maori Pacific 60% Other 50% Maori adj Pacific adj 40% Other adj 30%
20%
10%
0% Dose 1 Dose 3
Note: Data as at 30 June 2006
6w-4yr Dose 1 Dose 3 diff Maori 73% 56% 17% Pacific 94% 78% 16% Other 92% 81% 11% Maori adj 88% 67% 21% Pacific adj 97% 83% 14% Other adj 86% 76% 10%
The adjusted dose 1 coverage figure show that Maori coverage rates were slightly above the coverage for “Other”. Uptake curves presented in section 15 suggest that Maori uptake is slower initially but more sustained. This suggests that the dose 1 / dose 3 differences may reduce if more time is allowed for Maori dose 3 vaccination.
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Reasons for not vaccinating
In the practice survey, the average proportion of patients normally declining immunisations was reported as being 5.8% (Range 1 – 70). The average proportion of patients that have declined MeNZB TM was 2% higher at 7.9% (Range 1 - 60).
Practices were asked to list the reasons parents gave for declining vaccinations. The main reasons practices said parents gave for declining is as follows:
Table 11 Clinicians views on reasons for declining
% of times mentioned by Reasons for parents declining MeNZB TM provider Concern about safety and effectiveness of vaccine 55 Usually do not receive vaccinations 32 Negative media reports 13 Stated a lack of knowledge regarding vaccination 7 Negative reports from other parents 6 Influenced by anti-immunisation lobby 6 Other reasons (e.g. too painful, has bad reaction to vaccinations, too young) 49
Providers had high levels of trust that the vaccine was safe (4.4 / 5) and likely to be effective (3.9 / 5) in general but a third of providers themselves had some concerns about giving the vaccination to 6 week old children. The concerns given by this third (that is approximately 80 respondents, mainly vaccinating practice nurses) were:
Table 12 Clinicians concerns about giving MeNZB at 6 weeks
% of times mentioned by Concerns about giving MeNZB TM at 6 weeks provider Concern about the number of injections 6 week olds receive 77.6 Concern about the size of 6 week olds 71.7 Felt 6 weeks is too young 22.4 Concern about lack of information and research on vaccine 11.8 Other 30.6
Two surveys of parents of young children gave more information on the reasons the parents of some under 5s declined vaccinations. A telephone survey of 313 randomly selected households in seven central North Island DHBs found 32 (10.2%) parents who had not had their child vaccinated and were not likely to do so. They gave a wide range of reasons, with the two commonest being concerns about vaccine safety and side effects. In this survey some relationships could be tested quantitatively. Further specific questions showed a strong association between both lack of parental belief in safety and lack of parental belief in efficacy and having received no immunisations.
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In household survey relating to the youngest child in 250 houses in Kawerau and 250 houses in selected census areas of Auckland region (that had high numbers of Maori children) a similar pattern was observed. In this survey 5.8% of respondents had no vaccinations and were not likely to, with the same concerns regarding safety and efficacy. These factors were once again strongly associated with non-vaccination in the full sample.
In both these surveys it appeared that non-vaccinators were comprised of two groups of approximately equal size – the “good intenders” that had not got around to vaccinating, and the “active decliners” that had a principled opposition to the vaccination.
The free text responses to the questions in these two surveys shows that there is also a section of the non-vaccinators that could be characterised as opposed to “big pharma” , being suspicious of the relationship between government and the supplier of the vaccine, or expressing an explicit preference for herbal or natural responses to a disease threat.
DHB communication with practices via PHOS
In three cases DHBs had no direct contact with practices, using PHOs as the channel for communications. These DHBs recorded the lowest and third lowest coverage for 6w-4y (the third DHB in this group recorded the seven lowest).
Key lessons and recommendations
Although considerable progress has been made towards achieving internationally acceptable vaccination rates (90%+) in recent years the processes for delivering vaccinations to a primary care population still need to be improved.
Based on ethnicity adjusted figures Primary Care was equally effective delivering first dose vaccinations to Maori and Other ethnicities. The higher coverage achieved for Pacific children suggests the Pacific model of complete community involvement should be considered whenever circumstances permit.
Based on the fact that adjusted dose 1 rates are the same for Maori and Other and the known slower uptake of immunisations by Maori (see uptake curves in section 15) it is possible that the same dose 3 coverage could be achieved for Maori as for Other given more time.
Primary care did not appear to use Outreach services particularly effectively with 44% of practices not referring to Outreach. The main reasons were the difficulty of referring and impact on practice income.
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R12 Outreach referral processes from primary care should be streamlined in any future vaccination campaign. One possibility is to incorporate a specific “refer to outreach” code into the NIR system so that practices only have to enter a single code to precipitate an effective referral. This could be picked up automatically by the business rules of the NIR and distributed back to the appropriate agency.
Vaccine distribution and cold chain maintenance can be successfully implemented with available systems in primary care. Practices are now well placed to store and maintain vaccine for a similar campaign.
R13 The processes used to establish vaccine management procedures were effective and should be used again in the event a similar campaign is required in the future.
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11. School aged children
The delivery of the schools-based component of the Programme was a large logistical exercise requiring extensive planning and coordination. The Programme was delivered by Public Health Nurses (PHNs) supported with additional DHB resources and significant assistance from schools themselves. The schools-based component of the Programme was regarded as highly successful by Ministry and DHB participants in interviews. As shown in Table 13, it delivered an overall dose 3 coverage of over 86% with over 80% coverage to all ethnic groups, and 97% for Pacific children. The data in Table 13 is for children aged 5-17 yrs old and includes children in this age group who are not going to school.
Table 13 Coverage for 5 – 17 yr olds dose 1 and dose 3 Dose 1 Dose 3 Ethnicity n imms % imms % Maori 182350 162,585 89% 149,925 82% Pacific 66540 68,991 104% 64,394 97% Other 537380 476,860 89% 459,508 86% ALL 786270 708,436 90% 673,827 86%
The following graph shows the pattern of vaccination for children aged 5-17 by DHB, for the “initial cohort”.
Figure 11 5-17 dose 3 vaccination uptake by DHB
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The pattern of uptake for 5-17 yr olds is quite different from the pattern for the under 5s. The school based component had a “captive audience” and as PHNs visited schools large numbers of vaccinations were delivered. At each school there were children that did not get vaccinations, and the process of delivering vaccinations to these children at “catch-up” clinics was labour intensive. Some children had immunisations at their GPs as well, and these also contribute to the steady trickle of vaccinations many weeks after the formal schools-based component had finished.
The Schools-Based Vaccination System
The Schools Based Vaccination System (SBVS) was the key supporting IT infrastructure for delivery of vaccinations for school-aged children. The system was administered at the DHB level. The system was preloaded with school rolls, and consenting and vaccination data was entered into the system as the data became available. Vaccination records were uploaded regularly from the SBVS to the NIR. The SBVS generated reports that could be used to monitor vaccination progress in a given school.
The schools case studies described some major early implementation problems with the SBVS. In Waikato it was reported that the SBVS suffered from difficulties in data entry, reporting and uploading. Due to various delays, pre-vaccination information could not be entered onto the system in sufficient time to provide accurate consent information to guide vaccination days. Nurses reported having to manually sort through forms to coordinate the vaccinations for their schools. In the absence of accurate SBVS reports, nurses explained that they had to employ time consuming manual paper-based systems to support the clinical services delivery and planning of vaccination clinics.
However, by the time of the final schools case study interviews in Waikato (15/7/2005) the system was considered by users to be fully functioning, performing well and generating reports that supported clinical service delivery.
In the survey of a random sample of 100 PHNs delivering vaccinations to schools, 95% of respondents reported that they were using the SBVS to support programme delivery.
The SBVS was designed as a community based public health system that could prove useful beyond immunisations. In the case studies the DHB and PHN teams hoped that SBVS would be employed in the future to support year seven vaccinations and other public health services.
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Giving the vaccine in schools
Public Health Nurses typically used their existing links with schools to set up systems for administering vaccines, including processes for obtaining consents and the physical delivery of the vaccinations. Schools received a small payment in recognition of the considerable resources they made available to assist delivery of the Programme.
Consenting Consent forms for vaccination were given to children to take home for completion. The time allowed for completing returning consent forms varied between DHBs and schools from a few days to two weeks.
In the Waikato case study the workload involved in managing consent forms was a major source of extra work for PHNs, to the extent that in Waikato the effective follow-up and checking of the forms, was seen to have gone beyond the capacity of the PHN workforce. A large percentage of the returned forms required some follow-up by the PHNs. This was found to be very labour intensive. In the survey of PHNs it was estimated that nearly a quarter of all consent forms were not completed correctly. When asked for ways in which forms could be improved, PHNs most frequently suggested that forms required clearer formatting.
In some communities, nurses and teachers advised that parents had complained that the requested return time for consent forms did not provide enough time in which to make an informed decision whether to consent to vaccination. In the survey the average suggested time was 12 days, but most nurses suggested shorter time frames, less than a week. A few nurses felt a month or more was required in order to make an informed decision.
The sending out of the consent information resulted in lots of parents approaching teaching staff to try and access more information. School staff reported that they had facilitated parents accessing further information by directing them to the Ministry’s 0800 number and/or website.
It was reported that many parents were aware of controversial information that was being circulated via the anti-immunisation media. Teachers and nurses felt that parents needed more opportunities to discuss and explore this information.
In one case study area staff reported that many parents appeared to be unsure of their original consent decision and those parents were later notifying that they had changed their minds and wanted to complete a new consent form. School staff advised that, with every new media story on meningococcal B, significant numbers of parents changed their consent. Nevertheless the schools based Programme still achieved a very high level of coverage.
In one case study school staff and nurses noted that some parents reluctantly gave their consent, preferring to have their children’s vaccinations completed by the family doctor. These families were reported to have been distressed by the consenting and/or school vaccination process. However SBVS data for these areas showed only a small percentage (0.3%) of parents who returned the consent form declined the offer of vaccination because
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they preferred the vaccinations to be completed by a GP. In Hutt Valley, SBVS data reported a decline rate of 5.8% with 0.4% stating they preferred to have the immunisation with a GP.
In the Waikato it was reported that the 9% decline rate and the 5% who did not return a form did not appear to be associated with any particular ethnic group. Anecdotal evidence suggests that the problem may have been middle income ‘Other’ families.
In fact, SVBS data records Maori decline rate of 6% and an overall decline rate of 8.5% (which includes Maori – hence decline rate in non Maori will be higher than this)
Across all DHBs the decline rate ranged from 4% to 14%, with an average of 8.5%. As shown in the following figure, the decline rate was strongly associated with overall coverage, also consistent with this being a real act of declining vaccination, and not a preference for GP vaccination.
Figure 12 Coverage versus decline rates
Coverage 5-17 year olds
100% 90% 80% 70% 60% 50% 40% Coverage 30% 20% 10% 0% 4% 6% 8% 10% 12% 14% Decline
The management of large numbers of physical consent forms was a major organisational undertaking. In the survey of PHNs 8.6% of respondents found that the service had problems finding consent forms for dose 2 and 3. They estimated that around 2% of these forms were not locatable when required.
Giving the vaccine
In parent interviews the majority of parents appeared happy to have their children’s vaccinations completed in a school setting. The household survey of 250 children in Kawerau and Auckland also showed that people were very happy to have their children vaccinated at school.
In the case study areas some schools had invited worried parents, parents of primary school children, or special needs children to accompany their children through the vaccination
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process. The nurse managers advised that they had actively encouraged schools to allow any parent, who would like to support their child, to accompany them to the vaccination.
Some high school students whose parents gave consent to receive the vaccinations, were reportedly ‘going missing’ on the day of vaccination. In the larger high schools the nurses explained that this is a significant problem, because students are difficult to locate in the school system.
DHB data services reported that student movement between schools proved to be problematic. It has generated a large workload for the data administrators. This was not foreseen at the start of the project.
The process of giving the vaccination appeared to be straightforward. In the survey only 2 % of respondents reported problems with vaccine supply, and only 1% experienced any difficulty with cold chain maintenance. The physical environment for vaccination was considered comfortable by 80% of nurses. There was some concern about confidentiality, with 12% of nurses considering that confidentiality was difficult to maintain. This could be important when asking about medical history.
Catch-up clinics
When a child did not attend for a vaccination various methods of providing “catch-up” were available. Some DHBs allocated a special team to undertake catch ups at a designated time, e.g. every Monday. In other DHBs there were regular clinics available for providing catch-up.
Many DHBs used the school holidays as an opportunity to invite any children that had missed immunisations to attend catch-up clinics. Catch-up clinics were sometimes organised at short notice and one DHB project manager specifically mentioned the flexibility of schools in accommodating these. Some schools supported the catch-up process themselves maintaining IT systems for recalling students. Catch up clinics after every dose were contracted as an integral part of all the school programmes.
Second and Third doses
As for the under 5s there was some fall in coverage rates for doses two and three.
The commonest reason given by PHNs as to why children might not attend a second or third vaccination was that they were sick or absent (48%). Other reason included:
Negative media Reactions Lack of parental support/knowledge Fear of injections/pain
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According to the Ministry of Education 7, nationally 1 in every 11 children is away from school on a given day.
Reasons for not vaccinating
Respondents in the household survey of 500 children were asked why children did not get vaccinated. The results were similar to those for under 5s. There were only 15 children aged 5-17 who had received no immunisations. The reasons given were (in order of frequency):
Dislikes needles Feels clinical studies inconclusive Side effects Doesn’t think there’s a need to immunise Doesn’t like chemicals: prefers herbal alternatives More research needed/new vaccine Only effective for 2 years
Public Health Nurses gave their own views for the reasons consent might not be given; over a third felt that issues of uncertainty around a new vaccine were important. Other reasons suggested for not vaccinating included lack of knowledge, needing more time to make a decision, and the complexity of the consent form.
Vaccination coverage by age for school children
It is interesting to look at immunisation rates in age bands more closely. It seems likely that as children get older they are less likely to get an immunisation. This may be related to increased independence associated with growing older, leaving school and possibly leaving home.
The following graph shows the dose 3 coverage pattern for all children, based on the age in years of the child at the time schools started vaccinating in their DHB area. The bars show the inter-quartile range across DHBs (25% - 75%), with whiskers at 95%. Extremes can be greater than 1 as cell counts are small – e.g. in West Coast some cells had zero Pacific children.
7 Attendance and absence in New Zealand Schools in 2002. Robert Cosgrave,Fred Bishop, Ngaire Bennie, Research Division, Wähanga Mahi Rangahau 2002 Ministry of Education, Wellington
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Figure 13 Coverage by age in years for children aged 5 -17
The next graph shows the pattern for Maori children:
Figure 14 Coverage by age in years for Maori children aged 5 -17
At around age 13 years the dose 3 coverage in all children and in Maori children separately starts to fall away. This is of course before the legal school leaving age and may reflect the impact of independent decision making. Although this phenomenon starts at the same age in the pooled and Maori data, the Maori rate falls away much more quickly to be 55% at age 17
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compared to 68% in the data from all ethnic groups. The difference would be even more stark if Maori data were excluded from the pooled data.
Key lessons and recommendations
The delivery of MeNZB TM through schools was a large and complex logistical exercise. The achieved coverage shows that Public Health Nurses can deliver large numbers of vaccinations quickly to school children.
R14 Schools based vaccination delivery is very effective for delivering a mass vaccination and should be utilised if possible for school aged children, particularly if rapid coverage is an important objective.
Co-operation of schools is critical to success. Schools were willing and able to help, including assisting with managing consent distribution and follow-up. However schools need as much time as possible to plan for vaccination days.
R15 Schools need to be advised of vaccination rollout planning and timetables as early as possible
Even though considerable work was done to design an easy to use consent form it was generally regarded as too complicated. Approximately a quarter were not completed correctly and a lot of nurse time was used completing consent forms.
R16 Consent forms should be as simple as possible, and not appear complex. A significant field test of forms for any future vaccination project is recommended.
Managing the volume of consents was a challenging task. Some consent forms were not able to be located when required.
R17 Consideration could be given to scanning consents and using electronic systems (mobile computers) for recording information.
It was reported that some parents did not have enough information. The use of school information evenings is a sensible way to provide this, with expert advice available, and has the added benefit of contributing to community awareness raising.
R18 The use of schools as locations for wider information dissemination and community awareness raising (as well as vaccination venues) should be considered in any future vaccination campaign.
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Most people are happy to have their children immunised at school. The average decline rate was 8.5%. It is likely that only a very small proportion of these people preferred their GP to give the vaccination. Absenteeism is the commonest reason for missing vaccinations. Nine percent of children are absent on any single day. Catch-up clinics are thus an essential part of any schools based vaccination strategy.
R19 Any future vaccination campaign delivered through schools must include planning for catch-up clinics similar to those in the Programme.
Some DHBs reported that timing vaccinations so that catch up could occur at holiday periods, at the school, had been very helpful.
R20 Timing of any future vaccination campaign should consider the timing of catch-up clinics in relation to school holidays.
The SBVS IT infrastructure has enhanced the capacity of PHNs to deliver vaccinations.
R21 The SBVS is now fully functional and should be used for other vaccination programmes. Consideration should be given to methods for maintaining the knowledge and skills of the people that used that this system.
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12. 18-19 yr olds
The lowest coverage rates achieved were those for young people aged 18-19. It was planned that vaccinating young people aged less than 20 but who were not attending school, would be undertaken by primary care, predominantly general practices, but also including clinics at educational institutions and workplace clinics. The highest dose 3 coverage rate was achieved in Otago DHB, with a large student population, and some recent well publicised cases of meningococcal disease. Unfortunately this highest coverage rate was still only 58%.
The following table shows the national coverage achieved:
Table 14 Coverage for 18-19 yrs olds (no adjustment)
Dose 1 Dose 3 Ethnicity n imms % imms % Maori 182350 11,958 53% 8,542 38% Pacific 66540 6,214 74% 4,973 60% Other 537380 58,399 64% 51,558 57% ALL 786270 76,571 63% 65,073 54%
The pattern of vaccination uptake by DHB is shown in the following graph, following the “initial cohort”
Figure 15 18-19 dose 3 vaccination uptake by DHB
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It is well known that it is very difficult to provide primary care services to young people in this age group given their low consultation rates with traditional primary care. In this context the coverage achieved is not as disappointing as it might first appear. However, there was a general feeling from many providers and managers that not enough planning and resources had been devoted to developing strategies for vaccinating this group.
The delivery of vaccination to Maori in this group was particularly disappointing, achieving a coverage rate of only 38%.
Reasons for non-immunisation
To explore why young people were not getting vaccinated two focus groups were held in Hutt Valley, with young people aged 16-19, from school and from a youth centre.
Participants understood that meningitis is a serious disease, but often believed that younger children were most at risk. These young people did not appear to feel personally threatened by the disease.
High-school students described complying with parental vaccination choice whereas young people who had left school described making a decision with little or no parental influence.
Young people yet to be vaccinated varied in their readiness to get a vaccination. Some were not contemplating any action, but others seemed to be considering the pros and cons of vaccination, and/or overcoming barriers to complete the vaccination.
All of the participants, regardless of vaccination status, believed that apathy underpins young people seeming resistant to accept the offer of vaccination. They were united in the view that a large number of their peers would not want to be seen to take any action, including making an appointment at the GPs, to have a vaccination. However, they felt that if young people were confronted with having the vaccination there and then most would comply.
“We are lazy, that’s the truth. We don’t care, so if you asked, have it now, people would as long as you didn’t have to do anything.”
Young people identified a range of obstacles to participating in the Programme:
They perceive that the programme is targeting younger children whom they believe are more at risk
Few young people feel personally threatened by the disease and thus lack any motivation to protect themselves against it.
The situations that are being used to create awareness have not seemed real to the older participants.
Some young people seem to like the image of “not caring” about an issue, or being “laid back”.
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The campaign is not something that has stimulated much youth interest or discussion.
Many young people fear needles and the prospect of three injections.
For independent young people this is the first time that they have been required to make a vaccination decision or take independent health action.
‘Be wise immunise’ was perceived to be catchy but not youth-trendy, and/or real. In order to make vaccination a priority and give some real status to the key message, these young people suggested that advertisements should depict the impact of the disease on the life of a young victim.
Key lessons and recommendations
Young people were aware of meningococcal disease and the vaccination Programme, however they did not generally consider Meningococcal B be a threat, and therefore do not think they are at risk from contracting it.
R22 In future campaigns advertising resources should be devoted to documenting and advertising situations that describe the disease and its impact on young people aged 16-19.
Some young people require easy access alternatives because they do not want to be seen to actively seek vaccination, and/or go to the GP.
R23 Future vaccination campaigns should consider providing multiple vaccination opportunities for young people including at youth centres, work sites, tertiary education and other training sites and at community venues such as parks and shopping malls.
Vaccination offered at sports events or concerts are unlikely to be effective – youth don’t like being approached for vaccination when they have gone to an event for quite a different purpose. However, the young people thought that it would be acceptable for Meningococcal B providers to create fun events for the specific purposes of providing vaccinations.
R24 Opportunities for group vaccination should be explored, and incentives such as free coffee, competitions or vouchers should be considered.
Some school leavers have fallen behind the vaccination schedule because they have not sought vaccination through primary care or, to the best of their knowledge, have not been approached to complete the vaccinations.
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R25 Young people who leave school should be offered subsequent doses via primary health care services. This would require formal handover to primary care and would involve linking SBVS data with primary health care records.
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13. Outreach services
From the early planning stages of the Programme it was realised that achieving the 90% targets for vaccination coverage would require significant effort to deliver vaccinations to the hard-to-reach. In 1992 less than 60% of children had completed scheduled vaccinations by the age of two 8; this figure has improved in the past decade to 79.4% according to the 2005 immunisation survey. 9 The National Health Committee has estimated that it could require the same amount of resources to immunise the last 20% as the first 80% 10 .
One of the key strategies for immunising the hard to reach was the funding of Outreach Immunisation Services (“OIS”) for MeNZB TM . OIS services are already funded by the National Immunisation Programme for the delivery of the immunisations on the childhood immunisation schedule. Sixteen DHBs have provided these services, starting in July 2003, delivered through contracts with predominantly Maori and Pacific providers. As suggested in the Ministry guidelines to DHBs, MeNZB TM OIS services built on existing capacity rather than establishing new services. Because of the explicit prioritisation of Maori and Pacific children, MeNZB TM OIS contracts were often awarded to existing Maori OIS providers.
Outreach providers facilitated vaccination by contacting children referred from primary care, either directly or through a central coordination facility (typically run by the DHB), by holding community clinics and by running mobile vaccination services.
Outreach data
Although Outreach providers had defined two-monthly reporting requirements the data returned to DHBs, and then forwarded to the Ministry, was often incomplete. Narrative reports and findings from DHB interviews advised that the services were reaching target populations, but the quality and quantity of data provided varied greatly with information sometimes unclear or incomplete. Reasons for this include:
Delays and/or inability of providers gathering and collating the material.
Under-reporting of OIS facilitated vaccination events.
Difficulties following up outcomes of families that advised OIS personnel that they would make their own appointment to see a provider.
Variations in what constituted or was counted as OIS vaccination.
Difficulties extracting the information from NIR reports.
Inability to produce reports based on age and / or ethnicity.
8 Stehr-Green PA, Baker M, Belton A, et al. Immunisation coverage in New Zealand. Communicable Disease NZ, 1992;92(Suppl 12):1–15. 9 Ministry of Health. 2006. Immunisation Handbook 2006. Wellington: Ministry of Health p6. 10 Review of the wisdom and fairness of the Health Funding Authority strategy for immunisation of 'hard to reach' children, National Health Committee, 1999
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Reports giving numbers of children being vaccinated rather than numbers of doses administered.
Changes in personnel submitting the reports.
Referring to Outreach from primary care
Once a primary care provider decided that they were not going to be successful in immunising an eligible child, typically after three attempts at contact, they were able to refer the child to OIS. This was typically done using a template referral form. Referrals from practices were either made directly to the OIS provider, through a PHO or through a centralised DHB coordinating centre.
Thirty one of an identified 59 OIS providers responded to a questionnaire about the services they had provided. Sixty-seven percent provided other outreach immunisation services as well as MeNZB TM services. Fifteen OIS providers provided data on referrals, including the largest single OIS provider and some very small ones. These providers received 10825 referrals (range 95 to 4712).
When a referral form was received OIS delivered outreach services according to the protocol they had agreed with their DHB. Generally OIS providers facilitated immunisations being given at existing primary health care providers. The protocols typically had three levels:
Active encouragement to get vaccinated – making appointments, checking they were kept
More active engagement with the client including possibly providing transport and,
Very rarely – giving immunisations in the home
In six DHBs facilitation only was provided. Two DHBs funded outreach via a mobile clinic that could give vaccinations.
What proportion of referred children were vaccinated?
The data returned by OIS providers included both immunisations facilitated at GPs and immunisations given at clinics run by Outreach providers. This means figures can not be easily compared with GP estimates, which exclude community Outreach activity and services delivered to non-enrolled children. With the earlier caveats on data quality, a total of 29,276 MeNZBTM vaccinations were reported as given through OIS from Programme commencement through to 31 May 2006; this would represent 4.5% of all doses given to children aged 6w-4y. However this may underestimate the impact of Outreach as subsequent vaccinations may have been delivered in primary care that would not have been given without the input of Outreach in facilitating an earlier dose.
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Although this figure provides some insight into the volume of referrals it is also useful to estimate the number of children referred to Outreach that were subsequently vaccinated.
In the survey of 250 practices, described in an earlier section, practices estimated they made 13 referrals on average, representing 17,000 referrals nationally. Practices estimated that 40% of children referred were subsequently vaccinated, or 6800 vaccinations.
Northland DHB (NDHB) Outreach referrals were managed centrally, at the DHB level and good data was available. The following table summarises the referrals received by Northland DHB outreach service for children that did not receive dose 1 and the classification of the referral at the end of June 2005:
Table 15 Northland Outreach referrals for dose 1 Total referrals 2119 Relocated 353 17% Declined by parent/s 169 8% Non Responders 539 25% Vaccinated by Outreach 181 9% Vaccinated by GP 643 30% Awaiting Outcome 234 11% Thirty nine percent of 2119 children referred for first dose were known to have received vaccinations. The figure would be higher if any of the “awaiting outcome” children were vaccinated. Far fewer referrals were received for 2nd and 3 rd doses. In NDHB 60% of children referred for dose 2 successfully received it (446 referrals), 40% dose 3 (158 referrals). The total for all doses is 42% (1154/2723).
Data provided by survey respondents from the 15 providers that were able to supply figures, showed 40% of referrals were for dose 1, 15% for does 2, 18% for dose 3 and 27% for unspecified dose. Of the 10825 referrals, 92% were able to be contacted, 59% received a home visit, 10% were provided with transport. Data from 13 providers indicated that 42% of referred children were known to subsequently to have received an immunisation. If these respondents are representative of all OIS providers, approximately 18000 vaccinations would have been given as a result of referrals.
The NIR was able to provide some information about children that had ever been associated with an Outreach provider. This data showed that 32% of the 2437 children that had ever been enrolled on the NIR by an outreach provider subsequently received a vaccination (from any provider i.e. including GPs and outreach providers).
Although there is some variability in these estimates, they are all consistent with between 32%-42% of referred children being subsequently vaccinated.
For another perspective on Outreach referral the Household survey asked parents of the 55 children that had not been vaccinated whether they had been contacted by a provider other than their normal primary care provider regarding getting a vaccination, which would
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presumably be an Outreach provider. Nearly 40% of the non-vaccinated respondents were contacted by another provider
What worked in community clinic and mobile vaccination services?
Outreach services also contacted clients directly in the community through a wide range of Outreach services including community clinics, mobile vaccination services, and, less frequently, home vaccination.
The experience of Northland DHB with a door knocking campaign is interesting. In low uptake (<50%) urban areas households were visited by outreach providers and families invited to attend community clinics for immunisations. Clinics were advertised on local radio stations and in community newsletters. School newsletters were sent home and letterboxes were leafleted. Shops and supermarkets displayed posters. Three separate clinics were run offering immunisations on Mon / Tues and Thurs from 10-12am for four consecutive weeks. Despite this intensive effort, after four weeks a total of 8 children received an immunisation, 5 of which were under 5 years old.
In Auckland a series of community outreach clinics were run from March to June 2005. 17 clinics were held, open from 9 am to noon, with the majority in a mobile bus. There were three community vaccination days. Sixty-four vaccinations were given, the majority for dose 1.
Four DHBs were separately interviewed to describe their experience with community clinics and mobile vaccination services (Counties Manukau, Northland, Waitemata, and Auckland) 11
The DHBs viewed community clinics as a sensible and feasible option for some harder to reach families residing in some rurally isolated, or otherwise well defined communities. The home and mobile vaccination services were reported as being important options for families who had mobility or transport issues. In the experience of the providers that had offered these services, they were often welcomed when other alternatives had been rejected.
The most successful community catch-up clinics appeared to have targeted identified families living in more connected communities. The providers of these clinics had specifically asked families known to have children requiring vaccination to give their commitment to attending the clinic.
Harder to reach families living in lower decile areas were thought to require personal contact either by phone, or home visits. The level of contact required was considered to be dependent on each case. Personal contact was advocated as a means of finding problems or issues that prevent vaccination attendance.
11 Evaluation of the Meningococcal B Immunisation Programme - Community Clinics and Mobile Vaccination Services, CBG Health Research Ltd, September 2005
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Some providers recommended that communities should be engaged in the planning of the clinics. In the experience of both Counties Manukau and Northland, the most successful clinics had been with communities that had pledged their support to the event.
Counties Manukau (CMDHB) reported the most consistent results from the primary care and schools catch-up community clinics. They outlined a number of processes that they, and some of the other participating DHBs, had found to influence the probability of vaccination:
The Counties Manukau schools catch up community clinics were held in the school holidays, and had proved to be a successful means of capturing school children that had missed vaccinations. It was advised that, like the primary care clinics, the option should be specifically targeted at identified families that are known to have children who still require vaccination.
The Counties Manukau team supported school community clinics making provision for the vaccination of children of all ages. They had referred pre-school children to the primary care outreach team. However, one DHB who had extended school catch up clinics to accommodate under-five year olds, reported that the venue had not proved to be attractive that audience.
The DHBs which had a number of children who were either not enrolled with a PHO, and/or not using general practice services, had successfully used Plunket databases, PHO lists of casual patients, and Accident and Emergency attendance lists, to try to identify those children requiring vaccination. DHBs reporting high rates of PHO enrolment had not found it necessary to use lists of casual patients, and had relied on outreach referral information from general practice.
Community clinics, and home and mobile vaccination services were reported to demand high levels of clinical, and cultural competency. It was reported that DHBs should find providers within a community who have the necessary competencies, community knowledge, links, and access to infrastructure. It was felt that such providers would be best placed to implement the alternative vaccination services.
The following table summarises the lessons and recommendations regarding community clinics and mobile vaccination services from interviews with these four DHBs:
Lessons Recommendations Community and mobile clinics It was recommended that the clinics should be reserved for are a preferred option for many families who have rejected other alternatives. of the harder to reach families, All participants supported that these options must be but they are highly labour and strategically planned, and targeted towards identified resource intensive. families that are known to have children who still require vaccination. Some community clinics have Community clinics were recommended as a feasible option proved to be highly successful. for more connected communities, especially those with The achievement seemed to be established community clinic venues. associated to the type of It was supported that clinically and culturally competent
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community, level of strategic providers, who are known and trusted within the community, planning, and targeting of should run clinics. families. The team advised that resources should be devoted to tracking down the addresses of the families that are known to require vaccination Several processes were found to The team recommended that clinics be advertised in local increase the support and newspapers, and on radio stations, through schools, and the attendance at community and local community. mobile clinics. It was suggested that communications should aim to encourage discussion, and prompt families, friends, and neighbours to come along together. Nurses and support workers should be encouraged to recruit families from outside schools and supermarkets. Mail out, personal contact, home visiting and follow up, and reminder calling of families were all recommended. It was advised that staff should follow up those that fail to attend with an invitation to attend the next clinic, without any judgement of previous non-attendance. DHBs have experienced some Participants advised that one off clinics, established in more variable and lower than expected urban and disconnected communities, often yield poor attendance rates at a few of the turnouts. community and mobile clinics. It was considered that clinic turnout is weather dependent, and where possible, providers should avoid running such clinics in the winter months. The location and operating hours Participants recommended that sites for clinics be selected of community clinics were using the vaccination coverage reports, addresses of thought to be critical to their outreach referral families, and from previous knowledge of success. To be effective, utilisation trends in the area. community clinics were also When selecting a venue for a community clinic, it was seen to require the right venue. recommended that consideration should be given to how the venue will be accessed, and the appropriateness of the space to accommodate adults and children socialising. It was advised that linking community clinics to other community health related activities, such as Tamariki Ora days, could yield good vaccination results. Some teams cautioned that aligning clinics to non-health related activities such as shopping at a market does not always result in vaccinations. It was recommended that, where possible, vaccinations should be offered before 9 am and between 3-7pm to accommodate working families. Participants advised that after-hours clinics require the provision of security for staff and families. Appointment making increases Appointment making was recommended as an effective families’ resolve, and improves means of building families’ resolve to attend the vaccination. the probability of vaccination Teams that had used appointment making with all families attendance. advised that the majority were willing to commit to a booking. It was supported that, where possible, all families, even those that the providers suspect may reject the offer of an appointment, should be personally contacted and offered an approximate appointment. Where the making of an appointment is rejected, it was suggested that the family could then be offered the option to attend at any time. It was felt that drop in clinics require access to back-up staff to ease situations where attendance escalates beyond capacity. The distribution of appointment Providers recommended that appointment cards should
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cards in the absence of any follow, or be followed up with, some form of personal personal contact or follow up contact. The schools catch up clinic representatives did was not known to significantly advise that families living in higher decile areas had influence turnout. responded well to advertising, flyers, and reminders cards. But, when this was coupled with personal telephone calls, attendance rates had improved considerably. Cost of Outreach
The total budget for Outreach included an initial $4.5M and an additional $1.7M targeted at DHBs with high disease rates. The averaged cost for an OIS vaccination per DHB, according to reported numbers of vaccinations given and total OIS funding, is illustrated below in Figure 3. Overall national figures average $240.35 per OIS vaccine given, with a median cost of $207.65. The two regions with the highest average costs (S, T) were amongst the last regions to commence Programme roll-out and one of these areas had no existing OIS.
Figure 16 Average Cost per Reported OIS Vaccination by DHB
AVERAGE COST PER REPORTED MeNZB OIS VACCINATION
$600
$500
$400
$300
$200 Average cost per vaccination per cost Average
$100
$0 ABCDEFGHIJKLMNOPQRST Anonymised DHB
Key lessons and recommendations
The data available on Outreach service provision was very variable and limits an assessment of impact. Much better reporting can be reasonably expected, even of newly established organisations.
R26 Future vaccination programmes that include outreach provision should have tighter reporting requirements. The variable reporting suggests building some functionality into the NIR for supporting the registering and tracking of outreach referrals.
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The limited data that was supplied by Outreach providers was highly variable in scope and presentation.
R27 To assist outreach providers manage the delivery of Outreach services within their organisation a free web based application could be developed and provided to any group that wanted to use it. This would automatically provide remote access to client management tools (allocating responsibility to an outreach provider, checking status, recording an immunisation given) through a mobile internet connection.
Many primary care providers did not use Outreach effectively, typically because it was too time consuming.
R28 Outreach referral could be improved by adding a “referral to outreach” immunisation claim. These “claims” could then be collated and referred to the appropriate outreach provider, or regional coordination service.
The available data shows at least 1% of all vaccinations given were facilitated through Outreach. This represents 4.5% of all vaccinations given to children aged 6w-4y.
Community Outreach is most effective when targeted to children and families known to still require vaccination
The venue for community clinics is important and should be culturally appropriate and easily accessible. Opening times should recognise that many children are in working families.
Door knocking and providing clinics to non-specific families contained within an area of lower coverage does not result in a high number of vaccinations.
R29 Home visiting resources should only be devoted to calling on identified families who cannot be otherwise contacted.
Outreach vaccination is expensive, approximately $240 per vaccination given.
R30 Opportunities to incorporate the delivery of outreach immunisations into other home health visitor services should be explored.
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14. 4th dose
Final data from the clinical trials demonstrated that following dose 3, 53 percent of infants (enrolled aged 6 to 10 weeks) developed a four-fold rise in bactericidal antibody titres. Additional data showed that a fourth dose, administered at 10 months of age, raised this percentage to 82%. A 4th MeNZB dose was licensed in January 2006 for all infants who received their 1st dose before they were 6 months old, and primary care providers were asked to administer this vaccination to eligible children.
An evaluation of the uptake of the fourth dose was not included in this evaluation, and reporting of current coverage is complicated by a lack of useful denominator data at this time.
In a series of interviews about the administration of the 4th dose conducted by the Ministry of Health shortly after its introduction, GPs expressed some uncertainty about the reasons for extending the vaccination schedule. The Ministry commissioned a survey to measure the prevalence of these concerns quantitatively. A survey of 100 randomly selected practices found that approximately 20% of practices were uncertain about (each of) timing, eligibility, rationale and funding. The Ministry responded with further information being distributed to practices.
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15. Has the Programme achieved its coverage objectives
This section reports achieved Programme coverage against targets and examines delivery of vaccinations to these groups.
Achieved coverage against targets
The following table describes achieved dose 3 coverage rates for the groups specified in Programme targets. One of the important considerations in the design of the Programme was that it contributed to reducing inequalities. The high rates of meningococcal disease for Maori and Pacific children, and the known low vaccination rates for Maori children, meant that the Programme had the potential to actually increase inequalities unless vaccinations were effectively delivered to these groups.
The Programme consequently prioritised delivery of vaccinations to Maori and Pacific children. Against this background it is clear that correctly identifying the ethnicity of children receiving immunisations was very important. The table shows the coverage achieved for both the current age and initial cohorts, and shows the impact of ethnicity adjustment on the estimated achieved coverage.
Table 16 Achieved coverage versus targets Initial cohort Current age Group Target No No With ethnicity ethnicity ethnicity adjustment adjustment adjustment Maori 90% 64% 57% 67% aged under 5 Maori 90% 79% 82% - at school Maori 90% 20% 38% - out of school Pacific 90% 90% 80% 83% aged under 5 Pacific 90% 90% 97% - at school Pacific 90% 29% 60% - out of school Children 90% 84% 76% - under 5 years old Children 0-19 90% * 77% - in NZDep 9 and 10 areas Non-Maori non-Pacific at 90% 84% 86% - school Non-Maori non-Pacific 90% 38% 57% - out of school * initial cohort analysis not undertaken by ethnicity and deprivation
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For the current age cohort the target coverage was achieved for Pacific children aged 5-17. It was also achieved for the initial cohort of Pacific children aged under 5. The targets were appropriately set high in comparison to known vaccination coverage figures, and although the target was only reached for one sub-group, the achieved coverage needs to be considered in relation to historical vaccination rates, the fact that it was a new vaccine, it was a three dose vaccine, and the high level of anti-immunisation activity for much of the Programme.
The overall coverage achieved for children under 5 can be compared with that reported for the scheduled childhood vaccinations in the latest national immunisation survey 12 . The latest available figures from the 2005 immunisation survey show that that coverage for three doses of Diptheria / Tetanus / Pertusis (DTP) vaccine was 88.6%, of Oral Polio or DTP + Polio vaccine was 88.5%, of Haemophilus Influenzae (Hib) vaccine was 79.6% and Hep B vaccine was 86.5%. All these vaccines are given to children under 2 years of age. These estimates have 95% confidence interval of 1-2%. Survey data for vaccination rates by ethnicity are not yet available.
It is worth observing that, from a reducing inequalities perspective, even if lower coverage rates were achieved in the target groups, the net effect could be to reduce inequalities in disease burden, as the incidence of meningococcal disease in Maori and in particular Pacific children is so much higher than in “Other” children.
Views about the Programme from NRAG
A series of interviews were held with members of the National Rollout Advisory Group (NRAG) to obtain their perspectives on the Programme in May 2006. All but one of the participants felt that the campaign had been extremely successful in terms of its coverage. Some of these participants advised that 90% coverage was always unlikely and the number of refusals was underestimated. They admired the achievement of the Ministry team in obtaining such high total population coverage but commented that the results for Maori (when compared to those achieved for the rest of the population) were disappointing.
“A highly successful campaign. It was always a big ask and it’s been an incredible achievement.”
The remaining participant felt that the New Zealand health sector should be able to attain 90% immunisation coverage. They advocated that this outcome, whilst good in New Zealand terms, was disappointing because it reminds one of the national state of immunisation.
12 Ministry of Health. 2006. Immunisation Handbook 2006. Wellington: Ministry of Health.
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“Good that we achieved what we did, in New Zealand terms but disappointing that it is still only three quarters of the kids, disappointing.”[final coverage was 76% 6w-4y, 80% for 6w-19y]
Coverage by deprivation
For a wide range of health status indicators and health outcomes there is a known socioeconomic gradient, with people living in areas of relative socioeconomic disadvantage experiencing poorer health. The following graphs plot dose 3 vaccination coverage for the initial cohort, with NZDep2001 deprivation scores grouped into quintiles (ie Q1 = NZDep 1-2, to allow comparisons with other Programme analyses). NZDep2001 scores are derived for the census meshblock containing a child’s address and were supplied as part of the extract from the NIR.
The expected gradient is evident, but the plots also show some evidence of successful targeting to NZDep2001 9 and 10 children, with the plots showing vaccination rates higher than the trend for quintile 5. There is no difference in uptake rates by deprivation for the under 5 cohort and the 5-17 yr olds cohort (and both had an overall coverage of 83%).
Figure 17 Coverage by Deprivation for initial cohort.
Coverage by NZDep2001 Initial cohort
100% 90% 80% 70% 60% 0-4 50% 5-17 40% 18-19 Coverage 30% 20% 10% 0% Q1 Q2 Q3 Q4 Q5 NZDep2001
Coverage by ethnicity controlling for deprivation
It is useful to describe the independent effects of ethnicity and socioeconomic deprivation on MeNZB TM coverage rates. This can provide increased understanding of the previous graph, some guidance as to the best interventions for improving coverage rates, and give further insight into the success of the Programme in targeting disadvantaged communities.
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The following analysis examines the dose 3 vaccination coverage for the three ethnic groups within NZDep2001 categories.
The numerator data for the rate calculation is (unadjusted) counts of the number of children receiving dose 3 vaccination categorised by age group, ethnicity and NZDep2001 score.
To define denominators for rate calculations the national distribution of ethnicity by NZDep2001 was applied to the Programme population projections by age and ethnic group. The result of this was a series of denominators that added to the estimated population, but estimated numbers in each age group, ethnicity and NZDep2001 decile. The data is for the initial cohort.
Using these data coverage rates can be plotted by ethnicity and NZDep2001. The three graphs below show these plots for each age group. The first plots coverage for 6w-4yr olds.
Figure 18 Coverage by deprivation by ethnicity for 6w – 4 yr olds
Ethnicity by NZDep2001 6w - 4 year olds
100% 90% 80% 70% 60% Maori 50% Pacific 40% Other Coverage 30% 20% 10% 0% 1 2 3 4 5 6 7 8 910 NZDep2001
This graph shows that Maori and Pacific children living in areas of high deprivation were successfully targeted by the Programme, as the expected socio-economic gradient (highest coverage in high socio-economic status areas) has been reversed. The expected gradient is still slightly in evidence for “Other” children.
The other major feature of this graph is the fact that the low coverage of Maori occurs across the socio-economic spectrum, showing that low Maori coverage can not be explained by the socioeconomic factors captured in the NZDep2001 score.
A similar pattern is observed for Pacific children living in high socio-economic status areas; but in the more deprived areas, where the vast majority of Pacific children live, coverage rises and for the most deprived areas exceeds coverage for “Other”.
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As shown in the next graph, for children aged 5-17 years old there is a slight socio-economic gradient, but once again there is evidence of increased coverage for Pacific, and to a lesser extent Maori, at the most disadvantaged areas.
Figure 19 Coverage by deprivation by ethnicity for 5-17 yr olds
Ethnicity by NZDep2001 5 - 17 year olds
110% 100% 90% 80% 70% Maori 60% Pacific 50% Other Coverage 40% 30% 20% 10% 0% 1 2 3 4 5 6 7 8 910 NZDep2001
The final graph shows the data for young people aged 18-19. This graph has the least evidence of any socio-economic effect. The numbers are small and coverage estimates by socio-economic status less reliable. The spike for NZDep2001 score 4, represents less than 100 young people in each case.
Figure 20 Coverage by deprivation by ethnicity for 18-19 yr olds
Ethnicity by NZDep2001 18 - 19 year olds
100% 90% 80% 70% 60% Maori 50% Pacific 40% Other Coverage 30% 20% 10% 0% 1 2 3 4 5 6 7 8 910 NZDep2001
The overall pattern observed in Figure 17 earlier is the result of high coverage for “Other” children in high SES areas and increased coverage for Pacific, and to a lesser extent Maori,
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in more deprived areas.
Delivery to Maori
The extent to which the Programme was successful in delivering immunisations to Maori was a key determinant of overall success. Even after ethnicity adjustment some differences in dose 3 coverage for under 5s remained (9% less), and the coverage for Maori children aged 5-17 was less than that achieved for “Other” (3% less).
These differences are similar to those observed in the 2005 national immunisation survey. In that survey the proportion of Maori children that had competed all scheduled immunisations by age two was 69% compared with 80% for all others, ie an 11% difference. Given the resources devoted to delivering vaccinations to Maori it was hoped that these differences could have been eliminated completely.
Coverage
Table 17 below shows the current age coverage data for different age groups, for each dose, showing the unadjusted and ethnicity-adjusted coverage rates.
Table 17 Coverage for different groups showing effect of adjustment, by ethnicity dose 1 dose 3 NIR Adjusted NIR Adjusted 6w-4yr N coverage Coverage coverage coverage Maori 74716 54659 73% 65486 88% 41632 56% 49739 67% Pacific 28759 26994 94% 27847 97% 22517 78% 23818 83% Other 174927 161728 92% 150048 86% 141869 81% 132461 76% 6w – 19yr Maori 279656 228959 82% 239786 86% 199697 71% 207804 74% Pacific 103649 102070 98% 102923 99% 91658 88% 92959 90% Other 803047 696361 87% 684681 85% 651822 81% 642414 80% 6w-17yr ie excl 18-19 yr Maori 257066 217081 84% 227908 89% 191263 74% 199370 78% Pacific 95299 95875 101% 96728 101% 86722 91% 88023 92% Other 712307 638128 90% 626448 88% 600596 84% 591188 83%
Note: Data as at 30 June 2006
Maori uptake of MeNZB TM
Uptake of immunisations by Maori, especially in the 0-4 age group, has been comparatively slow compared to other ethnic groups. The national uptake of vaccinations by ethnicity, and
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the impact of ethnicity adjustment of primary care on these plots, is shown in the next graph, following the vaccinations delivered to the initial cohort.
The dashed line shows the dose 1 uptake for Maori without adjustment for primary care ethnicity under-coding of Maori and Pacific. The solid lines are all adjusted for under-coding. Almost as soon as vaccinations commenced, Maori coverage began to fall away, reaching a maximum difference from “Other” of 7% by week 5. Over the next year this gap was slowly closed, until coverage rates converged at week 67 at 85%. In comparison, Pacific coverage was greater than “Other” coverage at all times.
Figure 21 Dose 1 uptake for children aged 0-4, all DHBs
Dose 1 uptake patterns by ethnicity
100% 90% 80% 70% 60% 50% Maori / Other gap Maori (adj) closed at 67 Other (adj) Coverage 40% w eeks 30% Pacific (adj) Maori (no adj) 20% 10% 0%
0 6 4 0 6 6 2 2 12 18 2 3 3 42 48 54 60 6 7 78 84 90 96 0 1 Week
Similar plots for dose 3 are more difficult to interpret as they reflect the accumulated delays in the delivery of doses 1 and 2. The dose 1 plot above is not confounded by these effects.
Based on the dose 1 plot it is appears that although Maori uptake is initially slower than that of other groups (Pacific and “Other’) Maori coverage for dose 3 may reach the coverage for “Other” after enough time has elapsed. This delay in accessing vaccinations could have a number of causes including some Maori needing more time to make a vaccination decision, the emergence of new information that influenced the decision to vaccinate, and some Maori being unable to access primary care as easily as other ethnic groups.
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Understanding Maori coverage
Access barrier
Based on consent forms returned to schools Maori are at least as willing to have their children vaccinated as “Other” ethnicities. Based on the adjusted dose 1 coverage figures for the under 5s, Maori take their children to get vaccinated with coverage rates slightly higher than “Other”. However adjusted dose 3 coverage is 9% lower than “Other”. Finally the shape of dose 1 uptake curves show that Maori take longer to achieve the same level of dose 1 coverage.
These facts support the hypothesis that Maori experience an access barrier to primary care and that this barrier can be overcome given enough time.
The data for school aged children 5-17 (which do not require any ethnicity adjustment) show a 3% difference in final coverage between Maori and “Other”. This may represent children not immunised at school (typically as they were absent) that were not able to be contacted by catch-up services. There is also considerable mobility between schools, and this may be greater for Maori children than “Other”. This may have increased the difficulty in delivering catch-up vaccinations.
Maori concerns about vaccine safety
The household survey of 502 children in Auckland and Kawerau collected data from 336 parents of Maori children (or the children themselves). These data provided an opportunity to explore attitudes to vaccination on ethnicity dimensions for people living in areas with a high number of Maori households.
In this survey Maori had a significantly lower dose 3 completion rate than Other or Pacific children (half the sample was school aged). There is no association between ethnicity and perception of effectiveness of vaccination. However there was a significant relationship between ethnicity and perception of safety. 17.5% of Maori surveyed did not consider MeNZB TM safe, 10.5% of “Others” and 7% of Pacific. There was also a very strong association between perception of safety and completion of immunisations. Respondents were much more likely to complete if they considered the immunisation safe.
Differences in perception of safety may be responsible for some of the ethnic differences in completion rate. Probability of completing was modelled on four attitudinal variables in a logistic regression. The variables are “is the vaccine safe”, “is it effective”, “how serious is meningococcal disease” and “how likely is your child to get the disease”. The point estimate in the following table is the “odds” associated with a variable. For example, a person that regards the MenZB TM vaccine as safe is four times more likely to complete all three doses.
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Table 18 Predictors of vaccination completion Point 95% Wald Effect Estimate Confidence Limits Area Auckland vs Kawerau 0.6 0.4 1.0 Age in years 1.0 0.9 1.0 Ethnicity M vs P 1.3 0.6 2.6 Ethnicity O vs P 0.8 0.3 2.0 safe N vs Y 4.4 2.5 7.8 effective N vs Y 0.6 0.3 1.1 serious N vs Y 4.2 1.5 12.1 likely N vs Y 0.7 0.5 1.2
The differences between ethnic groups were explained by differences in attitudes to immunisation, with perception of safety and perception of seriousness significantly associated with probability of having completed vaccination.
This household sample might not be representative of all Maori, as it was chosen from areas with high numbers of Maori households. However if these results can be extrapolated, Maori concerns with vaccine safety may be contributing to the primary care uptake patterns, for example delaying the decision to commence vaccination until more information is available. It should be noted that this result does not fit easily with observed school vaccination consent rates. The high consent rate for school immunisation suggests that nationally parents / guardians of Maori children were willing to have their children vaccinated; if they were concerned about vaccine safety they did not withhold consent.
Do DHBs with high proportion of Maori have lower coverage?
An examination of coverage achieved by DHBs by proportion of Maori in the DHB population showed no association between proportion Maori and coverage. Some DHBs with high proportions of Maori delivered high coverage rates (eg Tairawhiti) and others did not (eg Bay of Plenty).
Do practices with Maori patients have less capability?
Responses from the survey of 250 randomly selected practices were a potentially useful source of information on the types of services Maori receive from primary care. Each Practice was classified according to whether they had more or less than the national average of Maori patients (17%), and compared on a number of dimensions. The comparisons are shown in Table 18.
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Practices with high proportions of Maori patients were less likely to be urban, devoted slightly more extra nurse hours to MeNZB TM and were less likely to use the NIR or submit claims electronically. Beliefs about the vaccination on safety, effectiveness, and whether the Programme was a good use of public money, were the same.
Practices with a large proportion of Maori patients reported a higher decline rate for routine immunisations. Interestingly the estimated decline rate for MeNZB TM increased by 3% in the practices with lower proportion of Maori patients, and not at all in those with a higher proportion of Maori patients. The most striking difference is that practices with higher proportions of Maori patients made nearly twice as many outreach referrals. They also estimated a lower final coverage of their populations.
Overall there is no evidence of any under-delivery of services by practices with a high proportion of Maori, although these practices may be less capable users of IT infrastructure.
Table 19 Practice characteristics by % Maori patients Maori > 17pct Feature N Y Practice characteristics Size 4395 4316 Urban 90% 78% Extra PN hrs 15.26 19.64 Can use NIR to check if an immunisation given 77% 66% Electronic immunisation claiming 94% 88% Attitudes of staff to the Safety 4.37 4.32 Programme Effectiveness 3.92 3.92 Good use public money 4.16 4.17 Decline rates Usual decline rate 4.77 7.45 TM MeNZB decline rate 7.83 7.18 Use of outreach Outreach referrals 9.53 22.17 Estimated final Estimated final coverage coverage 85% 80%
A view from the community One community awareness raiser gave a comprehensive reply to the question “Are there any special reasons Maori might not access vaccinations”?
“To some [Maori] families health is not a priority especially if they struggle to provide the basics of living for their families i.e food, housing, clothing, Some families have chosen to opt off due to information from both sides of the campaign i.e positives versus negatives. Some families have chosen the wait and see approach. Some families have had the disease and lost loved ones and are too scared to take a risk with their other family members. Some families have a she’ll be right attitude, like it won’t happen to us. Some families are
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upset when their babies / children have their first shot and how sore or ill they are after and don’t bother to complete the other two. The timing of the campaign couldn’t have come at [a worse] time of the year – winter. Families wanted the option of immunising all their children (all age groups) at the same clinic, this was off-putting when they were not allowed and decided to opt off.”
National Advisory Group perspectives on Maori coverage NRAG representatives were interviewed in May 2006 to gain their perspectives on the Programme in its final stages. Interview participants considered that the lower overall coverage of Maori was a key issue for the Programme. Participants felt that the Ministry had found it difficult to secure the service delivery required by the Maori sector. Members of NRAG, while sympathetic to the resource constraints faced by the Ministry felt that early action to build the capacity of Maori providers, engage outreach services and to invite Maori into the planning of the programme, could have prevented the service delivery problems that arose.
“The Maori strategy initially was not as strong or coherent as it needed to be. Very frustrating because we knew Maori uptake would be slower. In some ways it took service delivery problems to hit before the advice was really taken up.”
Representatives reported that many DHBs delayed Maori providers’ involvement in the campaign because of protracted contracting processes. Participants appreciated that this was not an exclusive problem for Maori but noted that the consequences for them were far greater. They feared that, unlike Pacific who started mobilising their population during the contracting process, many Maori providers waited to secure approval before committing resources and/or involving iwi.
“There were such delays in DHBs contracting with these providers. Maori providers waited for permission, approval whereas Pacific moved to implement this no matter what. The two populations are entirely different. Hence, the Maori picture is very different.”
Participants advised that the key issue preventing better coverage for Maori was that many Maori under fives do not engage, or have not enrolled with primary care providers. In their view, many Maori families wished to vaccinate their children but could not, or were not willing to, seek vaccination from these providers. They felt that the campaign failed to outreach to those harder to reach because Maori and/or OIS providers often did not have sufficient community health workers and non-medical vaccinators to serve that population.
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“Maori parents wanted to get their children immunised, the low decline rate shows that. But the structure they had to engage with to do that – it just does not work for them.”
NRAG had a number of specific suggestions for improving the delivery of vaccinations to Maori.
Invite Maori, through iwi, to be part of the planning of how to mobilise their population in support of the programme
Engage key influencers of the Maori community in the planning stages of the campaign.
Have timeframes that accommodate Maori protocols for accessing their population
Give DHBs an action plan outlining a ‘step-by-step’ plan of Maori engagement.
Build the capacity of Maori providers (especially around non-medical, outreach, vaccinators) and ensure that they, and outreach providers, receive contracts and resources at the outset of the campaign.
Resource outreach services as the primary means of finding and engaging Maori harder to reach families; rather, than as a ‘back up’ to primary care services.
Provide alternative means of vaccination, community clinics and home vaccinations, for Maori families who do not wish to engage with general practice services.
Encourage OIS and CARs providers to offer vaccination at the time of the awareness raising.
Ensure DHBs prioritise Maori under fives and/or teens.
Guarantee standard ethnicity recording across all IT systems.
Appoint Maori medical representatives, who commit to treating the campaign work as a priority, to the advisory boards
Find the right internal Ministry Maori advisor to ensure strong internal team relations throughout the programme. This advisor should provide ongoing reports to NRAG on Ministry activity for Maori and any issues arising, and may have a role in creating a Maori specific communications campaign that is informed and endorsed by important Maori leaders
Consider the use of incentives to appeal to each age group.
It should be noted that in response to apparent lower coverage being achieved in Maori under 5s a revised Maori strategy 13 was developed in early 2005. Key strategies were
13 Ministry of Health (2005). Maori Strategy - The Next Steps Meningococcal B Immunisation Programme - Internal report.
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A detailed Maori communication plan – leading ultimately to a series of targeted advertisements Additional funding for outreach – initially in the nine DHBs with the highest rates of disease but eventually to all DHBs An examination of data collection strategies, which resulted in the identification of under coding of Maori ethnicity in primary health care.
Delivery to Pacific
The coverage rates achieved for Pacific children were a high point of the Programme, and they even improved slightly after ethnicity adjustment. Pacific coverage rates were higher than for “Other” ethnic groups, despite many Pacific people (over 40%) living in NZDep 9 and 10 areas.
Understanding Pacific coverage
The high Pacific coverage rates appear to the result of a total community effort, coupled with some very strong existing community infrastructure, in particular churches. The extremely high incidence rates of meningococcal disease in Pacific children, and the high numbers of Pacific meningococcal disease survivors in the community, is likely to have resulted in extremely high awareness of meningococcal disease and its possible effects.
The Programme engaged early with key Pacific clinicians and contracted with a collaboration of Pacific providers to develop the national strategy. Pacific health leadership was strong in PHOs, and influential individuals played key roles. Counties Manukau DHB has developed very good working relationships with Pacific health providers and community representatives (for example local government Pacific groups), and these were used effectively in the early stages of the Programme.
There was saturation exposure of the Pacific community with MeNZB TM messages, including Pacific radio and TV, extensive community networking, strong endorsement from key leaders (in particularly church ministers) and involvement of child care facilities. Pacific leaders characterised the achievement as “Pacific people taking responsibility to protect our kids”
Interestingly, in the household survey in Auckland (and Kawerau, although there was only 1 household) 70% of Pacific people recalled being invited for a vaccination, versus 37% for Maori and 32% for Other. This probably reflects high level of MeNZB TM activity by specific Pacific providers in West and South Auckland.
However, it is notable that only 15% of Pacific people attend Pacific providers, therefore high rates for Pacific represent the effects of the Pacific community. Even if rates at Pacific
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providers achieved 100% coverage this would not be enough to explain the high national coverage rates achieved.
National Advisory Group interviewees celebrated the success of the Pacific campaign and described how that this population rallied all sectors of their community to support the programme. They admired the way in which Pacific communities had used all networks to attain a successful outcome. Some reported that the Pacific sector used this campaign to demonstrate that they can reach their population and effectively run public health campaigns.
“The Pacific rates are particularly noteworthy – really, they have to be admired because they are outstanding. The Pacific population got behind this and they have the results to prove it.”
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16. Other factors influencing Programme success
The lessons and recommendations presented so far have summarised the findings from interviews and surveys of Programme stakeholders to describe how the Programme was implemented and how these stakeholders considered they might have delivered the Programme more effectively. This section reviews these findings from an overall Programme perspective and examines the patterns of coverage in relation to DHB characteristics.
National planning and communications
The planning and setting up of the Programme was generally considered to have been very successful. The high level of detail required in Project Implementation Plans, the more than usually rigorous enforcement of the variation to Crown Funding Agreements with DHBs (with funds not being released until all requirements had been met) and the system of Relationship Managers were all effective. These features of the Programme were implemented at a national level, by the Ministry of Health, and applied to all DHBs.
One area that could have been improved in national planning was the liaison with Maori, in particular early engagement of Maori as Programme leaders, including clinical champions. The delays reported by some DHBs in finalising contracts with some Maori providers suggests that more time needed to be allowed for the consultation and contracting process with Maori. This need for extended consultation, and the timeframes required for Maori community engagement could have been incorporated into PIPs.
R31 In any future vaccination campaign sufficient time should be allowed for consultation with Maori, at both a local and national level. Maori key influencers should be engaged early in campaign development. Maori clinical champions should be engaged and have a high profile.
Another feature of Programme implementation at the national level that could have been improved prior to the national roll-out was the operation of IT infrastructure. The functionality of both the SBVS and the NIR was deficient even in Phase 3 (national roll-out, after initial Programme implementation in Counties Manukau then Auckland, Waitemata and Northland).
The national communications campaign was highly effective, as evidenced by the very high levels of awareness achieved. This was assisted by the high visibility of the personal stories of meningococcal disease survivors, which reinforced key messages of the Programme advertising regarding the severity of the disease. In addition, anti-immunisation activism promoted high levels of media interest at various points of the Programme, and very high audience numbers were reported for TV programmes covering the Programme. Progress reports of Programme milestones from the MVS team were also given wide coverage.
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DHB characteristics
The DHB contracting processes, national Programme infrastructure and national communications activity were Programme features common to all DHBs. However, with access to the same resources and within the same national context, at an individual DHB level coverage varied significantly.
The dose 3 coverage achieved ranged from 71% in Bay of Plenty DHB to 91% in Counties Manukau. The following set of graphs illustrates relationships between coverage and DHB characteristics. Histograms along the top show (unadjusted) current age coverage 14 distributions for total dose 3 coverage (“Coverage”), total Maori coverage, Maori coverage for under 5s and Maori coverage for children aged 5-17 years old.
Figure 22 Associations with DHB coverage
DHB Coverage by DHB characteristics
Coverage Maori coverage Maori coverage 6w-4y Maori coverage 5y-17y
Weeks
DHB Population
DHB Maori population
Maori % DHB
School decline rate
The distributions down the side show the number of weeks for which DHBs have been delivering the Programme, the total DHB population, the DHB Maori population, the percentage of the DHB population that is Maori and the percentage of children whose parents
14 Applying the national ethnicity adjustment for undercoding of Maori would not affect these relationships. Applying a different adjustment for each DHB may influence results however.
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/ guardians declined vaccination at school. The scatterplots show the relationship between these variables, with a regression line.
School decline rates predict overall coverage The strongest relationship is between national coverage and school decline rate. Previous analysis showed the (expected) relationship between school coverage and school decline rate. The scatterplots presented here suggest that the school decline rate is good proxy measure for overall negative attitudes towards MeNZB TM immunisation, as the relationship between Maori coverage for under 5s is the same as the relationship for 5-17 year olds.
Coverage weakly related to time a DHB has been vaccinating Overall coverage is very weakly related to the number of weeks that a DHB has been delivering the Programme, but this is entirely due to the Counties Manukau point at the top right of the Coverage x Weeks scatterplot. Counties Manukau was highly atypical as it was the first DHB to deliver the Programme, thus receiving atypical scrutiny, and included a number of children from trials. In addition Counties Manukau has the highest number of Pacific children, who received very high coverage as a result of special features of that community. If this point is removed there is no relationship between the time Programme has been delivered and coverage. This suggests that 1 year (the shortest time the Programme was delivered, in Nelson Marlborough) is long enough for a similar vaccination Programme to be delivered.
Overall Coverage not related to DHB size Overall coverage is not related to DHB size. It might have been hypothesised that larger DHBs may have been able to mobilise more resources, utilising economies of scale in, for example management resources or IT infrastructure. This does not appear to be the case. However, the last three scatterplots for this variable show that larger DHBs achieved lower coverage for Maori. This relationship would be even stronger if the influence of the atypical Counties Manukau was removed. This may reflect difficulty providing urban Maori with access to primary care services, and reinforces earlier findings that service delivery may be easier to more defined, connected, communities.
The lowest Maori coverage achieved was from one of the largest DHBs and the second and third highest Maori coverage was for two very small DHBs .
There is a negative relationship between overall coverage and the number of Maori in a DHB, as expected based on known lower dose 3 coverage for Maori, in children aged 5-17 and 18- 19. However the next variable down, the percentage of Maori in a DHB (as expected negatively associated with overall coverage) is positively associated with Maori coverage. The DHB with highest proportion of Maori is Tairawhiti, which also achieved the highest coverage of Maori children aged 6w-4y.This overall association is mainly due to relationship between the percentage of Maori in a DHB and the coverage achieved for children aged 6w-4y – there
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is no association between the percentage of Maori in a DHB and coverage of children aged 5y-17y. This might reflect the impact of Maori providers and Outreach providers effectively delivering immunisations to Maori children. This interpretation is supported by the analysis of general practice survey data which showed that practices with more Maori children were more likely to use Outreach.
Other DHB characteristics A number of other DHB level features were examined:
A further association between DHB coverage and organisation at a DHB level, noted earlier, was that the three DHBs that always communicated with practices through PHOs (and not directly) had the lowest, second lowest and seventh lowest total coverage.
Nine DHBs ran a centralised outreach referral service. There was no association between a DHB running a centralised Outreach referral service and coverage of Maori children aged 5-17y, but for children aged 6w-4y, the target group for Outreach, coverage was 7% higher in DHBs that ran a centralised service.
The assessment of DHB Programme Managers of the effectiveness of Community Awareness Raising in their DHB had no overall association with achieved total coverage, although the CAR assessed as least effective was in the DHB with lowest coverage.
The assessment of DHB Programme Managers of the working relationship the DHB had with primary care was also unrelated to achieved coverage.
These findings lead to two further recommendations:
R32 Larger DHBs are likely to face greater difficulty in achieving high coverage rates for Maori and need to devote extra resources to reaching urban Maori (possible approaches listed on page 80)
R33 Centralised outreach referral mechanisms should be preferred to relying on practices referring directly to Outreach. Also see R27 – build referral into NIR.
Increase delivery of dose 2 and dose 3
The Programme achieved national dose 1 coverage of 87%. Excluding young people aged 18-19 the dose 1 coverage was 90%. Initial cohort dose 1 coverage was only slightly lower (88%). If all children and young people that received dose 1 completed the vaccination course the target coverage of 90% would have been nearly achieved, although this national figure conceals the under delivery of vaccinations to Maori.
Once a first dose has been delivered the vaccination provider is likely to have contact details for the child or young person. One of the possible strategies for increasing delivery of doses 2
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and 3 would be to increase the immunisation benefit for successive doses. An alternative would be to provide a more finely tuned incentive structure for practice incentive rates. Very few providers (2.5% of PHOs) achieved the rates required to qualify for the highest payments in the Programme.
R34 In future campaigns make sure immunisation payments are regarded as reasonable by providers and build incentive payments around realistic targets.
Characterise good intenders and address any access barriers
It is likely that the key to raising vaccination rates in future vaccination campaigns above those achieved in the Programme is to improve delivery of vaccinations to the “good intenders”. Up to a quarter of the active declining population may also decide to immunise when they have considered further information on vaccine safety and efficacy, as there was a 2% difference between the usual vaccination decline rate and the MeNZB TM decline rate in primary care (and similar decline rates in primary care and school children). However the 5% or so of the population opposed to all vaccinations in the past is unlikely to choose to vaccinate in the future.
Data from the telephone survey and the household survey both suggested an approximately 50/50 split of the non-immunised into active decliners and good intenders. This fits well with national data. Current dose 1 coverage is 87%. Schools data (and GP estimates) suggest 5- 8% decliners. If we assume that only a small proportion of decliners can be convinced to vaccinate, then to get 90% we need to get “good intenders” to (a) start (b) complete vaccination courses. This analysis also fits with data BRC Research collected when they carried out research to develop the Programme communications strategy 15 . On the basis of the research they proposed that the population was likely to fall into three groups: initial adopters (76%), a group who could go either way (12%), and decliners (12%).
The data on ethnicity and deprivation profiles let us target a bit more closely. People living in NZDep 9 and 10 areas have reasonable vaccination rates and major resources were devoted to this group. Coverage rates at the NZDep 1 end are high, This suggests targeting families in the middle NZDep deciles. Analyses of census data, or the algorithms for NZDep calculations might help define these families. It is possible that they are two income families and find it difficult to arrange time to take children for vaccinations. They may use child care / after school care.
A set of strategies to reach the “good intenders” in this group might include using PHNs visiting day care centres, advertising in trade union publications (i.e. targeting workers) and
15 Meningococcal Vaccine Strategy - Exploratory Qualitative Research. BRC Research (2003).
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trying to reach the adults in sports clubs. Schools are a powerful community raising resource, and could be used to help encourage vaccination for non-school aged children. Schools could be explored as immunisation venues for non-school children, given working families often have school and pre-school children. Finally, the use of mobile home-visiting vaccinators might be required to deliver more vaccinations at home.
R35 If all “good intenders” completed vaccinations 90% coverage may have been reached. In future campaigns this group should be carefully characterised and strategies designed to remove all possible access barriers this group may face.
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17. Discussion of the validity of the Programme logic
The evaluation of the initial roll-out reviewed findings against the programme logic developed by the MVS team (see p107), making a number of additions, particularly to make the functions of Community Awareness Raising and Outreach services more explicit in the logic. Generally the assumptions and process models developed to date have been validated, but there are some further additions. The headings below follow the programme logic numbering schema, and include previous findings, any additional insights into these, and extra components when these have been identified.
The concept behind the Programme Logic Model is that a programme can be conceived of as series of steps, each connected to the next by an if / then relationship. Testing the programme logic involves assessing whether the assumed linkages between steps really hold.
1.1 People trust in source of information (e.g. kuia, kaumatua)
Added Phase 2: CAR and other initiatives (1) reach people and (2) motivate / support people to obtain vaccinations.
The first step in the Programme is trusting the information source regarding meningococcal disease and the vaccine. When this source has been a known person it is likely that trust levels have been high. However, for some people, anti-MeNZBTM activity has raised doubt about government sources of information, as described in family interviews and in free text replies to telephone and household surveys. The public statements of two MPs have helped undermine the credibility of government sources for some people. In family interviews people that did not trust government sources were less likely to immunise their children.
2.1 People believe that: 1. Disease is serious
Added Phase 2: Vaccine is the best way to prevent catching the disease: Almost all believed this prompted (BRC tracking survey)
2. Vaccine is safe and effective 3. Disease could affect them
This lack of trust manifests itself predominantly as some ambivalence about the key messages that the vaccine is safe and effective. There has been little indication that people do not believe the disease is serious, although some people interviewed felt that vigilance was a substitute for immunisation. Questions about how likely it is a particular person is to get meningococcal disease have been confusing – for the respondent and the analyst. In earlier research in South Auckland (BRC tracking survey) 47% thought it was “somewhat likely” that they or their family would contract meningococcal disease. This data is difficult to interpret – the chance of getting meningococcal disease small. The correct reply to a question about
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probability of infection is “unlikely” or “very unlikely”. The questions did not allow a rational assessment of risk.
Decline rates from school consent forms are close to those described by primary care. An average of 8.5 % of school children decline vaccination. Practices report that decline rates in primary care are higher from MeNZB TM (median 5, mean 8) from those normally seen for other immunisations (median 4, mean 6).
To clarify the Programme logic perhaps this box should be split into a number of components. (1) people believe the disease is serious, (2) people believe that vaccination will significantly reduce my risk of getting disease, (3) people believe that vaccination is the best way of reducing my risk of getting disease (as opposed to say, strengthening the immune system with multi-vitamins)
3a.1 People motivated to go and get vaccinated Added Phase 2: People who are not motivated are followed up by outreach, which: 1. Reaches people: Monitoring data on outreach not yet available 2. Follows them up to maximise attendance likelihood: Also not available from monitoring data 3. Addresses impediments to attendance: Some provision of links to a practice and transport when required
It appears that even of in the absence of any significant barriers to immunisation some children are not being immunised, even though parents do not oppose immunisation. When asked for free-form responses, some providers have recorded “apathy” as a key reason why Maori are not accessing immunisations at the same rate as “Others”. When adjustment for ethnicity coding has been applied in primary care, it appears that Maori first dose coverage rates are actually higher than Other rates. Thus there does not seem to be an ethnicity component in access to first dose vaccinations, given sufficient time.
Telephone and household surveys have shown that there is a group of people that know that vaccination is available, and where to get it, but still do not get vaccinations. These people were characterised as “good intenders” in the survey analysis.
3a.2 People know where they can be vaccinated
There is no evidence that people do not know how to get an immunisation.
3b.1 Adequate payment for providers: Added phase 2: Providers are supportive of MVS:
Providers have not raised inadequate payment as a disincentive to provide immunisation, although workloads have been very high at times.
3b.2 Providers proactively promote vaccination on every possible occasion Added phase 2: Providers increase opportunities for vaccinations:
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Although it seems obvious that providing increased opportunities for vaccination will improve coverage this has yet to be verified quantitatively. Providers have actively promoted vaccination, including recalls by mail and phone, opportunistic vaccination, drop in clinics and computerised reminders in practice software. In the initial roll-out evaluation there were some data to suggest special clinics may improve coverage. Provider surveys showed that all practices invited eligible children to attend for vaccination and used a wide range of techniques to promote vaccination.
3b.3 Providers believe that: 1. Disease is serious 2. Vaccine is safe and effective:
The initial roll-out evaluation judged the number of providers not having full confidence in the vaccine to be a “cause for concern”. In the survey of providers, providers state that they believe the disease is serious and that immunisation is safe and effective. There was some concern about giving vaccinations to very young babies. It is worth noting that some providers were justified in questioning the effectiveness of the vaccine in young babies. Indeed as more data became available the Ministry instituted a fourth dose to increase antibodies in children that had vaccinations while young.
3b.4 Vaccine is available
Vaccine availability has not been a problem.
4.1 Vaccination offered in an appropriate way for population 4.2 Vaccination offered in appropriate location
There is evidence that people that want a vaccination do not get it. This should to be explored further. This box in the model could usefully disaggregate different components of access to primary health services and possibly to catch-up services for missed first vaccinations at school.
In an attempt to provide a testable framework for thinking about the different aspects of "access", Penchansky and Thomas 16 proposed a definition "in which access is regarded as a general concept which summarises a set of more specific areas of fit between the patient and the health care system". After a review of the literature they proposed five separate dimensions:
Availability: The relationship of the volume and type of services to the clients' volume and type of needs; a measure of adequacy of supply. Accessibility: The relationship between the location of supply and the location of clients, taking account of travel time and transportation resources.
16 Penchansky R and Thomas JW, The concept of access. Medical Care 1981;19:127-40
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Accommodation: The relationship between the manner in which the supply of resources are organised to accept clients and the clients' perceptions of their appropriateness. This includes appointment systems, telephone services and waiting room facilities. Affordability: The relationship between the cost of services and the clients' ability and willingness to pay. Acceptability: The relationship of clients' attitudes about the personal and practice characteristics of providers to the actual characteristics of the existing providers. This framework has been tested in New Zealand 17 and seems to have some validity in that the different components can be distinguished. Further, satisfaction with different components of access was able to related to consultation rates. It has been recently employed in a New Zealand investigation into access to asthma care 18 Disaggregation of access components may assist identification of the reasons some people that say they want to vaccinate have not yet done so.
5.1 Person or guardian accepts 1st vaccination.
6.1 Vaccination is adequately recorded in follow-up system 6.2 Active follow-up occurs in all situations 6.3 Good vaccination experience 6.4 Vaccinated people/parents believe that: 1. Benefits of vaccination outweigh small side-effects 2. Once is not enough
The NIR, after teething problems, has worked well capturing data, and provided excellent reporting on the Programme. Providers are providing active follow-up, usually devoting more resources to follow-up than immunising new children. Clients have reported good vaccination experiences, although children report that the vaccination can be very sore.
7.1 Person or guardian accepts 2nd and 3rd vaccinations
There is some attrition between doses, with fall off observed in both schools and primary care settings. In the case of Maori it may just be a matter of allowing sufficient time for vaccination to be arranged.
8.1 Adequate vaccination coverage in all groups (90%) Only Pacific children achieved vaccination rates over 90%.
17 Gribben B. Do access factors affect utilisation of general practitioner services in South Auckland? N Z Med J. 1992;105:453–5.
18 Buetow S, Adair V, Coster G, Hight M, Gribben B, Mitchell E. Reasons for poor understanding of when and how to access GP care for childhood asthma in Auckland, New Zealand. Fam Pract. 2002 Aug;19(4):319-25.
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Meningococcal B Immunisation Evaluation Final Report p 108 CBG Health Research November 2006
18. Key lessons and recommendations
The specific lessons and recommendations from earlier sections are brought together below, and this section then considers why the Programme worked well in some areas and not so well in others, and considers other key findings that could be used to improve future Programme delivery.
Analysis of coverage data The methods used to quantify ethnicity under-coding in primary care have a significant impact on conclusions regarded coverage by ethnicity.
R1 Further research should be undertaken to understand the extent of ethnicity under-coding in primary care.
Vaccine control and distribution R2 Tight inventory control, strict inventory reporting and systematic vaccine allocation are effective vaccine management strategies. The vaccine management and distribution processes for used the Programme were highly effective and would form a solid basis for any future immunisation programme.
Setting up the Programme DHBs can successfully manage establishing the infrastructure for the delivery a major mass vaccination campaign that uses Public Health Nurses for school based delivery and existing primary care providers for children aged under 5. Other more centrally driven or devolved delivery mechanisms could have been employed, but the DHB approach has worked well.
R3 DHBs could be used to coordinate and manage the delivery of a similar vaccination campaign in the future.
Tight specification of contracting requirements between DHBs and local providers helped DHB meet national requirements for equity and effectiveness.
R4 The Ministry should consider using tight contracting with DHBs in any future vaccination campaign.
Relationship managers were an important reason for successful implementation. Relationship managers facilitated communications between DHBs and the Ministry of Health and also provided a useful way to share information regionally.
R5 The Ministry should consider using a system of “relationship managers” responsible for managing the Ministry / DHB interface for groups of DHBs within the same region in any future vaccination campaign.
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The three DHBs that did not communicate directly with practices had low vaccination rates.
R6 Direct communication between DHBs and practices may be more effective than PHO mediated communication in any future vaccination campaign.
Communications and media The communications strategy was successful in achieving its goal of high intensity coverage.
This consisted of planned releases about programme development and implementation but also included high profile MeNZB TM cases. These were powerful media opportunities.
Even negative coverage appeared to be followed by a positive response, further increasing exposure for the Programme.
R7 The Ministry communications team advised that in future programmes they would:
• Encourage tighter linkage between advertising and vaccination opportunities • Use more print advertising, especially advertorials • Capitalise on local knowledge for distribution • Consider funding DHBs for communications including employing additional communications staff Despite a large amount of information being made available, journalists still suggested improving accessibility of spokespeople, and making more information available on the website.
R8 Provide access to as much information as possible, through spokespeople with high availability, briefings and a comprehensive web site.
By far the most common theme of print stories was informational (eg advising vaccination was about to start), distantly followed by discussions of risk and benefits of the vaccine itself and safety of the vaccine. The discourse was most often neutral, followed by “scientific” and “fear”
There may be some weak evidence of local media activity encouraging vaccination, but the evidence available is difficult to interpret.
Community Awareness Raising It is difficult to assess the impact of specific CAR activities over and above the effect of the intensive national advertising campaign.
Some primary care providers reported influxes of children for vaccination after CAR community events. DHB project managers were less certain of its overall value. Some DHBs reported very poor results from non targeted CAR for example leaflets, radio advertising, general door knocking.
Meningococcal B Immunisation Evaluation Final Report p 110 CBG Health Research November 2006
On the other hand, targeted CAR with specific Maori or Pacific communities, for example at kohanga reo or “whanau ora” days, with opportunities for one-on-one engagement, was considered effective by CAR providers, PHOs and some DHBs.
R9 CAR activities that involve direct engagement with small groups and individuals are likely be the most effective, and should be preferred over other local activities.
In all cases CAR works best when delivered by people with established links with the targeted community.
R10 CAR is most effectively delivered by individuals known to the target community.
Many CAR providers emphasised that CAR should be linked with vaccination if possible.
R11 Individually oriented CAR should be linked with an immediate opportunity to vaccinate whenever possible. In practice this might mean starting CAR when vaccinations start.
Under 5s Although considerable progress has been made towards achieving internationally acceptable vaccination rates (90%+) in recent years the processes for delivering vaccinations to a primary care population still need to be improved.
Based on adjusted figures Primary Care was equally effective delivering first dose vaccinations to Maori and Other ethnicities. The higher coverage achieved for Pacific children suggests the Pacific model of complete community involvement with should be considered whenever circumstances permit.
Based on the fact that adjusted dose 1 rates are the same for Maori and Other and the known slower uptake of immunisations by Maori (see uptake curves in section 15) it is possible that similar dose 3 coverage could be achieved for Maori as for Other given more time.
Primary care did not appear to use Outreach services particularly effectively with 44% of practices not referring to Outreach. The main reasons were the difficulty of referring and impact on practice income.
R12 Outreach referral processes from primary care should be streamlined in any future vaccination campaign. One possibility is to incorporate a specific “refer to outreach” code into the NIR system so that practices only have to enter a single code to precipitate an effective referral. This could be picked up at the NIR and distributed back to the appropriate agency.
Vaccine distribution and cold chain maintenance can be successfully implemented with available systems in primary care. Practices are now well placed to store and maintain vaccine for a similar campaign.
R13 The processes used to establish vaccine management procedures were effective and should be used again in the event a similar campaign is required in the future.
Meningococcal B Immunisation Evaluation Final Report p 111 CBG Health Research November 2006
School aged children The delivery of MeNZB TM through schools was a large and complex logistical exercise. The achieved coverage shows that Public Health Nurses can deliver large numbers of vaccinations quickly to school children.
R14 Schools based vaccination delivery is very effective for delivering a mass vaccination and should be utilised if possible for school aged children, particularly if rapid coverage is an important objective.
Cooperation of schools is critical to success. Schools were willing and able to help, including assisting with managing consent distribution and follow-up. However schools need as much time as possible to plan for vaccination days.
R15 Schools need to be advised of vaccination rollout planning and timetables as early as possible
Even though considerable work was done to design an easy to use consent form it was generally regarded as too complicated. Approximately one quarter were not completed correctly and a lot of nurse time was used completing consent forms.
R16 Consent forms should be as simple as possible, and not appear complex. A significant field test of forms for any future vaccination project is recommended.
Managing the volume of consents was a challenging task. Some consent forms were not able to be located when required.
R17 Consideration could be given to scanning consents and using electronic systems (mobile computers) for recording information.
It was reported that some parents did not have enough information. The use of school information evenings is a sensible way to provide this, with expert advice available, and has the added benefit of contributing to community awareness raising.
R18 The use of schools as locations for wider information dissemination and community awareness raising (as well as vaccination venues) should be considered in any future vaccination campaign.
Most people are happy to have their children immunised at school. The average decline rate was 8.5%. It is likely that only a very small proportion of these people preferred their GP to give the vaccination. Absenteeism is the commonest reason for missing vaccinations. Nine percent of children are absent on any single day. Catch-up clinics are thus an essential part of any schools based vaccination strategy.
R19 Any future vaccination campaign delivered through schools must include planning for catch-up clinics similar to those in the Programme.
Meningococcal B Immunisation Evaluation Final Report p 112 CBG Health Research November 2006
Some DHBs reported that timing vaccinations so that catch up could occur at holiday periods, at the school, had been very helpful (although this had just happened by chance).
R20 Timing of any future vaccination campaign should consider the timing of catch-up clinics in relation to school holidays.
The SBVS IT infrastructure has enhanced the capacity of PHNs to deliver vaccinations.
R21 The SVBS is now fully functional and should be used for other vaccination programmes. Consideration should be given to methods for maintaining the knowledge and skills of the people that used that this system.
18 – 19 year olds Young people were aware of meningococcal disease and the vaccination Programme, however they did not generally consider Meningococcal B be a threat, and therefore do not think they are at risk from contracting it.
R22 In future campaigns advertising resources should be devoted to documenting and advertising situations that describe the disease and its impact on young people aged 16-19.
Some young people require easy access alternatives because they do not want to be seen to actively seek vaccination, and/or go to the GP.
R23 Future vaccination campaigns should consider providing multiple vaccination opportunities for young people including at youth centres, work sites, tertiary education and other training sites and at community venues such as parks and shopping malls.
Vaccination offered at sports events or concerts are unlikely to be effective – youth don’t like being approached for vaccination when they have gone to an event for quite a different purpose. However, the young people thought that it would be acceptable for Meningococcal B providers to create fun events for the specific purposes of providing vaccinations.
R24 Opportunities for group vaccination should be explored, and incentives such as free coffee, competitions or vouchers should be considered.
Some school leavers have fallen behind the vaccination schedule because they have not sought vaccination through primary care or, to the best of their knowledge, have not been approached to complete the vaccinations.
Meningococcal B Immunisation Evaluation Final Report p 113 CBG Health Research November 2006
R25 Young people who leave school should be offered subsequent doses via primary health care services. This would require formal handover to primary care and would involve linking SBVS data with primary health care records.
Outreach The data available on Outreach service provision was very variable and limits an assessment of impact. Much better reporting can be reasonably expected, even of newly established organisations.
R26 Future vaccination programmes that include outreach provision should have tighter reporting requirements. The variable reporting suggests building some functionality into the NIR for supporting the registering and tracking of outreach referrals.
The limited data that was supplied by Outreach providers was highly variable in scope and presentation.
R27 To assist outreach providers manage the delivery of Outreach services within their organisation a free web based application could be developed and provided to any group that wanted to use it. This would automatically provide remote access to client management tools (allocating responsibility to an outreach provider, checking status, recording an immunisation given) through a mobile internet connection.
Many primary care providers did not use Outreach effectively, typically because it was too time consuming.
R28 Outreach referral could be improved by adding a “referral to outreach” immunisation claim. These “claims” could then be collated and referred to the appropriate outreach provider, or regional coordination service.
The available data shows at least 1% of all vaccinations given were facilitated through Outreach. This represents 4.5% of all vaccinations given to children aged 6w-4y.
Community Outreach is most effective when targeted to children and families known to still require vaccination
The venue for community clinics is important and should be culturally appropriate and easily accessible. Opening times should recognise that many children are in working families.
Door knocking and providing clinics to non-specific families contained within an area of lower coverage does not result in a high number of vaccinations.
R29 Home visiting resources should only be devoted to calling on identified families who cannot be otherwise contacted.
Meningococcal B Immunisation Evaluation Final Report p 114 CBG Health Research November 2006
Outreach vaccination is expensive, approximately $240 per vaccination given.
R30 To reduce the cost of outreach immunisation opportunities to incorporate the delivery of outreach immunisation services into other home health visitor services should be explored.
Other considerations
One area that could have been improved in national planning was the liaison with Maori, in particular early engagement of Maori as Programme leaders, including clinical champions. The delays reported by some DHBs in finalising contracts with some Maori providers suggests that more time needed to be allowed for the consultation and contracting process with Maori. This need for extended consultation, and the timeframes required for Maori community engagement could have been incorporated into PIPs.
R31 In any future vaccination campaign sufficient time should be allowed for consultation with Maori, at both a local and national level. Maori key influencers should be engaged early in campaign development. Maori clinical champions should be engaged and have a high profile
An analysis of associations between DHB characteristics and coverage showed that, within a DHB, school decline rates predicted overall coverage. Coverage was only weakly related to time a DHB has been vaccinating and overall coverage was not related to DHB size. There is a negative relationship between overall coverage and the number of Maori in a DHB, as expected based on known lower dose 3 coverage for Maori, in children aged 5-17 and 18-19. However the percentage of Maori in a DHB is positively associated with Maori coverage.
R32 Larger DHBs are likely to face greater difficulty in achieving high coverage rates for Maori and need to devote extra resources to reaching urban Maori (possible approaches listed on page 75)
R33 Centralised outreach referral mechanisms should be preferred to relying on practices referring directly to Outreach. Also see R27 – build referral into NIR.
One of the possible strategies for increasing delivery of doses 2 and 3 would be to increase the immunisation benefit for successive doses. An alternative would be to provide a more finely tuned incentive structure for practice incentive rates. Very few providers (2.5% of PHOs) achieved the rates required to qualify for the highest payments in the Programme.
Meningococcal B Immunisation Evaluation Final Report p 115 CBG Health Research November 2006
R34 In future campaigns make sure immunisation payments are regarded as reasonable by providers and build incentive payments around realistic targets.
It is likely that the key to raising vaccination rates in future vaccination campaigns above those achieved in the Programme is to improve delivery of vaccinations to the “good intenders”. A set of strategies to reach the “good intenders” in this group might include using PHNs visiting day care centres, advertising in trade union publications (i.e. targeting workers) and trying to reach the adults in sports clubs. Schools are a powerful community raising resource, and could be used to help encourage vaccination for non-school aged children. Schools could be explored as immunisation venues for non-school children, given working families often have school and pre-school children. Finally, the use of mobile home-visiting vaccinators might be required to deliver more vaccinations at home.
R35 If all “good intenders” completed vaccinations 90% coverage may have been reached. In future campaigns this group should be carefully characterised and strategies designed to remove all possible access barriers this group may face.
Conclusion
Overall the Meningococcal B Immunisation Programme has been implemented successfully, and is a tribute to the Meningococcal Vaccination Strategy team, and the large numbers of other health workers that have contributed to its success. In the historical context of low vaccination rates in New Zealand and high levels of anti-immunisation activity, it has achieved a very good result. The final coverage rates of 80% (78% of the “initial cohort”) may increase slightly as the Programme has been extended from the original June 30 until December 2006 for children 5-19 years and until 2009 for children less than 5 years old.
Key components have been put in place for future vaccination programmes, in particular vaccine management procedures, the NIR, and an expanded range of outreach immunisation services. Most valuable is probably the experience of numerous individuals in the health sector that have been directly involved in delivering the Programme. In the event of the requirement for another mass vaccination campaign, for example for pandemic influenza, the country is better placed than it has ever been to deliver vaccinations.
Meningococcal B Immunisation Evaluation Final Report p 116 CBG Health Research November 2006
Glossary
BRC BRC Marketing and Social Research CAR Community Awareness Raising CHW Community Health Worker DHB District Health Board CARM Centre for Adverse Reactions Monitoring CFA Crown Funding Agreement ESR Environmental Science and Research (a Crown Research Institute) GM General Manager IMAC Immunisation Advisory Centre ISMB The Independent Safety Monitoring Board MeNZB TM The trade marked name of the vaccine produced by Chiron Corporation against the strain of Neisseria meningitidis responsible for the NZ epidemic of meningococcal disease The Ministry The New Zealand Government Ministry of Health MVS Meningococcal Vaccine Strategy NHI National Health Index NIR National Immunisation Register OIS Outreach Immunisation Service Initial roll-out evaluation The evaluation of the initial roll-out Phase 1 (Counties Manukau and “Eastern Corridor”) and Phase 2 (wider Auckland) by Phoenix Research PHN Public Health Nurse PHO Primary Health Organisation PIP Project Implementation Plans PMS Practice Management System SIA Services to Improve Access SIMPL Programme National Meningococcal B Immunisation Programme SBVS School Based Vaccination System
Meningococcal B Immunisation Evaluation Final Report p 117 CBG Health Research November 2006
Appendices
CAR survey
GP survey
PHO survey
PHN survey
Outreach survey
DHB survey
CATI <5s
HH survey
Meningococcal B Immunisation Evaluation Final Report p 118 CBG Health Research November 2006
CAR survey
23 of the 42 (55%) CAR providers identified by DHBs answered the questionnaire. It was difficult to establish contact with some organisations, and when contact was established there was often uncertainty as to who should complete the questionnaire. This report summarises the replies from these 23 providers.
1. Service In your opinion, did the contract with the DHB provide a clear indication of what services it was expected would be provided? Average response: 3.7 (1=not clear at all 5=perfectly clear)
2. Staff
Average FTEs devoted to the implementation of Meningococcal B CAR activity 2.3
30% of CAR respondents had FTEs specifically allocated to Maori CAR. Average FTEs specifically allocated to Maori CAR: 1.5
22% of CAR respondents had FTEs specifically allocated to Pacific CAR. Average FTEs specifically allocated to Pacific CAR: 1.6
17% of services employed any extra staff to do MeNZB CAR – Average FTEs: 0.7
Did you have enough time to prepare for the delivery of your community awareness raising activities? Average response: 3.3 (1=not enough time 5=heaps of time)
Staff received training for community awareness raising activities in 78% of CAR respondents. Was the training received about the MeNZB vaccination sufficient to deliver the CAR that was requested? Average response: 3.9 (1=inadequate 5=excellent)
Was there enough preparation about how to actually deliver CAR itself? Average response: 3.7 (1=inadequate 5=excellent)
3. Set up
Were the resources and information available adequate to support the campaign? Average response: 3.7 (1=resource inadequate 5=no problems at all with supplied info and resources)
Meningococcal B Immunisation Evaluation Final Report p 119 CBG Health Research November 2006
How would you rate liaison with the DHB (or PHO) over the delivery of CAR for MeNZB? Average response: 3.7 (1=very poor 2= poor 3=reasonable 4=good 5=excellent)
How would you rate the liaison with primary care over CAR activities? Average response: 3.7 (1=very poor 2= poor 3=reasonable 4=good 5=excellent)
4. Barriers to MeNZB immunisation (score1-5)
Can you please give your views on the barriers to MeNZB Immunisation?
1 = Totally Disagree, 2 = Disagree, 3 = Neither, 4 = Agree, 5 = Totally Agree Patient difficulties in accessing services 3.6 Parental apathy regarding immunisation 3.6 Parental fear regarding immunisation 3.7 Parental ambivalence or uncertainty regarding immunisation 3.7 Poor DHB direction 1.9
Other barriers to immunisation – Initial coding:
Other barriers to immunisation % Lack of understanding/education 37.5 Barriers to access 25 Transient clients 6 Timing of the campaign 6 Fear of immunisation 6
5. Delivering CAR services
CAR activities initial coding:
CAR activities % Community meetings/education 86 Face to face 59 Posters/handouts 50 Promotions at community events 32 Radio/TV/newspaper 27 Other 1
Meningococcal B Immunisation Evaluation Final Report p 120 CBG Health Research November 2006
Most effective CAR activity initial coding:
Most effective CAR activities % Community meetings/education 25 Face to face 50 Posters/handouts 10 Promotions at community events 20 Radio/TV/newspaper 10 Other 0
6. Overall
CAR Service Providers identified the following successes during the MeNZB programme:
What has worked well? % Esatblished community links 48 Personal contact with clients 30 Well resourced/organised 17 Team work 17 Other 17
Factors identified as not being so successful during the MeNZB CAR programme are:
What has not worked well? % Negative reports/media 28 Lack of time/resources 17 Use of print media 17 Lack of communication/team work 11 Timing 6 Other 39
Meningococcal B Immunisation Evaluation Final Report p 121 CBG Health Research November 2006
CAR providers highlighted some improvements that could be made to subsequent MeNZB CAR programmes:
Improvements % More funding/resources 29 More one to one contact 18 More utilisation of media 12 Increase community invlovement 12 Other 35
The single most important reasons limiting vaccination uptake were identified as being:
Most important reason limiting vaccination uptake % Fear 13 Apathy 17 Not a priority 13 Lack of access 9 Lack of knowledge 9 Other 17
87% of CAR respondents detailed specific reasons why some Maori clients do not access MeNZB immunisations. These are listed in the table below:
Factors limiting Maori uptake % Access issues 35 Lack of knowledge 40 Not a priority 25 Fear 15 Lack of Maori providers 20 Other 25
35% of respondents offered specific reasons why some Pacific clients are not accessing MeNZB immunisations. These are as follows:
Factors limiting Pacific access % Language barriers/service not targeted to Pacific communities 14 Lack of knowledge/understanding 29 Access issues 29 Transient faimlies 14
Meningococcal B Immunisation Evaluation Final Report p 122 CBG Health Research November 2006
GP survey MeNZB Vaccination Campaign Evaluation Practice Questionnaire Summary
In total 322 practices were invited to participate in the provider survey. 69 practices declined and 3 clinics were not eligible (e.g. one was a sports medicine clinic only), leaving a final sample of 250. The overall participation rate was 78.4%.
1. Practice related questions The practices that have completed the questionnaire reported that 20% were Access funded, 76.4% were Interim funded, and 3.6% used other funding types. 81.8% of the practices were recorded as being urban practices, and 18.2% were on the rural funding formula.
The average percentage of Maori in practice populations was reported as 17.6% (Range 0.5 - 99). The average percentage of Pacific clients in practice populations was reported as 3.2% (Range 0.01 - 85).
85.9% of the respondents were practice nurses, 4% were practice nurses and managers, 4% were practice managers, 3.2% were GP’s, and 3.3% described themselves as ‘other’. 100% of the nurses responding were nurse vaccinators.
2. IT related questions 72% of practices were able to enter data into the NIR at the start of the Campaign. 95.5% can enter data into the NIR now. 84.1% are able use the NIR to check immunisation status, with 73.6% actually using it to do so. 91% of practices reported that the electronic claiming system is currently working.
3. Staffing questions 62.3% of practices reported employing extra staff to manage the demands and work arising from the campaign. A breakdown of the average hours per week used in practices is as follows: Extra nurse hours per week 16.8 (Range 1 - 80) Extra admin hours per week 12.9 (Range 1 - 120) Extra GP hours per week 10.8 (Range 1 - 40) Extra other hours per week 0.6 (Range 1 - 30)
32.1% of the practices would have ideally required extra staffing hours over and above the amount they received. A breakdown of the average ideal extra hours per week required for practices is as follows: Ideal extra nurse hours per week 4.6 (Range 1 - 100) Ideal extra admin hours per week 1.8 (Range 1 - 120) Ideal extra GP hours per week 0.4 (Range 1 – 5) Ideal extra other hours per week 0.4 (Range 1 – 70)
Meningococcal B Immunisation Evaluation Final Report p 123 CBG Health Research November 2006
Did the MeNZB work significantly affect the delivery of other services (e.g. other recalls delayed / services not delivered)? Average response: 3.1 (1=no impact 5 =very significant impact)
Impact of MeNZB on other services
80 60 40 20 Frequency 0 1 2 3 4 5 Response
How strongly do practice staff support the campaign? Average response: 4.6 (1=minimal support 5 =very strong support)
Staff support of MeNZB
200 150 100 50 Frequency 0 1 2 3 4 5 Response
In your opinion, is the MeNZB campaign a good use of public money? Average response: 4.2 (1=a waste of money 5=excellent use of money)
Good use of public money
150
100
50 Frequency 0 1 2 3 4 5 Response
Meningococcal B Immunisation Evaluation Final Report p 124 CBG Health Research November 2006
Average response confidence in the safety of the MeNZB vaccine: 4.4 (1=no confidence 5=full confidence )
Confidence in safety of vaccine
150 100 50
Frequency 0 1 2 3 4 5 Response
Average response confidence in the effectiveness of the MeNZB vaccine: 3.9 (1=no confidence 5=full confidence)
Confidence in effectiveness of vaccine
150 100 50
Frequency 0 1 2 3 4 5 Response
34.6 % of respondents had concerns regarding giving MeNZB at six weeks? Initial coding of responses is as follows:
Concerns about giving MeNZB at 6 weeks % Concern about the number of injections 6 week olds receive 77.6 Concern about the size of 6 week olds 71.7 Felt 6 weeks is too young 22.4 Concern about a perceived lack of information and research on vaccine 11.8 Other 30.6
Meningococcal B Immunisation Evaluation Final Report p 125 CBG Health Research November 2006
4. Set up
Were the resources and information supplied to your practice adequate to support the campaign? Average response: 4.3 (1=resource inadequate 5=no problems at all with supplied info and resources)
Adequate set up resources
150 100 50 Frequency 0 1 2 3 4 5 Response
90.5% of respondents were clear about the eligibility criteria for MeNZB at the start of the Campaign, and 98% are now clear about the criteria.
5. Barriers to MeNZB immunisation average responses: Patient difficulties in accessing services: 2.0 (1 = Totally Disagree, 2 = Disagree, 3 = Neither, 4 = Agree, 5 = Totally Agree)
Difficulties with access
150 100 50
Frequency 0 1 2 3 4 5 Response
Parental apathy regarding immunisation: 3.1 (1 = Totally Disagree, 2 = Disagree, 3 = Neither, 4 = Agree, 5 = Totally Agree)
Parental apathy
100 80 60 40 20 Frequency 0 1 2 3 4 5 Response
Meningococcal B Immunisation Evaluation Final Report p 126 CBG Health Research November 2006
Parental fear regarding immunisation: 3.7 (1 = Totally Disagree, 2 = Disagree, 3 = Neither, 4 = Agree, 5 = Totally Agree)
Parental fear
150 100 50
Frequency 0 1 2 3 4 5 Response
Parental ambivalence or uncertainty regarding immunisation: 3.7 (1 = Totally Disagree, 2 = Disagree, 3 = Neither, 4 = Agree, 5 = Totally Agree)
Parental uncertainty
150 100 50
Frequency 0 1 2 3 4 5 Response
Lack of funding for providers: 2.4 (1 = Totally Disagree, 2 = Disagree, 3 = Neither, 4 = Agree, 5 = Totally Agree)
Lack of funding
100 80 60 40 20 Frequency 0 1 2 3 4 5 Response
Meningococcal B Immunisation Evaluation Final Report p 127 CBG Health Research November 2006
Lack of time for providers to offer services: 2.7 (1 = Totally Disagree, 2 = Disagree, 3 = Neither, 4 = Agree, 5 = Totally Agree)
Lack of time
80 60 40 20 Frequency 0 1 2 3 4 5 Response
Lack of knowledge in health professionals: 1.8 (1 = Totally Disagree, 2 = Disagree, 3 = Neither, 4 = Agree, 5 = Totally Agree)
Lack of provider knowledge
150 100 50
Frequency 0 1 2 3 4 5 Response
Poor Ministry direction: 2.2 (1 = Totally Disagree, 2 = Disagree, 3 = Neither, 4 = Agree, 5 = Totally Agree)
Poor Ministry direction
100 80 60 40 20 Frequency 0 1 2 3 4 5 Response
Meningococcal B Immunisation Evaluation Final Report p 128 CBG Health Research November 2006
6. Declines The average proportion of patients normally declining immunisations was reported as being 5.8% (Range 1 – 70). The average proportion of patients that have declined MeNZB was reported as 7.9% (Range 1 - 60).
Of the practices reporting a proportion of patients declining immunisation, 28% reported that they had the same proportion declining MeNZB immunisation as normally declining, 52% had more patients declining MeNZB than usually declining, and 20% had less patients declining MeNZB than usually declining immunisation.
Initial coding for responses to the main reasons mentioned by parents for declining is as follows:
Reasons for parents declining MeNZB immunisation % Concern about safety and effectiveness of vaccine 55 Usually do not receive vaccinations 32 Negative media reports 13 Lack of knowledge regarding immunisation 6.5 Negative reports from other parents 6 Influenced by anti-immunisation lobby 6 Other reasons 49
7. Other support services 53.5% of practices have accessed services from their PHO. Practices have made on average 12.6 referrals to Outreach. 13% of practices reported that there were barriers to them using outreach services. Coding of these barriers is recorded in the table on the following page:
Barriers to using Outreach % Extra time and work involved 38 Funding issues 13 Other 66
62% of those using outreach services reported that it resulted in the referred children being immunised. On average, it was estimated that 41.3% of the children referred to outreach received MeNZB immunisation. However, 14% of practices using outreach were unsure of the whether any of the children referred to outreach had received immunisation.
8. Recalls 100% of respondents invited eligible children to come in for vaccination. 96.3% used letters to recall patients with an average of 1.9 letters sent. 93.8% used phone calls to recall patients with an average of 2 calls. 34.4% of practices phoned after hours or weekends.
Meningococcal B Immunisation Evaluation Final Report p 129 CBG Health Research November 2006
32.8% of practise used other methods used to recall patients are detailed in the table below:
Other methods of recalling patients % Opportunistic 54 Local advertising 20 Home visits 13 Other 38
91.3% of respondents give immunisations for “drop ins” i.e. without an appointment, with 87.1% feeling this is an effective method of vaccination. 22% of those surveyed operated a “drop in clinic” at special times, where children are seen without appointments. 28.2% felt this was an effective method of vaccination. 73.9% of practices operated an immunisation clinic that parents had to make appointments at. 71.8% felt this was effective.
82% of practices identified a group or groups that were proving hard to reach. Practices identified that the following groups are proving hardest to reach:
Groups proving difficult to reach % Maori 17 Transient patients 13 School leavers 58 Low socio-economic patients 12 Patients with no phone 5 Those who usually do not vaccinate 7 Pacific 6 Other 24
Meningococcal B Immunisation Evaluation Final Report p 130 CBG Health Research November 2006
9. Overall Practices identified the following successes GP delivery of the MeNZB vaccine:
What has worked well? % Adequate information and education for patients 21 Adequate organisation and resources 29 Having dedicated immunisation clinics 22 Team work/dedication of staff 19 The recall system 14 Drop-in immunisations 9 Having good relationships with patients 17 Incentive systems 7 Other 27
Factors identified as not being so successful in GP delivery of the vaccine are:
What has not worked well? % Timing of the vaccine (clashing with flu vaccinations and winter illness) 12 Negative media reports 6 Extra workload 15 Issues with school leavers 11 IT issues 6 Other 36
Average percentage coverage : Dose1= 84.6% Dose2= 76% Dose3= 62.4%
Average estimate of the final coverage (3 doses) practices will achieve: Estimated final coverage = 83.8%
The single most important reasons limiting vaccination uptake were identified as being:
Most important reason limiting vaccination uptake % Apathy 11 Negative media messages 11 Concern about safety and efficacy of the vaccine 13.5 Fear 4.5 Lack of knowledge 7 Winter illnesses 5 Anti-immunisation lobby 6 Other 32
Meningococcal B Immunisation Evaluation Final Report p 131 CBG Health Research November 2006
45% of practices detailed specific reasons why some Maori clients do not access MeNZB immunisations. These are listed in the table below:
Factors impacting on Maori access % Apathy 32 Transport issues 25 Negative messages from media and/or Maori leaders 10 Lack of knowledge 17 Debt with practice 5 Other 58
21% of respondents offered specific reasons why some Pacific clients are not accessing MeNZB immunisations. These are as follows:
Factors limiting Pacific access % Apathy 25 Lack of knowledge 24 Language barriers 18 Transport issues 20 Other 76
Meningococcal B Immunisation Evaluation Final Report p 132 CBG Health Research November 2006
PHO survey
1. PHO descriptions.
52 of 74 PHOs (70%) responded to the questionnaire, including all the PHOs with populations over 100,000.
Population Average – 63,165 % Maori Average – 26.2% % Pacific Average – 12.1% % Quintile 5 Average – 36% Number of Practices Average – 17 Access Average – 39% Interim Average – 20%
2. IT When your practices started immunising were PMS systems able to upload data to the NIR? Percentage yes – 64%
80% of PHOs surveyed indicated that practices experience any difficulties uploading to NIR. Initial coding below:
Difficulties uploading to NIR % Lack of training/human error 33 Error messages 31 Reliability issues 23 Incompatability issues 15 Connection issues 15 Other 18
Estimated average percentage of practices that use the NIR to check immunisation status: 68%
PHOs surveyed reported that 66% practices on average experienced problems checking immunisation status using the NIR. Initial coding below:
Problems checking immunisation status % Time delay 58 Relaibility/connection issues 36 Training issues 19 Accuracy of reporting 11 Other 14
42% of respondents indicated that reports generated from NIR and returned to practices were accurate.
Meningococcal B Immunisation Evaluation Final Report p 133 CBG Health Research November 2006
3. Staff
84% of the PHOs that responded felt that the MeNZB work significantly affect the delivery of other services by their PHO. On average respondents 1.6 devoted FTEs to the implementation of MeNZB.
4. Set up
How would you rate the liaison with the DHB over the delivery of MeNZB? Average Response: 3.8 (1=very poor 2= poor 3=reasonable 4=good 5=excellent)
Liaison with DHB
20 10 0 Frequency 1 2 3 4 5 Response
How would you rate the liaison with the NIR administration over the delivery of the NIR database processes? Average response: 3.8
(1=very poor 2= poor 3=reasonable 4=good 5=excellent)
Liaison with NIR Administration
30 20 10 0 Frequency 1 2 3 4 5 Response
66% of respondents indicated that their PHO provided Community Awareness Raising activities. Other organisations that provided CAR mentioned are: DHBs, organisations contracted by the DHB, individual providers, as well as existing youth health, Maori and Pacific providers.
Meningococcal B Immunisation Evaluation Final Report p 134 CBG Health Research November 2006
How would you rate the liaison with other providers of CAR? Average response: 3.6
Liaison with CAR providers
30 20 10 0 Frequency 1 2 3 4 5 Response
(1=very poor 2= poor 3=reasonable 4=good 5=excellent)
What is your overall impression of the success of CAR services? Average response: 3.2 (1=no impact at all 5=highly successful)
Success of CAR services
30 20 10 0 Frequency 1 2 3 4 5 Response
What CAR activities seemed to work? Initial coding: Most effective CAR activities % Community meetings/education 25 Face to face 50 Posters/handouts 10 Promotions at community events 20 Radio/TV/newspaper 10 Other 0
How could CAR be improved in any future campaign? Initial coding:
CAR improvements % Better funding/resources 41 More input/consultation 22 Better timing 16 More specific targeting to populations 8 Other 22
Meningococcal B Immunisation Evaluation Final Report p 135 CBG Health Research November 2006
Overall, were the resources and information available to your PHO adequate to support the campaign? Average response: 3.9 (1=resource inadequate 5=no problems at all with supplied info and resources)
Adequate resources
20 15 10 5 Frequency 0 1 2 3 4 5 Response
5. Barriers to MeNZB immunisation (score1-5)
Can you please give your views on the barriers to MeNZB immunisation?
1 = Totally Disagree, 2 = Disagree, 3 = Neither, 4 = Agree, 5 = Totally Agree Patient difficulties in accessing services 2.8 Parental apathy regarding immunisation 3.4 Parental fear regarding immunisation 3.7 Parental ambivalence or uncertainty regarding immunisation 3.6 Lack of funding for providers 3.1 Lack of time for providers to offer services 3.6 Lack of knowledge in health professionals 2.1 Poor Ministry direction 2.7 Poor DHB direction 2.3
Any other barriers to immunisation? Initial coding:
6. Outreach
75% of the PHOs responding provided MeNZB Outreach services. Other organisation that provided outreach services were DHB organisations and existing outreach providers.
Meningococcal B Immunisation Evaluation Final Report p 136 CBG Health Research November 2006
How would you rate the liaison with MeNZB outreach services? Average response: 3.9 (1=very poor 2= poor 3=reasonable 4=good 5=excellent)
Liaison with MeNZB Outreach services
20 15 10 5 Frequency 0 1 2 3 4 5 Response
92% of PHOs indicated that practices followed a protocol before referring to outreach. The general protocols indicated are as follows: 3 attempts to contact – 74% Phone, letter, and visit – 14% 2 attempts to contact – 11%
84% of respondents indicated that someone was keeping records of how many outreach referrals were made. Practices – 9.5% PHOs – 31% OIS – 31% DHBs – 17% Other – 12%
44% of respondents knew how many MeNZB outreach referrals were made per practice. The average estimated proportion of immunisations given by practices in your PHO that happened because of outreach activity was 21% The basis of the estimates was: Guess – 50% Some quantitative data – 11% Good quantitative data – 38%
What proportion of immunisations were given at other locations because of outreach referrals? Average 28%
38% of respondents believed inappropriate referrals were made to outreach services due to practice inability to use their PMS status query check.
Meningococcal B Immunisation Evaluation Final Report p 137 CBG Health Research November 2006
What is your overall impression of the success of outreach services? Average response: 3.8 (1=no impact at all 5=highly successful)
Success of Outreach services
20 15 10 5 Frequency 0 1 2 3 4 5 Response
9. Overall
70% of respondents had figures for immunisation uptake for their PHO.
% 0-4y dose1 Average – 85.5% % 0-4y dose2 Average – 80.4% % 0-4y dose3 Average – 71.6%
PHO respondents identified the following successes during the MeNZB programme:
What has worked well? % Team work 44 Hard working staff 44 Well resourced/organised 31 Eduaction/training 25 Communication 33 Other 27
Factors identified as not being so successful during the MeNZB programme are:
What has not worked well? % Lack of resources 25 Poor management 25 Lack of communication 11 Timing 6 Other 33
Meningococcal B Immunisation Evaluation Final Report p 138 CBG Health Research November 2006
The single most important reasons limiting vaccination uptake were identified as being:
Most important reason limiting vaccination uptake % Lack of resources 41 Fear 37 Apathy 28 Not a priority 10 Lack of access 7 Negative media 17 Other 14
84% of respondents detailed specific reasons why some Maori clients do not access MeNZB immunisations. These are listed in the table below:
Factors limiting Maori uptake % Access issues 43 Lack of knowledge 20 Not a priority 16 Fear 11 Apathy 23 Transient population 9 Other 20
32% of respondents offered specific reasons why some Pacific clients are not accessing MeNZB immunisations. These are as follows:
Factors limiting Pacific access % Not a priority 19 Lack of knowledge/understanding 31 Access issues 50 Transient families 12.5
Meningococcal B Immunisation Evaluation Final Report p 139 CBG Health Research November 2006
PHN survey
A sample of 100 randomly selected schools from around the country was chosen for the PHN questionnaire. Questionnaires have been returned from 83 of the 100 schools, making an overall participation rate of 83%.
DHB return rate
DHB Returns Auckland 12/12 Waitemata 4/13 Northland 4/4 Waikato 5/8 Lakes 3/3 BOP 3/5 Tairawhiti 5/5 Taranaki 1/1 Hawkes Bay 3/3 Whanganui 2/2 Mid Central 4/4 Hutt Valley 3/3 Capital & Coast 7/7 Wairarapa 1/1 Canterbury 11/13 South Canterbury 2/2 Nelson Marlborough 2/3 West Coast 1/1 Otago 6/6 Southland 3/3
1. School
Rural 26.5% School type Primary 43% / Int 16.8% / Sec 19.3% /Other 28.9% Roll Average 415 School Decile Average 5.2 % Maori Average 35.7% % Pacific Average 5.9% Return rate Average 94.8% Decline rate Average 7.3% % children dose1 Average 87.9% % children dose2 Average 86.9% % children dose3 Average 83.8%
Note: Responses were requested for each school; in 1 DHB pooled data were given on response rate.
Meningococcal B Immunisation Evaluation Final Report p 140 CBG Health Research November 2006
2. IT
95% of respondents used the SBVS to support programme delivery. Initial coding of responses is as follows:
How was SBVS used to support programme delivery? % Data entry & tracking 32.4 Forms support/transfer 24.3 Provided phone support 27 Used to establish dosage status 31 Reporting 40.5 Other 21.6
38.6% of respondents found that the service had problems finding consent forms for dose 2 and 3. They estimated that around 2% of these forms were not locatable when required.
3. Staff A majority of the PHNs that answered the questionnaire believe that the MeNZB programme had a major impact on the normal services provided by PHNs. Initial coding is as follows:
The impact of the MeNZB Vaccination Programme on PHN services % Large impact - only reduced services offered 49.4 Emergency/urgent services only 27.2 No other services offered 4.9 Extra work and stress to comlpete normal duites 16 Only a minor interference 1.2
4. Delivering the immunisation
Were the resources and information available adequate to support the campaign ? Average response 3.6 (1=resource inadequate 5=no problems at all with supplied info and resources)
Impact of MeNZB on other services
30 20 10
Frequency 0 1 2 3 4 5 Response
Meningococcal B Immunisation Evaluation Final Report p 141 CBG Health Research November 2006
85.5% of respondents used existing networks within the school for immunisation delivery. Initial coding to describe the role of the primary contact person in the schools is as follows:
The role of the primary contact in schools % Organisation/timetabling 32.5 Arranging venue 37.5 Arranging equipment/personnel 20 Tracking consent froms 22.5 Liaison with staff & parents 55 Other 16.3
97.6% of respondents had no problems with vaccine supply .
98.8% of respondents did not experience difficulties with cold chain maintenance.
79.5% felt that the physical environment for giving immunisations was comfortable. 88% felt there was adequate confidentiality during immunisations.
PHNs felt that the number immunisations per hour person that could be safely delivered was 20 on average. Initial coding:
Explanatory notes for safe vaccination per hour % Dependant on age of children 40 Dependant on need for reassurance/questions 47.5 Availability issues 2.5 Possible reactions 5 Other 30
It was estimated that 77 percent of consent forms were completed correctly. Coding for suggested improvements to consent forms:
Improvements to consent forms % Better demographic/ethnicity information 6.8 Clearer format 29.5 Need to be simpler 13.6 Need more media/education support 11.4 Other 34.1
PHNs felt that the best time frame for the completion of forms was 12 days on average. Nearly all respondents mentioned that a short time frame was best while still allowing enough time to understand the forms.
Meningococcal B Immunisation Evaluation Final Report p 142 CBG Health Research November 2006
Do you think MeNZB PHN teams should have worked full time on MeNZB or taken breaks to do other work?
Full time – 49.4% Full time with day off – 27.7% More than 1 day between MeNZB work – 23%
Overall, how would you describe the process of giving immunisations in this school? Average response 4.04 (1=very difficult 5=very smooth)
Process of giving immunisations
40 20 0 Frequency 1 2 3 4 5 Response
5. Barriers to MeNZB immunisation (score1-5)
Can you please give your views on the barriers to MeNZB immunisation
1 = Totally Disagree, 2 = Disagree, 3 = Neither, 4 = Agree, 5 = Totally Agree Patient difficulties in accessing services 2.2 Parental apathy regarding immunisation 2.8 Parental fear regarding immunisation 3.2 Parental ambivalence or uncertainty regarding immunisation 3.3 Lack of funding for providers 2.8 Lack of time for providers to offer services 2.6 Lack of knowledge in health professionals 1.7 Poor Ministry direction 2.7
Meningococcal B Immunisation Evaluation Final Report p 143 CBG Health Research November 2006
6. Fall off in dose 2 and dose 3
Main reasons for the decline in coverage observed in dose 2 and 3 initial coding:
Main reasons for decline in dose 2 &3 coverage % Lack of parental support/knowledge 12.7 Children sick/absent 48 Negative media 19 Fear of injections/pain 33 Reactions 15.2 Other 26.6
7. Overall
PHNs identified the following successes school based delivery of the MeNZB vaccine:
What has worked well? % Team work 45 Esatblished community links 37.5 Successful implementation 25 Well resourced/organised 21.3 Knowledgeable and experienced staff 11.25 Strong leadership 5 Other 11.25
Factors identified as not being so successful in PHN delivery of the vaccine are:
What has not worked well? % Extra workload/lack of time for normal services 37.3 Resourcing/planning issues 26.9 Funding issues 17.9 Leadership/communication issues 16.4 Timing of campaign 11.9 Other 34.3
Meningococcal B Immunisation Evaluation Final Report p 144 CBG Health Research November 2006
The single most important reasons limiting vaccination uptake were identified as being:
Most important reason limiting vaccination uptake % Media issues 27.2 Issues with consent & consent forms 22.5 Issues with the new vaccine 15.6 Lack of understanding/education 10.4 Transient families 6.5 Access issues 5.2 Other 15.6
71% of PHNs detailed specific reasons why some Maori clients do not access MeNZB immunisations. These are listed in the table below:
Factors impacting on Maori access % Lack of knowledge/understanding/education 28.8 Negative messages from media and/or Maori leaders 18.6 Truancy/transient families 18.6 Apathy/ambivalence 16.9 Access issues 11.9 Different priorities/beliefs 8.5 Other 35.6
40% of respondents offered specific reasons why some Pacific clients are not accessing MeNZB immunisations. These are as follows:
Factors limiting Pacific access % Lack of knowledge/understanding 60.6 Access issues 18.1 Truancy/transient faimlies 18.1 Language barriers 2 Apathy 0.6 Other 12.1
Meningococcal B Immunisation Evaluation Final Report p 145 CBG Health Research November 2006
Outreach survey
31 of 59 (51%) of outreach providers from around the country answered the questionnaire. Initial analysis and coding is provided in the following summary report.
1. Service
How many MeNZB outreach providers Average – 2.5 are there in this DHB? Do you provide other immunisation Yes – 67% Outreach services besides MeNZB? Did the DHB run a central outreach Yes – 67% referral service for primary care providers? Where did referrals come from – enter approximate % - Direct from practices (approx %) Average - 68% - From PHOs (approx %) Average – 31% - From central DHB service (approx %) Average - 47% - From other sources (specify) Average – 22%
Referrals have been received by Outreach providers from December 2004 through to May 2006. Average numbers are provided below:
Referrals Contact Phone Home Transport Known to made contact visits provided be later Immunised Dose 1 544 575 115 650 173 Dose 2 240 225 40 245 147 Dose 3 297 283 109 318 187 Dose not 379 365 262 50 14 42% known overall
These figures were assembled from data provided by 15 of the 31 OIS providers that responded, and a separate report was provided by Northland DHB.
Meningococcal B Immunisation Evaluation Final Report p 146 CBG Health Research November 2006
2. IT What IT systems did your service use to manage referrals? Initial coding:
IT Systems to manage referrals % Excel spreadsheet 16 MedTech 32 23 Access database 13 Profile 13 Manual 13 Other 13
74% of the services reported having access to the NIR. 96% of the services checked the NIR to see if a child had already been immunised.
3. Staff
MeNZB work significantly affected the delivery of other services by outreach providers for 15% of the providers that answered the questionnaires.
On average Outreach Services devoted 2 FTEs to the implementation of MeNZB Outreach . 71% of services employed an average of 1.6 extra staff to do MeNZB Outreach.
4. Set up
Were the resources and information available adequate to support the campaign? Average response: 3.9
(1=resource inadequate 5=no problems at all with supplied info and resources)
Adequate resources and information
15 10 5
Frequency 0 1 2 3 4 5 Response
Meningococcal B Immunisation Evaluation Final Report p 147 CBG Health Research November 2006
How would you rate the liaison with the DHB over the delivery of MeNZB? Average response: 3.9 (1=very poor 2= poor 3=reasonable 4=good 5=excellent)
Liaison with DHB
15 10 5
Frequency 0 1 2 3 4 5 Response
How would you rate the liaison with primary care over Outreach services? Average response: 3.9 (1=very poor 2= poor 3=reasonable 4=good 5=excellent)
Liaison with primary care
20 15 10 5
Frequency 0 1 2 3 4 5 Response
Meningococcal B Immunisation Evaluation Final Report p 148 CBG Health Research November 2006
5. Barriers to MeNZB immunisation (score1-5)
Average responses to the barriers to MeNZB immunisation question are as follows:
1 = Totally Disagree, 2 = Disagree, 3 = Neither, 4 = Agree, 5 = Totally Agree Patient difficulties in accessing services 3.5 Parental apathy regarding immunisation 3.7 Parental fear regarding immunisation 3.6 Parental ambivalence or uncertainty regarding immunisation 3.7 Lack of funding for providers 3.3 Lack of time for providers to offer services 3.2 Lack of knowledge in health professionals 2.2 Poor Ministry direction 2.7 Poor DHB direction 2.4
Other barriers to immunisation – Initial coding:
Other barriers to immunisation % Difficulties with access 81 Transient clients 31 Timing of the campaign 25 Fear of immunisation 12.5 Debt with practices 12.5 Work pressures 12.5 Other 44
6. Delivering Outreach services
93% of respondents phoned families to make contact and appointments for follow up. They estimated that on average 38.5% of families could not be contacted by phone (range 5 – 80%).
97% of services conducted home visits to referred families. Visited singly – 30% Visited in pairs – 30% Visited in other groups – 0% Visited in both pairs and singly – 40%
35% of respondents described safety issues during home visits. Initial coding is given below:
Meningococcal B Immunisation Evaluation Final Report p 149 CBG Health Research November 2006
Safety issues % Dogs 82 Drugs/alcohol 27 Negative reactions from people visited 27 Other 18
On average, services provided transport to 14% of referred clients. Services delivered immunisations in 36% (range: 1-100%) of homes on average.
7. Overall
Outreach Service Providers identified the following successes during the MeNZB programme:
What has worked well? % Esatblished community links 34 Personal contact with clients 31 Well resourced/organised 28 Communication/education 28 Knowledgeable and experienced staff 24 Team work 24 Other 41
Factors identified as not being so successful during the MeNZB outreach programme are:
What has not worked well? % Tracking/referral issues 32 Database/IT issues 24 Huge workload 20 Lack of communication 12 Lack of preparation/resources 12 Other 28
Outreach providers highlighted some improvements that could be made to subsequent outreach programmes:
Improvements % More funding/resources 35 Better client details/data 30 Better communication/promotion 26 More time 22 Improved access to services 9 Other 22
Meningococcal B Immunisation Evaluation Final Report p 150 CBG Health Research November 2006
The single most important reasons limiting vaccination uptake were identified as being:
Most important reason limiting vaccination uptake % Access issues 27 Fear 19 Apathy 15 Negative media 8 Lack of knowledge 8 Other 31
80% of Outreach providers detailed specific reasons why some Maori clients do not access MeNZB immunisations. These are listed in the table below:
Factors limiting Maori uptake % Access issues 28 Lack of knowledge 24 Fear 16 Debts with practices 12 Negative media 8 Apathy 8 Other 36
45% of respondents offered specific reasons why some Pacific clients are not accessing MeNZB immunisations. These are as follows:
Factors limiting Pacific access % Language barriers/service not targeted to Pacific communities 50 Lack of knowledge/understanding 43 Access issues 36 Transient faimlies 21 Other 50
Meningococcal B Immunisation Evaluation Final Report p 151 CBG Health Research November 2006
DHB survey
As part of the non-GP provider survey, 20 of the 21 DHB project managers were contacted in order to gain an insight into their experiences during the MeNZB vaccination campaign. A summary of the findings from the DHB questionnaire is provided below. Many DHB programme managers took considerable time to complete these questionnaires and supplied comprehensive answers to questions. The tables below have grouped the key themes from these longer replies.
1. DHB Related questions
Average Number of 46.3 (Range 149 – 7) Practices per DHB % Interim 59.2 % Access 40.8 Average Number of 130.2 (Range 260 – 37) schools per DHB Average Primary 78 Average Intermediate 5 Average Other 19.8
2. Community Awareness Raising Related Questions
Did CAR deliver the services for which they were contracted? Average response: 4.4 (1=no impact at all 5=highly successful)
CAR Delivery of Services
12 10 8 6 4 Frequency 2 0 1 2 3 4 5 Response
How do you assess the impact of the contracted CAR services? Average response: 3.8 (1=no impact at all 5=highly successful)
Meningococcal B Immunisation Evaluation Final Report p 152 CBG Health Research November 2006
Impact of CAR Services
7 6 5 4 3
Frequency 2 1 0 1 2 3 4 5 Response
Initial coding for responses to the question “What worked well in CAR?” is as follows:
What worked well in CAR? % Initial Planning/Resources/Training 45 Linking CAR with local initiatives 30 Knowledge of local community 55 Tailoring initiatives to specific communities 60 Using multiple media to communicate information 20 Other 30
Initial coding for responses to the question “What could be improved with CAR?” is as follows:
What could be improved with CAR? % More Time/Planning/Training 45 Linking CAR with vaccination services 45 Better reporting and feedback from CAR providers 20 Better innovation and targeting required 25 Other 50
Meningococcal B Immunisation Evaluation Final Report p 153 CBG Health Research November 2006
3. Primary Care Related Questions
How do you rate liaison with primary care in your DHB? Average response: 4.2 (1=no impact at all 5=highly successful)
Liaison with Primary Care
10 8 6 4
Frequency 2 0 1 2 3 4 5 Response
85% of DHBs communicated directly with practices at some stage during the campaign. 15% of DHBs only communicated with primary care through PHOs.
Initial coding for responses to the question “What worked well in Primary Care? ” is as follows:
What worked well in Primary Care? % Planning/organisation 50 Communication 95 PHO immunisation coordinators/managers 35 Innovative approaches 35 Programme resources 55 Other 50
Meningococcal B Immunisation Evaluation Final Report p 154 CBG Health Research November 2006
Initial coding for responses to the question “What could be improved in the Primary Care delivery of MeNZB?” is as follows:
What could be improved in Primary Care delivery? % Better Planning/Admin/ Communication 50 More PHO Liaison 20 Better Staffing and Resources 75 Timing of the campaign 30 Outreach Issues 40 Other 65
4. Schools based programme related questions
Initial coding for responses to the question “What worked well in the Schools Based Programme?” is as follows:
What worked well in the Schools Based Programme? % Organisation/management 75 Training/resources 50 Dedicated and experienced staff 60 Support from schools 45 Captured target group/good coverage 35 Other 45
Initial coding for responses to the question “What could be improved in the Schools Based Programme?” is as follows:
What could be improved in the Schools Based Programme? % Consent forms 40 Training/resources 40 OIS referrals/catch ups 25 Data entry/IT issues 40 Staffing 15 Other 50
Meningococcal B Immunisation Evaluation Final Report p 155 CBG Health Research November 2006
5. Outreach related questions
80% of the DHBs fund childhood immunisation Outreach services. On average, the DHBs entered in to 3.3 Outreach contracts. 50% of the DHBs used Outreach providers that were the same as the childhood immunisation outreach providers. For 15% of DHBs only some of the contracted were the same as the childhood immunisation outreach providers; for the remaining 35% different providers were used.
Did Outreach deliver the services for which they were contracted? Average response: 3.6 (1=no impact at all 5=highly successful)
Outreach Delivery of Services
10 8 6 4
Frequency 2 0 1 2 3 4 5 Response
45% of the DHBs provided a database for outreach referrals. A number of different outreach referral processes were used by DHBs.
Meningococcal B Immunisation Evaluation Final Report p 156 CBG Health Research November 2006
What is your overall impression of the success of outreach services? Average response: 3.7 (1=no impact at all 5=highly successful)
Success of Outreach Services
12 10 8 6 4 Frequency 2 0 1 2 3 4 5 Response
Initial coding for responses to the question “What has worked well in MeNZB Outreach?” is as follows:
What has worked well in MeNZB Outreach? % Use of community links 60 Using established services 50 A holistic approach 25 Advertising 15 Services being linked with vaccinators 15 Other 55
Initial coding for responses to the question “What could be improved in MeNZB Outreach?” is as follows:
What could be improved in MeNZB Outreach? % Better information/IT 25 More experience training 25 Closer links with other providers 25 More time/resources 40 Other 55
Meningococcal B Immunisation Evaluation Final Report p 157 CBG Health Research November 2006
6. Questions related to the overall programme
Initial coding for responses to the question “What has worked well in the delivery of MeNZB vaccine?” is as follows:
What has worked well in the delivery of the MeNZB vaccine? % Management/planning 70 Information/communication 70 Teamwork/relationships 55 Schools Based campaign 40 Hard work/dedication 20 Other 60
Initial coding for responses to the question “What has not worked well in the delivery of MeNZB vaccine?” is as follows:
What has not worked well in the delivery of the MeNZB % vaccine? The youth campaign 40 Information/communication 45 Outreach Services 25 Timing of the campaign 25 Other 75
Initial coding for responses to the question “What is the single most important reason limiting vaccination uptake ?” is as follows:
What is the single most important reason limiting uptake? % Misinformation/the anti immunisation lobby 30 Issues with the injection 15 Apathy 15 Other 40
Initial coding for responses to the question “In your opinion, are there any specific reasons why some Maori clients do not access MeNZB immunisations ?” is as follows:
Specific reasons why some Maori clients do not access % Access 45 Health not a priority 35 Other life issues 35 Cultural barriers 35 Debts with providers 15 Other 50
Meningococcal B Immunisation Evaluation Final Report p 158 CBG Health Research November 2006
Initial coding for responses to the question “In your opinion, are there any specific reasons why some Pacific clients do not access MeNZB immunisations ?” is as follows:
Specific reasons why some Pacific clients do not access % Language/cultural barriers 35 Health not a priority 25 Access 25 Other life issues 15 Other 55
Meningococcal B Immunisation Evaluation Final Report p 159 CBG Health Research November 2006
CATI <5s Client Telephone survey summary
Questionnaire completed for 313 randomly selected children < 5 living in Lakes / BOP / Taranaki / Tairawhiti / HB / Whanganui / MidCentral
Immunisation status:
N % None 47 15.3 1 12 3.9 2 34 11.1 3 214 69.7 Total 307 100.0
GP commonest source of info (33%), then school (16%, presumably from other children) TV (17%), other media (10%) 9% used 0800 number 62% use email, 5% received email about MeNZB (=3.1% of total), most couldn’t remember what email said. 4.5% though Men disease “not at all serious”, number of imms received positively associated with perceived seriousness. Most people thought not very likely their child would get Men disease. Weak association with uptake Ethnicity distribution:
N % Other 225 71.9 Maori 70 22.4 Pacific Is. 14 4.5 Asian 4 1.3 Total 313 100.0
Maori least likely to immunise
Distance from healthcare associated with immunisation status – further away less likely to have completed. 69% received an invitation to immunise, 80% got it by mail If had 3 imms - 88% got immunisation at GP If had no imms – only 20% v likely to get them. 50% “won’t” or “not very likely” get imms If had 1 or 2 – 98% plan to finish 6% do not normally get imms, strongly associated with no MeNZB imms Lack of belief in safety or efficacy both strongly associated with no imms 43% did not know youngest age, 24% knew 6 weeks, 3.5% > 1 yr
Meningococcal B Immunisation Evaluation Final Report p 160 CBG Health Research November 2006
Response
Status n Leaving… rate called 4917 no reply 636 4917 13% 3 callbacks 3 days declined 463 4281 11% not eligible 3505 3818 92% completed 313 313
1. Where did you get information about the MeNZB vaccine from? [LIST]
N % School 69 15.7 Pre School 9 2.1 Child Care Center 11 2.5 Media Sources 46 10.5 GP 146 33.3 Health Professionals 16 3.6 Personal 17 3.9 Don't know 5 1.1 Other 14 3.2 TV 75 17.1 Medical Facilities 19 4.3 Internet 12 2.7 Total 439 100.0
(Multiple responses possible)
2. Did you ever use an 0800 number? [Y/N]
N % No 281 90.6
Yes 29 9.4
Total 310 100.0
3. Do you use email? [Y/N]
N % No 119 38.3 Yes 192 61.7 Total 311 100.0
4. IF YES Did you receive any email about meningococcal B vaccine? [Y/N]
N % No 195 95.1 Yes 10 4.9 Total 205 100.0
Meningococcal B Immunisation Evaluation Final Report p 161 CBG Health Research November 2006
5. IF YES Can you remember what it said? [N or LIST]
N % Nationwide, got email sent out. 1 9.1 Internet, doctor’s office. 1 9.1 Can't recall. 1 9.1 Pro-vaccine. 1 9.1 Negative views. 2 18.2 No 5 45.5 Total 11 100.0
6. How serious a threat do you believe meningococcal disease is? Would you say it is a: 1 very serious threat, 2 serious threat or 3 not all serious
N % Very serious threat 186 60.0 Serious threat 110 35.5 Not all serious 14 4.5 Total 310 100.0
7. In your opinion, what chance has your under 5 yr old got of catching meningococcal disease? Would you say it is:
1 extremely likely 2 somewhat likely 3 not very likely 4 not at all likely 5 don’t know
N % extremely likely 19 6.1 somewhat likely 69 22.0 not very likely 114 36.4 not at all likely 42 13.4 don't know 69 22.0 Total 313 100.0
Meningococcal B Immunisation Evaluation Final Report p 162 CBG Health Research November 2006
8. Where would you go for more information if you wanted it? [LIST]
N % GP 240 67.2 Plunket 18 5.0 Internet 55 15.4 School 8 2.2 Medical Facilities 11 3.1 0800 9 2.5 Ministry of Health 3 0.8 Health Professionals 5 1.4 Other 5 1.4 Don't know 3 0.8 Total 357 100.0 (Multiple responses possible)
9. How many children under 5 are there in your family? [NUMBER]
N % 1 208 66.5 2 91 29.1 3 11 3.5 4 2 0.6 7 1 0.3 Total 313 100.0
Can I ask you to think about the under 5 yr old child living in the house that has the next birthday?
10. How old is xxxx? [ENTER YRS, GET MONTHS IF < 1 yr OLD]
N % 3 years 62 19.9 2 years 62 19.9 1 years 52 16.7 4 years 76 24.4 5 years 20 6.4 10 months 4 1.3 1 months 2 0.6 6 months 10 3.2 3 months 5 1.6 9 months 4 1.3 8 months 5 1.6 5 months 2 0.6 7 months 5 1.6 2 weeks 1 0.3 11 months 2 0.6 Total 312 100.0
Meningococcal B Immunisation Evaluation Final Report p 163 CBG Health Research November 2006
11. What ethnic group do they belong to? [CODE TO M / P / A / O]
N % Other 225 71.9 Maori 70 22.4 Pacific Is. 14 4.5 Asian 4 1.3 Total 313 100.0
12. How far away are you from the place you usually go to for health care [distance in km <1, 1-2, 2-10, 10+]
N % <1 52 16.6 1-2 53 16.9 2-10 127 40.6 10+ 81 25.9 Total 313 100.0
13. How long does it usually take to get there? [MINUTES]
N % 1 min 8 2.6 2 min 27 8.6 3 min 24 7.7 4 min 2 0.6 5 min 94 30.0 6 min 5 1.6 7 min 9 2.9 8 min 3 1.0 10 min 64 20.4 12 min 2 0.6 13 min 1 0.3 14 min 1 0.3 15 min 27 8.6 16 min 1 0.3 20 min 24 7.7 25 min 5 1.6 30 min 9 2.9 35 min 1 0.3 40 min 3 1.0 45 min 1 0.3 65 min 1 0.3 240 min 1 0.3 Total 313 100.0
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14. How do you normally get there? [RECORD]
N % Car 302 93.5 Walk 20 6.2 Horse 1 0.3 Total 323 100.0 (Multiple responses possible)
15. Do you have transport available whenever you want it? [Y/N]
N % No 10 3.2 Yes 303 96.8 Total 313 100.0
16. Did you receive an invitation to get MeNZB immunisation? [Y/N]
N % No 96 31.2 Yes 212 68.8 Total 308 100.0
17. How – mail / phone / other [RECORD]
N % Mail 185 78.4 Phone 16 6.8 School 14 5.9 Medical Facility 2 0.8 Health Professionals 7 3.0 GP 6 2.5 Other 6 2.5 Total 236 100.0 (Multiple responses possible)
18. How many MeNZB immunisations has xxxx had? [NUMBER]
N % None 47 15.3 1 12 3.9 2 34 11.1 3 214 69.7 Total 307 100.0
Meningococcal B Immunisation Evaluation Final Report p 165 CBG Health Research November 2006
If had 3:
19. Where did they have them GP / Community Clinic / Other – specify]
N % GP 169 88.0 Community clinic 5 2.6 Medical Facilities 13 6.8 Child Care Center 2 1.0 School 3 1.6 Total 192 100.0
GOTO A If not had any:
20. How likely are you to vaccinate your child against meningococcal disease
1. extremely likely 2. only somewhat likely 3. Not very likely 4. Not at all likely 5. I won’t 6. depends 7. don’t know
N % Extremely likely 11 21.6 Only somewhat likely 7 13.7 Not very likely 7 13.7 Not at all likely 7 13.7 I won't 11 21.6 Depends 3 5.9 Don't know 5 9.8 Total 51 100.0
If answer 2, 3, 4:
21. Why is that? [RECORD]
1. Through school programme. 2. Needs to understand side effects. 3. In process. 4. If more info came out. 5. Struggle with it – friends are anti. Bad eczema. 6. Don’t know enough about it. 7. First at 6 months, next 4 weeks ago, next one not yet due.
Meningococcal B Immunisation Evaluation Final Report p 166 CBG Health Research November 2006
8. Bit slowly at first because kids were sick. 9. Not enough information regarding vaccine, too serious a job without getting another to question. 10. Not in at risk. Q - re testing of vaccine / safe. 11. He was sick, and is due next week. 12. Not being tested. 13. Mother doesn’t want it. 14. Because she doesn’t think doctors know how long it can protect the child for, plus they don’t give information about the side effects. 15. Because wife doesn’t believe the children don’t have a big chance of catching the disease. 16. Do think it is a serious threat, but not a widespread threat. 17. Health risks, not really into having immunisation which isn’t crucial. 18. Not enough info at the time. 19. There is a 75% chance of children catching the disease if you don’t vaccinate; Maori are a higher risk according to the ads; MeNZB is a big protection. 20. Don’t think its safe enough. 21. It was demanded, felt pushed into it. Not at high risks. Aimed more at teenagers. 22. At the time the legal age was 6 months, and she was not 6 months yet. 23. Researched and wasn’t convinced her child was vulnerable due to age and location. Fed up with overloading children with immunisation and concerned about creating superbugs for future. 24. Heard of other children having reaction, unsure about vaccinate – got advice from radiologist. 25. Choose not to, very new and very suspicious. 26. Just don’t believe it’s safe. 27. Don’t want to. 28. Because I don’t believe in immunisation. 29. Because it’s another chemical and more money for the government. 30. Don’t believe it’s fully tested. Not 100% sure. 31. Thinks it’s more harmful and is wrong; not enough information is researched on it; has decided not to get child immunised because.
If answer 5:
22. Why have you decided not to have your child immunised with MeNZB
1. Keep an eye on kids – not sure – Europeans not so affected. 2. Conflicting info – scare mongering going on. 3. Vaccine not proven, and vaccine not generally reported accurately. 4. Due soon, had flu so had to put off.
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5. Likely hood of your child getting MeNZB is very slim. 6. More danger in having immunization. 7. Side effects of the preservatives in the vaccine. 8. Scared it wasn’t going to work. 9. Not safe enough. 10. Believe that the B factor is only part of the disease, highly unlikely my child will get it. 11. Wanted all 3 children to be immunized at the same time. 12. Because she was too young. 13. Don’t like the fact that it’s artificial, rather leave them already healthy. 14. Death rate is lower than other strains of meningococcal, anti-vaccination attitudes as benefits don’t outweigh risks; waste of public money. 15. Because of the side effects from bigger daughter. 16. Feels that side effects can harm them more, than just leaving them healthy. 17. Doesn’t do any good.
GOTO A
If answer 6 or 7:
23. What would help you to make a decision about whether or not to get the vaccination? [LIST]
1. Wife is vet and done research. 2. Need more information on vaccine B. 3. Made the decision when there was enough clear information about it. 4. Knowing in 10 years time child unaffected by the vaccine, and don’t know well enough about vaccine, don’t want to be a guinea pig. 5. No. it’s my choice not a big priority anymore. High risk is over. 6. Do more research on vaccine. 7. She will get immunized when she gets older. 8. Word of mouth (i.e. if other parents recommend it). 9. Wants to see more info and more research done.
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If had 1 or 2
24. Where did they have them [location] – GP / Community Clinic / Other – specify
N % GP 29 87.9 Medical center 4 12.1 Total 33 100.0
25. Do you plan to finish the course [Y/N]
N % No 1 2.5 Yes 39 97.5 Total 40 100.0
If Y
26. What has been the main reason that you haven’t finished course so far?
1. Moved from Tauranga to Hastings – has been unwell. 2. Too young 3. Age 4. haven’t been down to GP (involved in a custody battle over child) 5. Normal time delay. 6. In process. 7. Child is only 5 months of age + the last dose is not due for 2 weeks. 8. Child was ill. 9. Not due till next month. 10. Not due. 11. Location. 12. No reason, this is normal finish time. 13. Newly born. Had one at 6 months, so is not due yet. 14. Too far away, need helicopter or ambulance to come pick up. 15. Just hasn’t made an appointment. 16. Child not registered. 17. Was nervous about getting it done, hasn’t had enough information, just got the nerve now. 18. Only 3 months old and not due yet. 19. Haven’t had the time. 20. Work commitments, and weather not good, and wants to take him herself.
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21. Haven’t gotten round to it, just had second vaccine. 22. Forgot about second appointment. 23. Because she’s young and needs to have more time. 24. Because he started at 6 months, still has to wait but others are all done. 25. Child is currently ill, so waiting for child to recover before getting last dose. 26. Age – child was sick – unsure whether to continue course. 27. Problems with access (used to live in the country and whenever they came into town, the child was sick so couldn’t get the next shot) 28. To protect them. 29. Six weeks isn’t over yet. 30. It hasn’t started just yet.
If N – classify as non-completer
27. Why have you decided not to complete the course? [LIST]
1. In process 2. Programme not complete in their area. 3. I haven’t thought about it yet. 4. Haven’t got around to it. 5. 2 months away.
A For all (vaccinated and not)
28. Do your children normally get immunisations. [ALL / SOME / NO]
N % All 284 91.0 Some 9 2.9 No 19 6.1 Total 312 100.0
29. Where would you prefer that your child was vaccinated, if you had the choice? [RECORD] N % Anywhere 14 4.4 Home or Closer 23 7.2 Medical Facilities 14 4.4 GP 248 77.7 School 12 3.8 Other 2 0.6 No vaccination at all 6 1.9 Total 319 100.0 (Multiple responses possible)
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30. How likely do you think it is that MenZB vaccination will provide effective protection against Meningococcal B disease?
1 extremely likely 2 somewhat likely 3 Not very likely 4 Not at all likely 5 depends
N % Extremely likely 92 30.0 Somewhat likely 148 48.2 Not very likely 19 6.2 Not at all likely 6 2.0 Depends 42 13.7 Total 307 100.0
31. How confident are you that the MenZB vaccination is safe
1 extremely confident 2 somewhat confident 3 Not very confident 4 Not at all confident 5 depends
N % Extremely confident 68 21.9 Somewhat confident 186 59.8 Not very confident 27 8.7 Not at all confident 17 5.5 Depends 13 4.2 Total 311 100.0
32. Do you know the youngest age a child can be given MeNZB immunisation? [N or RECORD AGE]
N % 6 weeks 74 23.7 6 months 57 18.3 less than 1 year 35 11.2 more than 1 year 11 3.5 No idea 135 43.3 Total 312 100.0
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Associations with number of imms
6. How serious a threat do you believe meningococcal disease? Would you say it is a: * 18. How many MeNZB immunisations has xxxx had?
Crosstab 18. How many MeNZB immunisations has xxxx had? None 1 2 3 Total 6. How serious a Very serious Count 9 7 23 144 183 threat do you threat Expected Count 27.7 7.2 19.9 128.2 183 believe % Row 4.9 3.8 12.6 78.7 100 meningococcal disease? Would % Column 19.6 58.3 69.7 67.6 60.2 you say it is a: % of Total 3.0 2.3 7.6 47.4 60.2 Residual -18.7 -0.2 3.1 15.8 Std. Residual -3.6 -0.1 0.7 1.4 Adjusted Residual -6.1 -0.1 1.2 4.0 Serious Count 30 5 10 63 108 threat Expected Count 16.3 4.3 11.7 75.7 108 % Row 27.8 4.6 9.3 58.3 100 % Column 65.2 41.7 30.3 29.6 35.5 % of Total 9.9 1.6 3.3 20.7 35.5 Residual 13.7 0.7 -1.7 -12.7 Std. Residual 3.4 0.4 -0.5 -1.5 Adjusted Residual 4.6 0.5 -0.7 -3.3 Not all Count 7 0 0 6 13 serious Expected Count 2.0 0.5 1.4 9.1 13 % Row 53.8 0 0 46.2 100 % Column 15.2 0 0 2.8 4.3 % of Total 2.3 0 0 2.0 4.3 Residual 5.0 -0.5 -1.4 -3.1 Std. Residual 3.6 -0.7 -1.2 -1.0 Adjusted Residual 4.0 -0.7 -1.3 -1.9 Count 46 12 33 213 304 Expected Count 46 12 33 213 304 Total % Row 15.1 3.9 10.9 70.1 100 % Column 100 100 100 100 100 % of Total 15.1 3.9 10.9 70.1 100
Positive association between perceived threat and number of imms p<.0001.
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7. In your opinion, what chance has your under 5 yr old got of catching meningococcal disease? Would you say it is? X 18. How many MeNZB immunisations has xxxx had?
Crosstab 18. How many MeNZB immunisations has xxxx had? None 1 2 3 Total 7. In your opinion, extremely Count 1 0 2 16 19 what chance has likely Expected Count 2.9 0.7 2.1 13.2 19 your under 5 yr old % Row 5.3 0 10.5 84.2 100 got of catching meningococcal % Column 2.1 0 5.9 7.5 6.2 disease? Would % of Total 0.3 0 0.7 5.2 6.2 you say It IS Residual -1.9 -0.7 -0.1 2.8 Std. Residual -1.1 -0.9 -0.1 0.8 Adjusted Residual -1.3 -0.9 -0.1 1.4 somewhat Count 8 8 8 45 69 likely Expected Count 10.6 2.7 7.6 48.1 69 % Row 11.6 11.6 11.6 65.2 100 % Column 17.0 66.7 23.5 21.0 22.5 % of Total 2.6 2.6 2.6 14.7 22.5 Residual -2.6 5.3 0.4 -3.1 Std. Residual -0.8 3.2 0.1 -0.4 Adjusted Residual -1.0 3.7 0.2 -0.9 not very Count 19 0 11 79 109 likely Expected Count 16.7 4.3 12.1 76.0 109 % Row 17.4 0 10.1 72.5 100 % Column 40.4 0 32.4 36.9 35.5 % of Total 6.2 0 3.6 25.7 35.5 Residual 2.3 -4.3 -1.1 3.0 Std. Residual 0.6 -2.1 -0.3 0.3 Adjusted Residual 0.8 -2.6 -0.4 0.8 not at all Count 8 1 5 28 42 likely Expected Count 6.4 1.6 4.7 29.3 42 % Row 19.0 2.4 11.9 66.7 100 % Column 17.0 8.3 14.7 13.1 13.7 % of Total 2.6 0.3 1.6 9.1 13.7 Residual 1.6 -0.6 0.3 -1.3 Std. Residual 0.6 -0.5 0.2 -0.2 Adjusted Residual 0.7 -0.5 0.2 -0.5 don't know Count 11 3 8 46 68 Expected Count 10.4 2.7 7.5 47.4 68 % Row 16.2 4.4 11.8 67.6 100 % Column 23.4 25 23.5 21.5 22.1 % of Total 3.6 1.0 2.6 15.0 22.1 Residual 0.6 0.3 0.5 -1.4 Std. Residual 0.2 0.2 0.2 -0.2 Adjusted Residual 0.2 0.2 0.2 -0.4 Count 47 12 34 214 307 Expected Count 47 12 34 214 307 Total % Row 15.3 3.9 11.1 69.7 100 % Column 100 100 100 100 100 % of Total 15.3 3.9 11.1 69.7 100
Meningococcal B Immunisation Evaluation Final Report p 173 CBG Health Research November 2006
12. How far away are you from the place you usually go to for health care x 18. How many MeNZB immunisations has xxxx had?
Crosstab 18. How many MeNZB immunisations has xxxx had? None 1 2 3 Total 12. How far away are <1 Count 3 4 11 33 51 you from the place you Expected Count 7.8 2.0 5.6 35.6 51.0 usually go to for health % Row 5.9 7.8 21.6 64.7 100.0 care % Column 6.4 33.3 32.4 15.4 16.6 % of Total 1.0 1.3 3.6 10.7 16.6 Residual -4.8 2.0 5.4 -2.6 Std. Residual -1.7 1.4 2.3 -0.4 Adjusted Residual -2.0 1.6 2.6 -0.9 1-2 Count 12 3 2 36 53 Expected Count 8.1 2.1 5.9 36.9 53.0 % Row 22.6 5.7 3.8 67.9 100.0 % Column 25.5 25.0 5.9 16.8 17.3 % of Total 3.9 1.0 0.7 11.7 17.3 Residual 3.9 0.9 -3.9 -0.9 Std. Residual 1.4 0.6 -1.6 -0.2 Adjusted Residual 1.6 0.7 -1.9 -0.3 2-10 Count 16 4 12 91 123 Expected Count 18.8 4.8 13.6 85.7 123.0 % Row 13.0 3.3 9.8 74.0 100.0 % Column 34.0 33.3 35.3 42.5 40.1 % of Total 5.2 1.3 3.9 29.6 40.1 Residual -2.8 -0.8 -1.6 5.3 Std. Residual -0.7 -0.4 -0.4 0.6 Adjusted Residual -0.9 -0.5 -0.6 1.3 10+ Count 16 1 9 54 80 Expected Count 12.2 3.1 8.9 55.8 80.0 % Row 20.0 1.3 11.3 67.5 100.0 % Column 34.0 8.3 26.5 25.2 26.1 % of Total 5.2 0.3 2.9 17.6 26.1 Residual 3.8 -2.1 0.1 -1.8 Std. Residual 1.1 -1.2 0.0 -0.2 Adjusted Residual 1.4 -1.4 0.1 -0.5 Count 47 12 34 214 307 Expected Count 47.0 12.0 34.0 214.0 307.0 Total % Row 15.3 3.9 11.1 69.7 100.0 % Column 100.0 100.0 100.0 100.0 100.0 % of Total 15.3 3.9 11.1 69.7 100.0
Positive association between perceived threat and number of imms p<.05.
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HH survey Household survey summary
The household survey was completed for 502 households in randomly selected meshblocks in census area units with most Maori in Auckland (3 DHBs, 252 respondents) and Kawerau (single CAU, 250 respondents). The survey was completed for youngest child in family to get most information possible about Maori < 5. Half the respondents were aged 5 or less. Overall 74% of the sample had completed immunisations (3 or 4). Data were collected for 336 Maori children, 69% of whom had completed their immunisations. The Auckland sample was slightly younger than the Kawerau sample and had a higher immunisation completion rate than Kawerau, 79% versus 68%.
The breakdown of the sample by area, ethnicity and number of immunisations is shown below:
Immunisation status by ethnicity by area Maori Other Pacific ALL N % N % N % N % Area Imms Auckland 0 15 10 3 8 2 3 20 8 1 6 4 2 5 5 7 13 5 2 16 11 1 3 5 7 22 9 3 106 73 31 82 56 81 193 77 4 2 1 1 3 1 1 4 2 All 145 100 38 100 69 100 252 100 Kawerau Imms 0 26 14 9 16 . . 35 14 1 11 6 2 3 . . 13 5 2 27 14 2 3 1 100 30 12 3 127 66 44 76 . . 171 68 4 . . 1 2 . . 1 0 All 191 100 58 100 1 100 250 100 All Imms 0 41 12 12 13 2 3 55 11 1 17 5 4 4 5 7 26 5 2 43 13 3 3 6 9 52 10 3 233 69 75 78 56 80 364 73 4 2 1 2 2 1 1 5 1 All 336 100 96 100 70 100 502 100
Meningococcal B Immunisation Evaluation Final Report p 175 CBG Health Research November 2006
Key points of Household survey
The Household survey successfully targeted Maori. The population had half the rate of email access of the telephone survey population, a good surrogate for socioeconomic status, and 89% had access to a vehicle when they needed it, compared to 97% in the telephone survey. The keypoints of the survey, presented in this report are:
Awareness of the programme was very high – 99% For school children, school was source of info. For others, GP commonest source of info, then school, then Plunket and tertiary institutions. For more info the most popular sources would be, in order of frequency, GP (75%), then internet, Plunket, school (all less than 6%). 39% use email, 4% received email about MeNZB, no recall of content. 70% thought Meningococcal disease was a serious illness, number of imms received positively associated with perceived seriousness. Most people thought not very likely their child would get Men disease. Strong association with uptake Distance from healthcare weakly associated with immunisation status – further away less likely to have completed. 41% received an invitation to immunise, 50% got it by mail, 25% in a face to face discussion and 15% by phone. If had 3 imms (365 = 73%) - 98% got immunisation at GP or school. Maori least likely to have 3 imms If had no imms – 43% say they plan to immunise, but 35% “won’t” or “not very likely” get imms, splitting this group into “active decliners” and ”good intenders”. If had 1 or 2 – 93% plan to finish 2.2% do not normally get imms, strongly associated with no MeNZB imms Lack of belief in safety was strongly associated with no imms A simple logistic regression showed the expected patterns of association between completion of immunisations and ethnicity, age and area (Auckland rate higher than Kawerau) Adding attitudinal variables to the model largely eliminated these differences, as perceived safety and seriousness were significant predictors associated with ethnicity.
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MeNZB household survey responses
Survey completed for 502 households in randomly selected meshblocks in census area units (CAU) with most Maori in Auckland (3 DHBs) and Kawerau (single CAU). 252 surveys were completed in Auckland and 250 in Kawerua.Ten CAUs with highest numbers of Maori children were chosen as the primary sampling units in Auckland. This method of selecting CAUs was agreed in discussion with the Ministry of Health. The survey was completed for the youngest child in family to get most info possible about Maori < 5.
1162 households were visited, with up to three callbacks at different times (am / pm / weekend) to achieve a response. A very low decline rate was reported in both Auckland and Kawerau, however interviewers reported that in some cases the person answering the door appeared unwilling to acknowledge children were living in house, when this was obviously the case. These are recorded as “ineligible” but would be more properly recorded as “declines”.
Status n leaving… Rate notes called 1162 no reply 332 830 29% 3 callbacks Declined 19 811 2% Not eligible 309 502 38% completed 502
All houses in a randomly selected meshblock were visited, rotating through selected census area units in the case of Auckland to achieve geographic coverage of the selected census area units. Thus the sample represents households in areas having large numbers of Maori children in an urban (Auckland) and a single provincial (Kawerau) setting. It is not valid to generalise these findings to all urban and provincial settings.
The tables that follow present the descriptive data for each question in the survey. The first few questions describe sample. Subsequent questions are grouped according to their relevance to particular evaluation questions. Descriptive tables are supplemented by cross tabulations by ethnicity, tables of text responses when relevant and a series of analyses of the association of immunisation coverage with attitudes towards immunisation.
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Description of sample
Respondents by ethnicity and area
An overview of the sample is shown in the table below, showing number of respondents by in ethnicity in each area.
Respondents by ethnicity by area
Ethnicity M O P All N % N % N % N % Area Auckland 145 43 38 40 69 99 252 50 Kawerau 191 57 58 60 1 1 250 50 All 336 100 96 100 70 100 502 100
The Kawerau sample had only 1 Pacific respondent, and was 57% Maori compared with 43% in Auckland.
Number of children in household (Q1)
The commonest household size had 1 or 2 children. No attempt was made to distinguish family units within a household. Household sizes did not differ between the two areas.
Area Auckland Kawerau All N % N % N % Number of children 1 69 27 78 31 147 29 2 59 23 81 32 140 28 3 59 23 46 18 105 21 4 38 15 22 9 60 12 5 14 6 13 5 27 5 6 10 4 3 1 13 3 7 3 1 4 2 7 1 8 . . 2 1 2 0 20 . . 1 0 1 0 All 252 100 250 100 502 100
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Age of youngest child under 20 living in house (Q2)
The age distribution of the sample is shown below. The Auckland sample was slightly skewed towards younger children. 46% were under 5 overall, 53% in Auckland and 41% in Kawerau.
Area Auckland Kawerau All N % N % N % Age 0 37 15 22 9 59 12 1 35 14 29 12 64 13 2 24 10 18 7 42 8 3 15 6 19 8 34 7 4 19 8 13 5 32 6 5 13 5 9 4 22 4 6 9 4 6 2 15 3 7 9 4 8 3 17 3 8 7 3 11 4 18 4 9 5 2 11 4 16 3 10 8 3 12 5 20 4 11 3 1 14 6 17 3 12 9 4 8 3 17 3 13 3 1 5 2 8 2 14 6 2 11 4 17 3 15 8 3 24 10 32 6 16 13 5 11 4 24 5 17 13 5 4 2 17 3 18 10 4 12 5 22 4 19 6 2 3 1 9 2 All 252 100 250 100 502 100
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Self Completion (Q4)
Older children we able to supply their own responses to questions. This happened 20% of the time in both areas.
Area Auckland Kawerau All N % N % N % Self completion? Yes 49 19 49 20 98 20 No 203 81 201 80 404 80 All 252 100 250 100 502 100
Relationship of person completing to child (Q4)
For the 80% of respondents where parent or guardian provided responses mothers responded for 65% of respondents and fathers for 24%.
Relationship N % Mother 263 65 Father 96 24 Step parent 5 1 Sibling 5 1 Aunt / Uncle 5 1 Grandparent 30 7 ALL 404 100
Were people aware of the programme?
99% percent of respondents were aware of the programme.
Did you know about the MeNZB immunisation (Q5)
Know about N % MeNZB N 5 1 Y 497 99 Grand Total 502 100
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How did people get information about the programme?
Schools, GPs and TV were the commonest sources of information. Key Source N % 1 School 204 40.6% 2 GP 92 18.3% 3 Plunket 17 3.4% 4 Kohanga Reo 2 0.4% 5 TV 98 19.5% 6 Print media 7 1.4% 7 Radio 4 0.8% 9 Cultural media 1 0.2% 10 Tertiary institution 16 3.2% 11 Other 1 0.2% 12 Contact with someone who had meningococcal disease 3 0.6% 13 Friends/family 3 0.6% 14 Hauora/iwi services 2 0.4% 16 MeNZB nurses 4 0.8% 17 Kindy/daycare 1 0.2% 1,2 3 0.6% 1,2,3,4,5,6,7 1 0.2% 1,5 6 1.2% 1,5,7,6 1 0.2% 1,6 2 0.4% 10,11 1 0.2% 10,5 1 0.2% 11,6 1 0.2% 12,5 1 0.2% 2,1 1 0.2% 2,12 1 0.2% 2,3,10 1 0.2% 2,3,11 1 0.2% 2,5 1 0.2% 2,5,7 1 0.2% 2,7 1 0.2% 2,7,5 1 0.2% 5,1 2 0.4% 5,10 1 0.2% 5,12,1 1 0.2% 5,2 4 0.8% 5,2,1 1 0.2% 5,2,6 1 0.2% 5,6 2 0.4% 6,1 1 0.2% 6,5 1 0.2% 7,1 1 0.2% (blank) 7 1.4% ALL 502 100.0%
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Where would you go for more information (Q7)
Key Source Total % 1 GP 379 75.5% 2 Internet 27 5.4% 3 Plunket 14 2.8% 4 School 14 2.8% 5 No response 1 0.2% 6 Books/Media 1 0.2% 7 0800 number 11 2.2% 8 Other 9 1.8% 9 Hauora 7 1.4% 10 MeNZB nurses 5 1.0% 12 (No code – following up) 6 1.2% 13 Friends/family 6 1.2% 14 PHN 1 0.2% 17 (illeg) 1 0.2% 1,12 1 0.2% 1,13 1 0.2% 1,2 3 0.6% 1,3 2 0.4% 1,4 1 0.2% 1,7 2 0.4% 1,8 1 0.2% 12,1 1 0.2% 2,12 1 0.2% 2,3 1 0.2% 2,4 1 0.2% 2,6 1 0.2% 3,1 1 0.2% 3,9 1 0.2% Grand Total 500 100
Three quarters of respondents would go to a GP for information. Did you know there was an 0800 number (Q8)
Know about 0800 N % N 283 56.4 Y 219 43.6 Grand Total 502 100
43.6% were aware there was an 0800 number.
Do you use email (Q9)
Use email N % N 307 61.2 Y 195 38.8 Grand Total 502 100
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Email usage was a lot lower than in the telephone survey (61.7% in CATI, 38.8% in HH)
Did you get any email about MeNZB (Q9a)
Any MeNZB email N % N 186 95.4% U 1 0.5% Y 8 4.1% (blank) Grand Total 195 100
Of those with email about 4% received info on MeNZB. Noone could recall the content. (4.9% in CATI, 4.1% in HH)
Meningococcal B Immunisation Evaluation Final Report p 183 CBG Health Research November 2006
Did the public believe the disease was serious
How serious (Q12)
serious N % Very serious threat 350 69.9% Serious threat 133 26.5% Not all serious 15 3.0% Don’t know 3 0.6% (blank) 0.0% Grand Total 501 100.0%
Meningococcal disease was regarded as serious by the vast majority of respondents. (Very serious 60% CATI, 70% HH)
Did the public believe the disease could affect them
How likely you would get meningococcal disease (Q13)
likely N % extremely likely 28 6% somewhat likely 121 24% not very likely 180 36% not at all likely 90 18% don't know 82 16% Grand Total 501 100.00%
Two thirds of those expressing an opinion felt it was not very likely they would get meningococcal disease (Not very + not at all 49% CATI, 54% HH)
Meningococcal B Immunisation Evaluation Final Report p 184 CBG Health Research November 2006
Ethnicity by perceived likelihood of getting meningococcal disease
Ethnicity M O P Total % Total N Likely % N % N % N extremely likely 7% 25 1% 1 3% 2 6% 28 somewhat likely 26% 86 22% 19 23% 16 24% 121 not very likely 34% 113 40% 41 37% 26 36% 180 not at all likely 16% 52 18% 20 26% 18 18% 90 don't know 17% 57 18% 15 11% 8 16% 80 6 1% 2 0% 0 0% 0% 2 Total 100% 335 100% 96 100% 70 100% 501
Maori were slightly more likely to consider themselves likely to get meningococcal disease.
Other potential barriers to vaccination
The physical access barriers of time and distance to usual provider did not appear to disproportionately impact on Maori when these were examined by ethnicity.
Distance to usual provider by ethnicity (Q14)
Ethnicity Total Total M O P N % km N % N % N % <1 71 21% 11 11% 21 30% 103 20% 1-2 109 32% 33 34% 11 16% 153 30% 3-10 103 31% 37 39% 27 39% 167 33% 10+ 50 15% 15 16% 11 16% 76 15% Don’t know 2 0% 0% 0% 2 0% Grand Total 335 100% 96 100% 70 100% 501 100%
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Time to usual provider by ethnicity (Q15)
Ethnicity Total Total M O P N % Travel time N % N % N % Up to 5 min 227 68% 55 57% 32 46% 314 63% 10 40 12% 20 21% 18 26% 78 16% 15 22 7% 7 7% 10 14% 39 8% 20 18 5% 2 2% 3 4% 23 5% 25 1 0% 0 0% 1 1% 2 0% 30 17 5% 7 7% 5 7% 29 6% Over 30 min 11 3% 5 5% 1 1% 17 3% Grand Total 336 100% 96 100% 70 100% 502 100%
In fact Maori appeared to be closer in both time and distance to providers than ‘Other” ethnicities.
Mode of transport (Q16)
Mode of Transport N % 1 Car 421 84.0% 2 Walk 65 13.0% 3 Bus 3 0.6% 4 Horse 1 0.2% 5 Plane 1 0.2% 6 Train 1 0.2% 1 3 0.6% 1,2 2 0.4% 1,2,3 1 0.2% 2,1 1 0.2% 2,3 1 0.2% 3,2 1 0.2% (blank) 0.0% Grand Total 501 100.0%
Car was the commonest mode of travel to usual care provider.
Is there any reason you might not go to that provider (Q17)
Any reason wouldn’t go N % N 461 91.8 Y 41 8.2 Grand Total 502 100.0
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Forty one people (8.2%) said there were reasons they might not go to their usual provider. These are listed in the following table.
List of reasons might not go (Q17a)
Key Reason N % 1 No 1 2.4% 2 GP inaccessible/times don’t suit 8 19.5% 3 Staff not friendly 1 2.4% 4 Child sick 3 7.3% 5 Distance/travel time 5 12.2% 6 Cost of vax – not NZ resident 1 2.4% 7 School age – done at school 7 17.1% 8 Don’t want to 2 4.9% 9 Reaction to vaccinations 1 2.4% 10 Don’t know 1 2.4% 11 GP sceptical about immunisations 1 2.4% 12 Scared of needles 3 7.3% 13 Easier at iwi provider 3 7.3% 14 Don’t believe in immunisations 3 7.3% 2,3 1 2.4% Grand Total 41 100%
Meningococcal B Immunisation Evaluation Final Report p 187 CBG Health Research November 2006
Do you have transport available anytime you need it (Q18)
Ninety percent of people had a care available when they needed it. (96.8% in CATI, 89.3% in HH)
Transport Available N % N 54 10.1 Y 448 89.9 Grand Total 502 100
Did your usual PHC provider contact you (Q19)
Ethnicity M O P Total N Total % Contact from usual pHC N % N % N % N 209 62% 65 68% 21 30% 295 59% U 1 0% 0 0% 0% 1 0% Y 125 37% 31 32% 48 70% 204 41% Grand Total 335 100% 96 100% 69 100% 500 100%
The notable feature of this table is the very high proportion of Pacific respondents that were contacted by their primary care provider. This must be an Auckland phenomenon as there was only 1 Pacific respondent in Kawerau.
How did they contact you (Q20)
How contacted N % 1 Mail 94 45.6% 2 Phone 37 18.0% 3 Discussion 50 24.3% 4 Other 4 1.9% 1,2 17 8.3% 1,3 1 0.5% 1,4 1 0.5% 2,3 1 0.5% N 1 0.5% (blank) 0.0% Grand Total 206 100.0%
Mail was the most common form of contact.
Meningococcal B Immunisation Evaluation Final Report p 188 CBG Health Research November 2006
Number of immunisations by ethnicity by area (Q21)
This table shows the breakdown of number of immunisations by area and ethnicity.
Maori Other Pacific ALL N % N % N % N % Area Imms Auckland 0 15 10 3 8 2 3 20 8 1 6 4 2 5 5 7 13 5 2 16 11 1 3 5 7 22 9 3 106 73 31 82 56 81 193 77 4 2 1 1 3 1 1 4 2 All 145 100 38 100 69 100 252 100 Kawerau Imms 0 26 14 9 16 . . 35 14 1 11 6 2 3 . . 13 5 2 27 14 2 3 1 100 30 12 3 127 66 44 76 . . 171 68 4 . . 1 2 . . 1 0 All 191 100 58 100 1 100 250 100 All Imms 0 41 12 12 13 2 3 55 11 1 17 5 4 4 5 7 26 5 2 43 13 3 3 6 9 52 10 3 233 69 75 78 56 80 364 73 4 2 1 2 2 1 1 5 1 All 336 100 96 100 70 100 502 100
Meningococcal B Immunisation Evaluation Final Report p 189 CBG Health Research November 2006
Reasons for Vaccination
The survey branched after asking how many immunisations a person had received into there streams – Group A “completers” (3 imms), Group B “non- vaccinators” (0 imms) and Group C “non-completers” (1 or 2 imms).
The 364 completers were asked where they got their immunisations:
Where did you get them (QA1)
Where % immunised for completers N 1 GP 174 47.8% 2 School 178 48.9% 3 University 1 0.3% 4 Home 1 0.3% 5 Other 4 1.1% 6 Prison 0.0% 7 Kohanga 1 0.3% 1,2 4 1.1% 1,6 1 0.3% Grand Total 364 100.0%
Why did you decide to get immunised (QA2)
They were then asked why they decided to get immunised. The replies were classified into themes shown in the table below.
Reason for getting immunised (completers) N % 1 Protection 119 32.7% 2 Worry 15 4.1% 3 Safety 56 15.4% 4 Compulsion 59 16.2% 5 Fear 31 8.5% 7 No response 5 1.4% 8 Advice from health professional 4 1.1% 9 Don’t know 10 2.7% 1,2 8 2.2% 1,2,3 3 0.8% 1,3 24 6.6% 1,3,2 1 0.3% 1,5 6 1.6% 2,5 4 1.1% 2,9 2 0.5% 3,1 7 1.9%
Meningococcal B Immunisation Evaluation Final Report p 190 CBG Health Research November 2006
3,1,2 1 0.3% 3,2 1 0.3% 3,4 1 0.3% 3,5 2 0.5% 4,1 2 0.5% 4,3 2 0.5% 4,9 1 0.3% Grand Total 364 100.0%
Meningococcal B Immunisation Evaluation Final Report p 191 CBG Health Research November 2006
Was there active follow-up of non-vaccinated?
For the 55 non-vaccinated respondents the survey explored if they had been contacted by another provider (not their usual provider) about getting an immunisation. This would be the expected outcome of a primary care provider that was monitoring their immunisation rates and referring unimmunised patients to outreach services.
Were you contacted by anyone other than your usual healthcare provider about getting an immunisation (QB1)
Other contact N % N 33 62.3% Y 20 37.7% Grand Total 53 100%
Nearly 40% of the non-vaccinated respondents were contacted by another provider.
Who (role) (QB1a)
This table describes the role of the person contacting the non-vaccinated person.
Other contact % (role) N 1 Health professional (nurse/doctor) 5 25 2 Plunket 5 25 3 School 3 15 4 Don’t remember 1 5 5 Hauora 2 10 6 Kohanga Reo 2 10 7 Family Start 1 5 2,1 1 5 Grand Total 20 100
Do you intend to immunise (QB2)
Intend to % immunise N 1 Extremely likely 23 42.6% 2 Somewhat likely 5 9.3% 3 Not very likely 3 5.6% 4 Not at all likely 1 1.9% 5 Depends 6 11.1% 6 Don’t know 1 1.9% 7 I won’t 15 27.8% Grand Total 54 100.0%
Meningococcal B Immunisation Evaluation Final Report p 192 CBG Health Research November 2006
The above table shows that the non-vaccinated divide into two distinct groups – the “good intenders” and the “active decliners”
Reasons for non-vaccination
If made a definite decision not immunise (“I won’t”) (QB3)
Feels clinical studies inconclusive Side effects Dislikes needles Doesn’t think there’s a need to immunise Apathy Doesn’t like chemicals: prefers herbal alternatives More research needed/new vaccine Only effective for 2 years
If still deciding (“depends”, “don’t know”) (QB4)
A visit Talking to a health professional 0800 line Cost – non-resident
Meningococcal B Immunisation Evaluation Final Report p 193 CBG Health Research November 2006
Reasons for non completion
The 78 “non-completers” provided an opportunity to explore reasons for not completing the full course of there immunisations.
Where did you get them (QC1)
C_where N % 1 GP 50 68.5% 2 Community Clinic 2 2.7% 4 School 13 17.8% 5 Iwi services 2 2.7% 7 Family Start 1 1.4% 1,3 1 1.4% 1,4 1 1.4% 1,8 1 1.4% 6,3 1 1.4% Y 1 1.4% (blank) 0.0% Grand Total 73 100.0%
Do you plan to finish the course (QC2)
C_will_finish N % N 4 5.3% U 1 1.3% Y 71 93.4% Grand Total 76 100.0%
The vast majority of non-completers (93%) planned to finish the course
Meningococcal B Immunisation Evaluation Final Report p 194 CBG Health Research November 2006
Main reason haven’t completed (C2a)
Non-completers gave a wide range of reasons they had not finished the full immunisation course, shown below, with sickness being the commonest (25%). Eighteen percent of respondents were still undergoing the immunisation programme.
C2_reas_no_done N % 1 Time constraints 10 13.7% 2 Next planned medical check 3 4.1% 3 No response 3 4.1% 4 Another baby in family 1 1.4% 5 Sickness 18 24.7% 6 Unsure whether has been completed at school 1 1.4% 7 Child not in parent’s care for a time 1 1.4% 8 Still undergoing immunisation programme 13 17.8% 9 Fear of needles 1 1.4% 10 Apathy/forgets 8 11.0% 11 Baby too young 4 5.5% 12 Questions whether necessary, fearful for children 1 1.4% 13 Reaction to 1st or 2nd vaccinations 1 1.4% 14 Finished school before 2nd or 3rd vaccination 3 4.1% 15 Moved areas 3 4.1% 1,5 1 1.4% 9,10 1 1.4% Grand Total 73 100.0%
Four respondents said they wouldn’t complete the course. Three gave reasons – fear of side effects and that they didn’t know how to.
Meningococcal B Immunisation Evaluation Final Report p 195 CBG Health Research November 2006
Final questions for all respondents
Do your children normally get imms (Q22)
Normally % get imms N N 11 2.2% U 3 0.6% Y 488 97.2% Grand Total 502 100.0%
Ninety seven percent of respondents normally got immunisations.
Where do you prefer to have immunisations (Q23)
Where prefer to be % immunised N 1 GP 286 57.2% 2 Community Clinic/school 114 22.8% 3 Home 88 17.6% 4 Other 6 1.2% 5 Kohanga 0.0% 1,2 3 0.6% 1,3 2 0.4% 2,5 1 0.2% Grand Total 500 100.0%
Most people preferred to have immunisations at the GP
How likely do you think it is that MeNZB vaccination will provide protection against Meningococcal B disease (Q24)
Approximately 15% of respondents had some ambivalence that the vaccine would provide protection against Meningococcal disease.
effective N % 1 Extremely likely 175 34.9% 2 Somewhat likely 252 50.2% 3 Not very likely 36 7.2% 4 Not at all likely 4 0.8% 5 Depends 34 6.8% 6 Don’t know 1 0.2% Grand Total 502 100.0%
Meningococcal B Immunisation Evaluation Final Report p 196 CBG Health Research November 2006
How confident are you that the MeNZB vaccination is safe (Q25)
A similar 15% of respondents had some ambivalence about the safety of the vaccine.
safe N % 1 Extremely confident 186 37.1% 2 Somewhat confident 242 48.2% 3 Not very confident 34 6.8% 4 Not at all confident 6 1.2% 5 Depends 31 6.2% 6 Other 2 0.4% 7 Declined 1 0.2% Grand Total 502 100.0%
Meningococcal B Immunisation Evaluation Final Report p 197 CBG Health Research November 2006
Analyses
1. Association between ethnicity and completing immunisations
Ethnicity Immunisations completed? Frequency Percent Row Pct Col Pct N Y Total M 101 235 336 20.12 46.81 66.93 30.06 69.94 75.94 63.69 O 19 77 96 3.78 15.34 19.12 19.79 80.21 14.29 20.87 P 13 57 70 2.59 11.35 13.94 18.57 81.43 9.77 15.45 Total 133 369 502 26.49 73.51 100.00
DF Value Prob Chi-Square 2 6.6639 0.0357 Likelihood Ratio Chi-Square 2 6.9216 0.0314 Mantel-Haenszel Chi-Square 1 5.9387 0.0148
There is a significant association between ethnicity and number of immunisations, with Maori being less likely to have completed 3 immunisations.
Meningococcal B Immunisation Evaluation Final Report p 198 CBG Health Research November 2006
2. Association between ethnicity and perception of effectiveness
Perceived Ethnicity Effective Frequency Percent Row Pct Col Pct Y N Total M 282 54 336 56.18 10.76 66.93 83.93 16.07 66.04 72.00 O 87 9 96 17.33 1.79 19.12 90.63 9.38 20.37 12.00 P 58 12 70 11.55 2.39 13.94 82.86 17.14 13.58 16.00 Total 427 75 502 85.06 14.94 100.0 0
DF Value Prob Chi-Square 2 2.9452 0.2293 Likelihood Ratio Chi-Square 2 3.2279 0.1991 Mantel-Haenszel Chi-Square 1 0.1512 0.6974
There is no association between ethnicity and perception of effectiveness
Meningococcal B Immunisation Evaluation Final Report p 199 CBG Health Research November 2006
3. Association between ethnicity and perception of safety
Safe Ethnicity (very or somewhat) Frequency Percent Row Pct Col Pct Y N Total M 277 59 336 55.18 11.75 66.93 82.44 17.56 64.72 79.73 O 86 10 96 17.13 1.99 19.12 89.58 10.42 20.09 13.51 P 65 5 70 12.95 1.00 13.94 92.86 7.14 15.19 6.76 Total 428 74 502 85.26 14.74 100.00
DF Value Prob Chi-Square 2 6.7677 0.0339 Likelihood Ratio Chi-Square 2 7.4398 0.0242 Mantel-Haenszel Chi-Square 1 6.5524 0.0105
There is a significant relationship between ethnicity and perception of safety. 17.5% of Maori do not consider MeNZB safe, 10.5% of “Others” and 7% of Pacific.
Meningococcal B Immunisation Evaluation Final Report p 200 CBG Health Research November 2006
4. Association between perception of effectiveness and completing immunisation
Perceived Immunisations Effective completed Frequency Percent Row Pct Col Pct N Y Total Y 113 314 427 22.51 62.55 85.06 26.46 73.54 84.96 85.09 N 20 55 75 3.98 10.96 14.94 26.67 73.33 15.04 14.91 Total 133 369 502 26.49 73.51 100.0 0
DF Value Prob Chi-Square 1 0.0013 0.9707 Likelihood Ratio Chi-Square 1 0.0013 0.9707 Mantel-Haenszel Chi-Square 1 0.0013 0.9707
There is no association between effectiveness and completing 3 immunisations
Meningococcal B Immunisation Evaluation Final Report p 201 CBG Health Research November 2006
5. Association between perception of safety and completing immunisations
Safe (very or somewhat) Immunisations completed Frequency Percent Row Pct Col Pct N Y Total Y 93 335 428 18.53 66.73 85.26 21.73 78.27 69.92 90.79 N 40 34 74 7.97 6.77 14.74 54.05 45.95 30.08 9.21 Total 133 369 502 26.49 73.51 100.00
DF Value Prob Chi-Square 1 33.8517 <.0001 Likelihood Ratio Chi-Square 1 30.2965 <.0001 Mantel-Haenszel Chi-Square 1 33.7843 <.0001
There is a very strong association between perception of safety and completion immunisations. Respondents were much more likely to complete if they considered the immunisation safe.
Meningococcal B Immunisation Evaluation Final Report p 202 CBG Health Research November 2006
6. Association between completing immunisations and distance from provider.
Immunisations completed Distance group Frequency Percent Row Pct Col Pct 1 2 3 4 Total N 32 43 36 20 131 6.43 8.63 7.23 4.02 26.31 24.43 32.82 27.48 15.27 31.37 28.10 21.56 26.32 Y 70 110 131 56 367 14.06 22.09 26.31 11.24 73.69 19.07 29.97 35.69 15.26 68.63 71.90 78.44 73.68 Total 102 153 167 76 498 20.48 30.72 33.53 15.26 100.00
DF Value Prob Chi-Square 3 3.5489 0.3145 Likelihood Ratio Chi-Square 3 3.5796 0.3106 Mantel-Haenszel Chi-Square 1 1.8416 0.1748
There was no association between distance and completing 3 immunisations.
Meningococcal B Immunisation Evaluation Final Report p 203 CBG Health Research November 2006
7. Association between completing immunisations and perceived likelihood of getting meningococcal disease
Perceived high likelihood of Immunisations completed getting disease Frequency Percent Row Pct Col Pct Y N Total N 48 84 132 9.58 16.77 26.35 36.36 63.64 32.21 23.86 Y 101 268 369 20.16 53.49 73.65 27.37 72.63 67.79 76.14 Total 149 352 501 29.74 70.26 100.00
DF Value Prob Chi-Square 1 3.7623 0.0524 Likelihood Ratio Chi-Square 1 3.6752 0.0552 Continuity Adj. Chi-Square 1 3.3443 0.0674 Mantel-Haenszel Chi-Square 1 3.7548 0.0527
There is a weak association between completing immunisations and perceived likelihood of getting meningococcal disease.
Meningococcal B Immunisation Evaluation Final Report p 204 CBG Health Research November 2006
8. Association between completing immunisations and perceived seriousness of meningococcal disease
Perceived to be Immunisations completed very serious Frequency Percent Row Pct Col Pct Y N Total N 123 10 133 24.55 2.00 26.55 92.48 7.52 25.47 55.56 Y 360 8 368 71.86 1.60 73.45 97.83 2.17 74.53 44.44 Total 483 18 501 96.41 3.59 100.00
DF Value Prob Chi-Square 1 8.0574 0.0045 Likelihood Ratio Chi-Square 1 7.0230 0.0080 Continuity Adj. Chi-Square 1 6.5882 0.0103 Mantel-Haenszel Chi-Square 1 8.0413 0.0046
There is a strong association between completing immunisations and perceiving the disease to be serious.
Meningococcal B Immunisation Evaluation Final Report p 205 CBG Health Research November 2006
9. Logistic regresion model of probability of completing immunisations.
It is often difficult to interpret multiple tables where there may be important interactions between variables, such as the above. The cleanest way to analyse these data is in a single model. A logit link function was used to fit a general linear model for the probability of completing three (or four) immunisations.
The variables in the model and whether they are significant in the model is shown in the 2 results tables below. The first table shows the results of modelling probability of completing immunisation by area (Auckland vs Kawerau), age (as we know there is an age distribution difference and age is strongly associated with completing immunisations) and ethnic group.
Analysis of Maximum Likelihood Estimates Standard Wald Parameter DF Estimate Error Chi-Square Pr > ChiSq Intercept 1 -0.8805 0.1820 23.4051 <.0001 Area Auckland 1 -0.2426 0.1132 4.5956 0.0321 ageyrs (cont) 1 -0.0463 0.0177 6.8438 0.0089 ethMPO M 1 0.3028 0.1616 3.5119 0.0609 ethMPO O 1 -0.2423 0.2119 1.3078 0.2528
Reading down the right column, this analysis shows the expected patterns. We knew that the Auckland rate was higher, that age was a strong determinant of uptake, and that Maori rates were lower than Pacific rates (the reference category), and “Other” and Pacific rates were quite close.
If we now add the attitudinal variables of perceived safety, perceived effectiveness, perceived seriousness, and perceived likelihood the ethnicity differentials disappear, shown in the table on the following page.
Care is required in interpreting these analyses, but they do seem to suggest that after controlling for differences in age structure and any environmental differences between Auckland and Kawerau (eg PHO activity, access to services) the differences in beliefs about the safety of the MeNZB vaccination and the seriousness of meningococcal disease between ethnic groups, may explain some of the ethnicity differentials in immunisation uptake.
These findings are preliminary. More work is being done on this analysis, which will be presented in the final evaluation report.
Meningococcal B Immunisation Evaluation Final Report p 206 CBG Health Research November 2006
Analysis of Maximum Likelihood Estimates Standard Wald Parameter DF Estimate Error Chi-Square Pr > ChiSq Intercept 1 0.1436 0.3276 0.1922 0.6611 Area Auckland 1 -0.2253 0.1189 3.5911 0.0581 ageyrs (cont) 1 -0.0459 0.0185 6.1493 0.0131 ethMPO M 1 0.2243 0.1684 1.7746 0.1828 ethMPO O 1 -0.2033 0.2219 0.8388 0.3597 safe N 1 0.7453 0.1436 26.9472 <.0001 effective N 1 -0.2891 0.1674 2.9819 0.0842 serious N 1 0.7179 0.2697 7.0849 0.0078 likely N 1 -0.1502 0.1163 1.6676 0.1966
For readers more familiar with an odds ratio presentation, this is presented below:
Odds Ratio Estimates Point 95% Wald Effect Estimate Confidence Limits Area Auckland vs Kawerau 0.637 0.400 1.016 ageyrs 0.955 0.921 0.990 ethMPO M vs P 1.278 0.618 2.645 ethMPO O vs P 0.833 0.347 2.004 safe N vs Y 4.439 2.529 7.794 effective N vs Y 0.561 0.291 1.081 serious N vs Y 4.203 1.460 12.096 likely N vs Y 0.741 0.469 1.168
Meningococcal B Immunisation Evaluation Final Report p 207 CBG Health Research November 2006
APPENDIX Do you have any other comments about the meningitis immunisation? Glad had vax: no side effects & haven't caught meningococcal B Hope it does help the kids, esp. the young ones Since my mokos have had they've been quite good Watch out for the symptoms; be aware; it's dangerous Hope the vax will protect & the children do not get meningococcal B Better safe than sorry It's a serious sickness and people out there need to get their kids immunised It's a lot of work;however it's a blessing as we have been able to give other immunisations Would have it if it wasn't an injection I like the way the public were informed of the programme. Multiple sources of information and using celebrities. Well Child Book was also useful. Grateful that it is free for our children It really hurts; it leaves your arm numb for a month Children's awareness has been raised about meningoccal disease - they have been informed along with the adults Hopefully it works for the benefit of the children. Recommend it to all mothers for their children's benefit Would like a pill or medicine - pref. In syrup form After having the imms, he shouldn't be catching meningococcal disease Disease is very dangerous If they could improve safety, as some people have caught disease post-vax It's really great. Really easy access. No. It's good that it's free. Good that it is available If children are healthy then they are not at risk of catching diseases Because of side effects daughter didn't want her children vaccinated Adults should be able to get the vaccinations free of charge Extremely glad they have it in the schools It was quick and painless Glad they brought it out. Gives you peace of mind. Good on ya fullas Mean Maori Mean Hasn't seen any side effects Suggests all children get immunised Relieved that the programme was offered and available for our children Should be advertised at courses / workplaces Very serious disease Keep going and give it to everybody No, haven't had any problems Tarawera doctors doesn't work! Better be worth it, because it works It's choice that the MOH is trying to stop meningococcal B Every child needs it Good that people here have a choice whether to have it done or not GPs should be able to administer immunisation to school age children as well as at school Will wait and see - don't trust drug companies' propaganda Would prefer to have them at home Good programme It is a pity the immunisations didn't cover all the different meningococcal strands as well Hope that it works Hope it's safe
Meningococcal B Immunisation Evaluation Final Report p 208 CBG Health Research November 2006
NB: children are home schooled and have not had any communication from health professionals No PHN available when MeNZB programme on: organisation difficulties - children immunised at different times. Children not educated enough. Problems with getting immunisations if away from school on imms day as parents expected to take the children to the local college Happy with the service. Disagree with imms under 6 months of age Confusion re: extra immunisation. More info re: pros/cons of immunisation. Wish it wasn't an injection No. Good programme. Hope it works and keeps the kids healthy Better to know your information before the vaccination! No. Kids haven't had any weird reactions, it's been good. Hope it works Government did a good job getting all children immunised Everyone should be immunised If it wasn't safe the government wouldn't give it to the children It's all good if it can prolong the life of my kids Nana would like to say that she has tried to encourage her grandson to have the vaccination however he is afraid of needles and won't have it at all. It's cool how everyone (kids) can be immunised at school Glas she has had it. A lot of our people (Maori) don't take it that serious and they should. Parents need to be given more education about the immunisation in order to make an informed decision. I want to encourage everybody to get the vaccine to prevent this sickness. They are really important. Wish I was vaccinated as well (Adults should also be able to get immunised free of charge). It is definitely a good thing. Everybody (including adults over 20yrs) should be able to have the immunisation free of charge particularly the lower income bracket. Good idea Would like to be kept up with further developments of immunisation research given out as available. Great programme Excellent programme It made my 15 yr old child sick for 7 days which was really scary. He was limp, weak, had welts (each dose). This prevented me from getting my 6yr old child done as didn't want him to have the side effects. Children had their own choice about this immunisation Likes the National Immunisation Register - able to track immunisation history Grateful the immunisation is here Thought the MeNZ B programme was rushed out without testing it properly Thank you for immunising our children New vaccination - long term risks not known Glad the govt did the immunisations for everyone Hope everyone gets their children vaccinated It's good they have had it Wish it wasn't an injection It's really good and it's important that everyone be immunised for meningoccal B - especially the children. It's really important. I hope it works Glad that I have done it. Would like more stastics - side effects, allergic reactions, death rates and protection rates Everyone get onto it! Great to be offered through school. Would like family group meeting immunisations available at home so the immunisations could be done at the start of the immunisation campaign It's a pity the vaccination had to be given in 3 injections as it was very hard for the kids.
Meningococcal B Immunisation Evaluation Final Report p 209 CBG Health Research November 2006
Didn't like the fact that doctor urged her to have the MeNZ B immunisation at the same time as the other immunisations (MMR) therefore she chose to wait until he was 6/12 old. Government should stop Asians coming into NZ and bringing in their diseases, coz once we've got a cure for one there's another one popping up. Hope they hurry to find a cure. I feel that the MeNZ B immunisation should be included in the regular immunisation schedule that babies have. Can it come in a pill? Time will tell Baby too young: will go to GP to have them done (Mum says she hopes they wouldn't give anything unsafe) Keep up with those who haven't got it yet. Keep the adverts up on TV! So far it's alright Glad the immunusation came out All mothers should get their kids immunised. It's really important Son needs to be vaccinated. Better to immunise as the disease is very serious for children. Drs need to explain more about side effects Thanks for the free immunisations It's alright Was good at school with good follow-up It's good. Everybody should get the injections Liked that they were done through schools: wide media coverage; good public awareness Lost letter from school - not followed up by anyone. Mum heard that the immunisations don't prevent meningitis Programme well set up 2nd or 3rd one made children sick - fever/runny stomach/vomiting/rash Information is quite good - promotion/education was good Children haven't contracted meningococcal - he is happy Everyone should get their shots Really good! Brilliant idea, especially for kids; safe feeling Ads are very effective and sad Had side effects; fever and pain - took a few days to a week to go away and felt sick I hope it works - good thing Don't add anymore Done without giving people enough time to think about it - put fear into people - would like to see stats re: side effects It's alright. Side effects were annoying. Would prefer a Samoan speaking surveyor as Samoan is first language Sore arm Very important for children to be immunised Rather be safe than sorry Thank you that it is free in New Zealand Visit the home would be better, more children would get immunised Good thing Would have been good to get info in Samoan Think need more language specific information Good for govt to provide immunisations for the children Glad she has had it Has anyone caught or contracted the disease after they have been immunised? It's good to see everything advertised on TV; good to have celebrities - reaches out to the Pacific Community As long as the kids are safe
Meningococcal B Immunisation Evaluation Final Report p 210 CBG Health Research November 2006
Meningococcal B Immunisation Evaluation Final Report p 211 CBG Health Research November 2006