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Why Is Influenza Vaccine Uptake So Low Among Aboriginal Adults?

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Why Is Influenza Vaccine Uptake So Low Among Aboriginal Adults? Why is influenza vaccine uptake so low among Aboriginal adults? Robert Menzies,1,2 Jalil Aqel,1 Ikram Abdi,1 Telphia Joseph,1 Holly Seale,1 Sally Anne Nathan1 he influenza virus is responsible Abstract for a substantial disease burden, estimated to kill more than 3,000 Objectives: Determine major barriers to, and facilitators of, influenza vaccination of Aboriginal T 1 Australians annually. However, the burden adults, in order to improve coverage from the current level of 30%. is much greater in Australia’s First Peoples, Methods: i) A focus group with 13 Aboriginal Immunisation Healthcare Workers; and ii) a with influenza hospitalisation rates five- cross-sectional survey of Aboriginal people aged ≥18 years at the 2017 New South Wales Koori 2 fold higher than those of non-Indigenous Knockout (29 September–2 October). people, probably due to their higher rates of Results: The focus group nominated poor identification of Aboriginality in general practice. chronic disease.2 Therefore, those classified Of 273 survey respondents, a substantial minority (30%) were unaware of their eligibility for as ‘at risk’ of severe outcomes from influenza free influenza vaccination. More than half (52%) believed the vaccine could cause influenza, infection – who are eligible for free annual 40% reported there were better ways than vaccination for avoiding infection and 30% said influenza vaccine – include all Australia’s they would not have the vaccine if it was offered to them. Regarding health service access, few First Peoples people aged ≥6 months, as well reported experiencing difficulty (17%), feeling uncomfortable (15%) or being discriminated as non-Indigenous people with underlying against (8%), but 53% reported not receiving a reminder from a health professional. medical conditions or aged ≥65 years.3 However, uptake is low among Australia’s Conclusions: Misconceptions about influenza disease and vaccine among Aboriginal people First Peoples, with the most recent influenza and inadequate identification of Aboriginality in general practice appear to be the greatest vaccine coverage estimate in 2013 being only barriers to vaccination, rather than health service access in general. 29% for people aged 18–49 years and 51% in Implications for public health: More active communication to and targeting of Aboriginal 50–64-year-olds, with little change since the adults is required; this is even more urgent following the arrival of COVID-19. vaccine became free of charge for younger Key words: Oceanic Ancestry Group, adult, immunisation programs, health knowledge, adults in 2010.4 attitudes, practice Common barriers in the general population to vaccine uptake include cost and other factors related to healthcare access, project were to investigate the awareness and Phase 1: Aboriginal Immunisation knowledge and awareness, and attitudes to a attitudes of Aboriginal adults towards the Healthcare Worker focus group specific vaccine or vaccination in general.5,6 It influenza vaccine and accessibility to it and to is estimated that one-third of Australia’s First Since 2013, AIHCWs have been employed in identify possible ways to improve influenza Peoples people feel discriminated against in a each local health district in New South Wales vaccination coverage. healthcare setting,7 so a lack of cultural safety (NSW), based at the Public Health Unit.11 Their for them may be another key barrier. role is to facilitate immunisation of Aboriginal people through working with community While there are several studies that examine Methods groups and providers and providing direct barriers to vaccination and strategies for The study consisted of two phases and used follow-up of parents of under-vaccinated improvement in the general Australian a multi-methods approach – a focus group Aboriginal children. A focus group was held population,26 and two on pregnant First of Aboriginal Immunisation Healthcare with all 13 AIHCWs at their annual workshop Nations women, no studies were identified Workers (AIHCWs) and a survey of Aboriginal at the NSW Ministry of Health in North that specifically targeted all Australia’s First community members. Sydney (18 August 2017). A discussion guide Nations adults. Therefore, the aims of this 1. School of Public Health and Community Medicine, University of NSW, New South Wales 2. Kirby Institute, University of NSW, New South Wales Correspondence to: Dr Robert Menzies, Sanofi, Building D 12/24 Talavera Rd, Macquarie Park ,NSW 2113; e-mail: [email protected] Submitted: October 2019; Revision requested: April 2020; Accepted: May 2020 The authors have stated they have no conflict of interest. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Aust NZ J Public Health. 2020; Online; doi: 10.1111/1753-6405.13004 2020 ONLINE Australian and New Zealand Journal of Public Health 1 © 2020 The Authors Menzies et al. was developed to explore the attitudes of knowledge and attitudes to adult vaccination Results staff towards the provision of Aboriginal adult and vaccination status. Most questions were immunisation, the barriers that they believe structured as ‘tick all that apply’ answers with Phase 1: Aboriginal Immunisation are impacting on uptake and the potential the additional option of free text (Tables 1 Healthcare Worker focus group strategies that could be used to improve and 2), plus a series of questions on attitudes All 13 AIHCWs agreed to participate in the uptake. Questions were asked in an open- with a five-point Likert scale for responses focus group. There were three main themes ended manner to allow room for expansion. (Table 3). identified by participants. Paraphrasing and additional questions/ prompts were added to seek clarification Data collection Identification of patient Aboriginality during the sessions. A total of 10 interviewers were responsible It was suggested that identification of for approaching prospective participants, Aboriginal patients was a huge problem in Data analysis obtaining consent, providing the paper areas where an Aboriginal Medical Service Interviews were digitally recorded and questionnaire and collecting it when is not available. It was reported that most transcribed verbatim. We used NVIVO 11 for completed. Interviewers were required to general practices do not know how many coding and management of the data. The be Aboriginal, as recommended by the Aboriginal patients they have, and this data were thematically analysed using an Reference Group, and were predominantly becomes an issue when deciding who to inductive approach.12 To analyse the data, we Aboriginal Health Workers from various parts offer certain vaccines to. One participant followed the steps proposed by Braun and of NSW. They circulated in pairs or groups stated: “it’s very important to educate and Clarke,13 comprising familiarisation by reading around the three different grounds where the empower Aboriginal community members to and re-reading during transcribing verbatim, games were being played and approached not be ashamed of who they are and that it’s generating initial codes and themes, and people in attendance to undertake the for their own health benefit if they identify; reviewing, defining and naming themes that survey. Only people who were Aboriginal and they’re not getting into trouble, as this is were most relevant to the research questions. over 18 years of age were surveyed. a common misconception when it comes to identification”. There was a consensus Phase 2: Community survey Data analysis among the participants that more education The NSW Koori Knockout is a NSW-wide Univariate and multivariate statistical was necessary (including of clinic staff) Aboriginal Rugby League Tournament analyses were conducted using SPSS 22.0 for on the importance of determining patient held each year over the October long Windows.10 As the questionnaire included Aboriginality. weekend. It is one of the largest gatherings only categorical data, the chi-squared test of Australia’s First Peoples population, with for proportions was used, with an α-level A peripheral part of the National Immunisation Program more than 35,000 attending in 2016.8 A set at 0.05 or less for significance. All survey survey was conducted via a self-administered questions were compared based on whether It was emphasised that if the eligibility of all questionnaire of attendees at the 2017 event individuals were vaccinated (or not). Aboriginal adults was more prominent in held from Friday 29 September to Monday 2 Stepwise multivariate logistic regression was promotions of the national schedule, doctors October at Leichardt Oval in Sydney. conducted to determine which factors were would see them as an important group associated with vaccination. and more actively promote vaccination. Sample size Currently, it is considered an additional A sample size of 320 participants was required Ethical approval, governance and vaccine at the bottom of the schedule, and in order to detect a significant difference in terminology perhaps as one participant suggested: “the the proportions of barriers reported between Ethics approval was obtained from the [visual presentation of the] schedule needs vaccinated and unvaccinated participants, Aboriginal Health and Medical Research to be changed for them, but I also think assuming coverage for young and
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