Introduction

The overall aim of this project is to increase the immunisation coverage in the Kaipara by facilitating a co-ordination and collaborative approach between providers and the implementation of health promotional strategies. By taking this approach, it is also expected the Tamariki Ora - Well Child checks will be better facilitated and pursued.

Immunisation coverage is a cause for concern in both developed and undeveloped countries. It has been estimated that less than 60% of all children in New Zealand, under the age of 2 years, are fully vaccinated.

In addition, some children are offered immunisations against tuberculosis (BBG) and bacterial meningitis. Each of these diseases act in different ways and contribute to the mortality and morbidity in children.

The Government's commitment to immunisation is based on sound evidence as one of the most cost effective means of preventing disease, and the benefits outweigh any risks associated with the vaccine (MOH). However, this position is not necessarily convincing to individuals for whom immunisation has a immediate impact.

There have been two New Zealand studies (White G. and Thompson A. 1992) and a North Health Immunisation Coverage survey in 1996, which provide insights into the low immunisation coverage. Both pieces of work examine the barriers to immunisation and although small changes have been noted between the 1992 and 1996 survey periods, they have remained - in substance - the same.

White and Thompson concluded that the socio cultural perspective to health beliefs which are based on folk medicine, knowledge and experience preclude the assumption that people make decisions based on knowledge from a bio medical perspective based on science. In fact, they argue mothers - the predominant respondents in the survey - tend to fall into three categories, believers, non-believers and vacillators. In addition, families may be described as stable or transient. Planned strategies for immunisation uptake should take into consideration the differences which lie between these categories.

Health professionals should share the responsibility by ensuring mothers receive accurate information on the pros and cons of vaccination, the prevalence of the diseases in New Zealand and elsewhere and of the potential consequences for children and family. The health professionals need to co-ordinate their efforts by setting up recall systems that generate reminders, providing accessible facilities and flexible times for appointments and following best practice guidelines for contradictions to vaccinations. Importantly health professional must provide an environment that is warm, inviting and welcoming.

There are a small number of non-believers in immunisation who act as society's watch dogs. The few who choose not to vaccinate do not make a difference to the immunity of populations when immunisation is high. It is estimated that about 5% of the population make an informed choice not to vaccinate.

Health professionals must answer questions related to vaccination dangers truthfully and in a non-biased manner. Distrust over vaccine schedules are confusing and they frequently change. The change is usually due to new information and improved technology making vaccines safer, but distrusting people need to be convinced.

Co-ordination of Immunisation in the Kaipara

The instigation of the project came from the clinicians themselves - particularly Te Ha o Te Oranga, who saw a need to co-ordinate immunisation and well child services. At the end of 1999, a request for projects was made by the Northland Health Medical Officer of Health, Dr Jonathan Jarman, to assist a Public Health Medicine Registrar - Dr Joy Robinson, meet the requirements toward gaining qualifications in the field of Public Health.

This request acted as a catalyst for a proposal to be put forward to Northland Health as an opportunity for Dr Robinson to act as an extra resource and participate in a co-ordination immunisation project. Dr Robinson accepted the proposal as a project. The Operational Team approved the project proposal.

This project has also been driven by the clinicians. It is based on Public Health and Health Promotion foundations, which sets it apart from the other co-ordination disease based projects Kaipara Care has so far instigated.

The process to create a multi-disciplinary team was instigated. An initial key stakeholder group was called. The process for identifying the stakeholders was word of mouth from providers who knew of other provider groups who would be interested in promoting a health focus to increase immunisation coverage in the Kaipara. The KCI Project Manager met with Dianne Lawson from Te Ha o Te Oranga and the Kaumatua and Kuia to gain support for the project and to identify other stakeholders in the Maori community.

The proposal was submitted to Northland Health's Jonathan Jarman in December 1999 and the stakeholder meeting was held in March. From that a multi-disciplinary team was formed.

The Immunisation Team

At the initial meeting, feedback was sought from the providers on their perception and experience around immunisation.

The team had a very good working knowledge of immunisation and was helped considerably by Coralie Zimmer, the Northland Health Immunisation Co-ordinator, who brought both her expertise and experience with the "Immunisation Outreach" project in Whangarei.

There was a general perception and concern by the team, including the consumers, that mothers were not receiving unbiased information about immunisation. Other providers perceived a general willingness of parents to vaccinate their children and recognised the socio cultural implications and barriers as to why they did not. One provider, not on the team but contributed later, estimated that 25% of the population actively chose not to immunise their children. This is alarmingly high, given the national estimate of those who actively do not vaccinate their children is estimated to be 5%. It also begged some clarification and validation on the nature of the information and advice parents were receiving.

Immunisation Multi-disciplinary Team and Team Co-ordinator

Rationale That the activities required to support and monitor the immunisation project are co-ordinated and communicated.

1. There is an appointed project team and co-ordinator;
2. The co-ordinator is guided by the list of responsibilities below;
3. The co-ordinator is responsible to the Immunisation project team and reports to the KCI project manager.

The Multi-Disciplinary Team

• Meets 3 monthly
• Monitors the progress of the project and makes changes
• Reports on progress to the providers involved
• Reviews the progress of the project on a n annual basis

Co-ordinators Responsibility

• To arrange project team meetings;
• To liaise with KCI Data Administrator to obtain required data;
• Maintain records of meetings and teaching activities;
• Ensure participation in outcome measurements of all those involved;
• Initiate quality management activities;
• Meet with the KCI Project Manager as planned.

Needs Assessment - The Kaipara Birth Statistics

Birth registration statistics from July 1999 - June 00 for the Kaipara region (Statistics New Zealand.) are separated into 9 domicile areas - Te Kopuru, Kaipara Coastal, Maungaru, Dargaville, Maungaturoto, Ruawai, Rehia-Oneriri and Mangawhai.

The births have been sorted into three ethnic groups - Maori, Other (Non Maori) and Maori/Other, which incorporate the babies, who are registered with two ethnicities stated - one being Maori. (Table One)
The age of the mother is also included. (Table Two)

Table One	Table Two

These figures include all birth registrations in the whole of the Kaipara Region. However, the only 0-5 year old target population available to us for planning potential immunisation, are those held by DMC. The DMC data does not hold ethnicity information.

Out of the total population of 287 births the revised figure becomes 202 when the geographical areas that can reasonably be extracted from the census figures are subtracted i.e. Kaiwaka, Mangawhai, and Maungaturoto as outside DMC catchment area. Of these, 120 were born at Dargaville, and 68 at Whangarei. It is assumed the remaining 24 were home deliveries or births in other regions.

The purpose of these figures is to try and make a connection between the total numbers of parents who actively choose not to vaccinate, and are those who slip through the net for any reason other than actively choosing not to vaccinate. This information on a population basis may help inform the project and target those parents/guardians/whanau who wish to have their children vaccinated but for some reason are having difficulty in accessing the service.

It is estimated there is a national average of 60% immunisation coverage in New Zealand. Kaipara does a little better than that with:

0-6 months 69% being up to date
7-14 months 68% being up to date
15-24 months 64% being up to date

Allowing for some small variations like the total population and other factors related to choice of GP outside the area, there could be 808 vaccination episodes over a three-year period.

Privacy

In order to meet the Privacy Act requirements, the lead Maternity Carers, Plunket and Te Ha o Te Oranga must inform the guardian/parent that immunisation information is shared between them. This is to assist the guardian or parent through the immunisation schedule, receive reminders of when vaccinations are due and to receive information about immunisation in general. For those who have actively chosen not to have their children immunised this will ensure they are not receiving such reminders.

See KCI Privacy Information Brochure

The Health Promotion Perspective

Health promotion theory and practice is based on the belief that health is more than absence of disease or illness, but is a positive concept emphasising social and personal resources as well as physical capability. Thus, what it means to be healthy is as important as what it means to be ill and it assesses the factors that determine health.

There are three approaches to promoting health, all of which have implications for the immunisation project.

1. The preventative medicine approach which promotes health by attempting to prevent disease. This approach includes vaccination
2. Life style/individual approach that promotes health by trying to give people the knowledge, attitudes and skills for healthier lifestyles.
. The socio-economic approach which addresses the wider socio-economic determinants of health and creates healthy communities.

There is a cost on promotional material to this project that has not been part of the previous projects. A large proportion of the cost is "one off" and is attributable to the launch day. This day is seen as being critical in a health promotional forum. There is an ongoing cost related to the certificates and photos of babies who have their vaccinations, and a colourful and inviting recall letter.

Northland Health and Te Ha o Te Oranga have made a major contribution to the organisation of the launch day and in the publishing of the necessary recall letters. The scope of this project extends to children from 0 to 6 years in the Kaipara Region where the GP database is accessed

This project has developed from a health promotion approach and the following table (on the next page) identifies the key areas of activity in which the multi-disciplinary team has been involved:

Project Strategy and Process

Management of the Immunisation Resources and Database

The Letters of Invitation to Parents and Guardians

The letters of invitation are sent by the Data Administrator who collects the information required from the DMC database.

The lead maternity providers will inform the mothers of the Immunisation Project and give the mothers the immunisation packs to be supplied by IMAX on discharge. The local lead maternity providers will access the mothers of babies born in Whangarei about the Kaipara project.

Privacy

The database is held at DMC as part of their every day business with an extension to the data needed for monitoring the outcomes of the project. DMC's own privacy procedures includes the matter of sharing information between providers as is necessary, as well as with KCI for monitoring purposes.

The brochure containing KCI privacy policy will be sent out with the first letters of invitation.

The Photos and Certificates

DMC Administration will responsible for taking the photo when asked by a practice nurse. A photo is printed and inserted onto the form letter with the six participating health provider's logos and given to the child's parent or guardian. A copy of the photo is identified with the child's NHI number and stored on disc until the next vaccination and another photo is taken and stored. Eventually the child will have 4 photos stored at the completion of the vaccination schedule. The photos are then transported onto the certificate held on the word doc. for this purpose. The child's name entered on the certificate and then printed and given to the parent or guardian. T he photos on the disc are then wiped.

Providers undertaking suitcase vaccinations will be provided with disposable cameras. Careful labeling of the photo number along with the name of the child will be required. Parents or caregivers will have to be informed the photo will either be delivered by post or by their provider. Two copies of the photos will be required and one copy held at DMC for the certificate when immunisation schedule for the child is completed and the photos can be attached to the certificate.

Data Collection

The care pathway sends all information to DMC who in turn refers patients as required. The assigned practice nurse enters all data as it is received. The DMC Data Administrator collects the data required to post out invitations and "we are late" letters on a monthly basis. The monitoring and analysis of outcomes will be initially three monthly and will be the responsibility of the KCI Data Administrator. This information is supplied to the immunisation team and any issue addressed and changes made to the project as necessary.

Manual

All provider organisations of immunisation will have a manual. It is the Immunisation teams responsibility to review and update manual. KCI assist in this activity with formatting and any changes.

Immunisation Certificate/Photo Letter

Immunisation Final Photo Certificate

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