Discuss About The Measuring Timeliness Childhood Vaccinations?
The health status of Maori has been a major focus of attention among researchers because of over-representation of Maori in many negative health statistics of New Zealand. Although there are many illness or health issues that give insight into poor health outcome in Maoris, however this report specifically looks at issues of high infant hospitalization rate in Maoris and relation of the high infant hospitalization rate to immunization coverage for the population group. With support from local and national health statistics, the report discusses about poor immunization coverage in the population group. The report also provides a critical discussion on the role of the government in addressing health inequities for Maoris. In addition, three recommendations to address immunization issue are also presented by application of the principles of Te Tiriti O Waitangi. Lastly, the rationale for each recommendation is discussed to show how they can address health inequities and improve health outcomes for Maori.
Review of Maori immunization rate:
The immunization schedule for New Zealand mainly covers vaccines like Rotavirus, DPT (Diptheria/Tetanus/Pertusis), measle, varicella and many other vaccines. Childhood respiratory infection is a large burden of disease in New Zealand with lifelong health consequence. The immunization schedule focuses on the delivery of special child immunization for pertussis and influenza to reduce hospitalizations due to childhood respiratory infection (Chang et al., 2015). Children have been hospitalized mainly for respiratory conditions, skin-related disorders and dental problems. Due to high rate of hospitalization for respiratory infection, the Ministry of Health in New Zealand has made asthma a priority area to reduce hospitalization rates among children aged 0-4 years (Ministry of Health, 2017). One of the issues that have increased rate of childhood hospitalization and deteriorated health of Maori infant is the poor rate of vaccination coverage in the group. Hence, to find out the reason for poor infant health status, there is a need assess immunization rates in the group. This is necessary because childhood vaccination is the most effective strategy to prevent disease and reviewing the rate of coverage in Maori may indicate the role of government in improving immunization uptake in the group (Ventola, 2016).
The Maori population experience great disparities in health compared to other population group. Infant death rate is also one health indicator that shows the status of health in Maori infants. High rate of infant hospitalization and infant mortality is a major health problem in Maori. The local statistics on infants health in Rotorua has revealed that infant death rate in the region was 7.0 per 1, 000 live births in 2011 (rotorualakescouncil.nz, 2011). In contrast, the national rate for infant death was 75.2 per 1, 000 live births (health.govt.nz, 2011). This statistics gives an idea about difference in rate between Maori population and non-Maori population. In terms of infant hospitalization statistics, it has been found that high rate of children admission to hospitals has occurred because of respiratory infections, skin infections and acute rheumatic fever. For example, for there were about 1700 respiratory infection related hospitalization in children per year between 2008 and 2012. The four conditions that were responsible for 80% of respiratory hospitalization for children includes upper and lower respiratory infection, pneumonia and bronchiolitis. The sudden increase in childhood hospitalization for respiratory infection among Maori living in Rotorua district was mainly seen in 2008 and 2009. Over-representation of childhood hospitalization data has been seen mainly for infant less than 1 year (because of bronchiolitis) (Toi Te Ora Public Health Service, 2012).
The review of national and local statistics on hospitalization rate among Maoris in New Zealand indicates that ambulatory sensitive hospitalization (ASH) is high in the group. ASH refers to hospital admissions that mainly occur due to preventable conditions or those conditions that could be treated earlier in primary care (Milne et al., 2015). Hence, ASH rate in any population groups suggest continuity of care is not maintained in the specific population group. In case of Maoris, the trend related to ASH rates for 0-4 age group shows that ASH rate has remained constant in Maori from 2012-2016 (Ministry of Health, 2017).
The national statistics on childhood immunization coverage in New Zealand in 2014 clearly indicates the disparities in vaccination coverage between Maori children and rest of the New Zealand children. According to National Immunization Register data, 88.9% Maori children completed age appropriate immunization compared to 91.9% total children in New Zealand (Ministry of Health NZ, 2014). Although data shows narrow difference in immunization coverage between Maori children and total New Zealand children, however the difference is wide considering the fact that Maoris comprise only 14.9% of the New Zealand population (archive.stats.govt.nz, 2013). To analyze the factors that have accelerated the problem of poor infant’s health in Maori population, understanding the New Zealand’s government’s action in addressing inequities in the group is necessary.
Role of government in addressing health issues for Maori:
The above national and local statistics proves that poor immunization coverage is a major reason for poorer health outcome in Maori infants. As per the Maori health strategy, it is necessary for health sector as well as government sector to work together with iwi (Maori community) to improve their quality of life and reduce disparities compared to other New Zealanders. However, Grant et al. (2010) has reported that immunization coverage has remained lower than expected because of many structural and organization factors. This can be said because the study showed that immunization coverage and timeliness differed in different areas. Secondly, socio economic deprivation was also a dominant factor behind low rate of coverage. The expected rate has not been achieved because there are still certain fractions of parents who have declined vaccination. Children from Maori community do not get immunized at the same rate as their peers. This is mainly because of lack of awareness, language differences and poverty and deprivation in the group (Grant et al., 2010).
The review of health statistics of Maori infants in New Zealand has revealed that poor immunization coverage rate and vaccine preventable disease is a challenge for the New Zealand government today. One of the most significant issues in immunization coverage is the large disparities for Maori children. To track the number of children who have immunized at birth, New Zealand implemented a National Immunization Register (NIR). The NIR has helped to track progress in immunization coverage and the data shows that equity gap is slowly decreasing For example, the immunization rate has reached 80% by 2009 and by June 2011, it reached to 90% (Turner 2012). The immunization coverage rate for Maori in 2011 was 88% (Turner 2012). This has happened because of government policy and local health board attention. The New Zealand Ministry of Health implemented many strategic goals to improve coverage. The NIR tool was one of the strategies to monitor and report about immunization delivery. Introducing the tool was a commendable act by the government as it helped to get real time data about immunization coverage (Turner 2012). This supported staffs to give feedback about immunization services. However, to achieve the target of 95% immunization coverage, New Zealand governments needs to future actions to change the attitude of Maori parents regarding immunization. This is because Maori people have poor perception about immunization and they lack confidence in the effectiveness of vaccination process (Lee, Duck & Sibley, 2017).
Apart from improving records related to immunization coverage and vaccine delivery through NIR tool, other strategies that New Zealand government implemented included increasing surveillance for vaccine preventable disease and outbreak preparedness. However, New Zealand government has not yet been successful in addressing poverty and family characteristics of Maori people that creates barrier to achieving immunization targets. In case of management system for immunization coverage, it was found that immunization program did not worked in a stable manner because of poor staffing ratio (Turner 2012). Little evidence has been found regarding the government’s role in supporting health care staffs for effective immunization service delivery (Roberts et al., 2017). However, in the future, New Zealand government needs to pay attention in this area because health care professionals have not been found to positively engage with Maori children and their families (Grant & Reid, 2010). Hence, gap in knowledge exist regarding effectively communicating with parents which is the most crucial aspect to improve immunization coverage (Turner et al., 2017). The government should also pay emphasis on the role of Maori in health service planning to address the problem of communication gaps between health professionals and clients. Maori participation in health service delivery is part of the five principles of the New Zealand Health strategy and this is likely to empower the community too (Ministry of Health NZ, 2018).
The review of New Zealand government’s role in immunization coverage has also revealed that they have made improvement in immunization coverage of prioritization of immunization coverage in national policy. This was an effective step to implement funding and implement financial barrier to accessing primary care service for children. However, the main shortcoming of the strategy is that certain groups like Maori children have sub-optimal coverage rate compared to other population groups in New Zealand. For example, people living in Northland region particularly has lower coverage compared to national average. It is the least urbanized region of the country and the higher percentages of Maori lives in the region. Only 87% of Northland babies were immunized till March 2015 (Rumball-Smith & Kenealy, 2016). This means coverage is below the national target. There were some groups in low coverage who did not received vaccines on a timely basis, whereas there were other groups whose caregivers actively declines coverage. Hence, the government needs to address these issues in the future. They need to analyze patterns of coverage at regional level and identify the factors contributes to vaccine hesitancy in Maori population. This step can help the government to implement tailor made interventions for groups who actively deny immunization for their child.
New Zealand government prioritized immunization coverage in health policy, however timeliness is also one factor where the government need to take future action. This is because receiving the first dose of primary vaccine on time is crucial to decrease susceptibility to vaccine preventable disease in Maori children (Walton et al., 2017). Hence, the government should take strategic steps to enhance timeliness of vaccination.
Using principle of Te Teriti O Waintangi to propose three recommendations to address the health issue:
In response to the challenges found in immunization coverage for Maori population, the problem can be addressed by using the principles of Te Teriti o Waitangi. The first principle is the partnership principle that focuses on working in partnership with Maori communities to develop health gain and improvement strategies. The second principles relates to participation of Maoris in decision making, planning and delivery of care. The third principle is related to the protection principle which states that the government has a role in safeguarding Maori and preserving their cultural values and practices. All the three principles have been applied to propose three recommendations to address immunization issues in Maori and improve infant health outcomes.
The three recommendations that have been proposed to address immunization coverage issue in Maori population include the following:
The first strategy is to increase the knowledge and confident of health care professionals in effectively communicating with Maori families so that rate of missed opportunities to immunization is reduced. This strategy has relevance with the protecting principles of the Te Tiriti O Waitangi as increasing the skills of health care professionals will serve to reduce missed opportunities of vaccination and protect Maori children from risk of vaccine preventable disease. Taking step in this area is important because evidence has revealed that poor health care staff confidence and knowledge towards immunization is a barrier at practice level that creates inequities in coverage (Turner et al., 2017).
The second strategy to address the issue of immunization coverage is to implement health education programme for Maori to change their attitude and perception towards immunization coverage. This strategy is related to the partnership principle as implementing educations programs with Maori people will help health promotion staffs to effectively partner with them and facilitate health improvement. Maori’s perception about the effectiveness of immunization has been proposed to reduce health inequity in the population because research evidence proved that many of them do not immunize their children because they do not felt the immunization was necessary or they distrusted vaccines for its effectiveness (Guiney & Walton, 2014).
The third strategy is to involve Maori in immunization service delivery to increase the gap in communication and enhance timeliness of immunization process. This strategy is relevant to the participation principle of Te Tiriti O Waitnagi as it will be an opportunity to bring Maori people in immunization service planning. It will also reduce socio-cultural and communication barrier in immunization coverage (Veerasingam et al., 2017).
Rational for the recommendation:
The first recommendation of improving staff’s knowledge towards vaccination and communicating with Maori people is necessary as it would help to enhance engagement with Maori parents. This is crucial because better engagement with Maori families can help them be aware about immunization schedule and not miss opportunities for immunizing their children on time. Secondly, skills of health care staffs towards immunization services and communicating with Maori people is necessary as it would support primary care to have a confident and engaged health care professional who can pay full attention to coverage schedule and missed cases of immunization (Grant et al, 2010). A confident health care professional can stabilize the immunization program and take the right steps to minimize missed opportunities of immunization. Providing culturally competent communication skill training may also help staffs in relationship building (Turner et al., 2017). For example, they can inform new parents about immunization and answer to the queries of parents when they come for their child’s immunization for the first time.
The second recommendation of addressing Maori people’s attitude towards immunization can be effectiveness in achieving target immunization rate because changing parent’s and Maori family’s attitude towards immunization can increase the likelihood of receiving first dose of vaccination on time. Lee, Duck and Sibley (2017) has investigated about skeptical attitude towards safety of childhood immunization in New Zealand population. The demographic and personality correlates of people revealed that lower confidence was found in Maori people and people living in rural areas. In contrast, high income and educational attainment was associated with greater confidence for immunization. This finding gives implications to the New Zealand government that public education about necessity of vaccination is necessary to address the issues of infant health and preventable disease in Maori infants (Odone et al., 2015). Hence, in accordance with this evidence too, educating parents regarding necessity of vaccination can positively influence parent’s attitude towards vaccination.
Low education and health literacy is the factor leading to poor perceptions about immunization in Maori people. Hence, Maori parents can be empowered by providing them health literacy in the area of immunization. This will build their trust and confidence on immunization programs and enhance interaction with health care professionals regarding vaccine delivery. Health literacy in the group can be achieved by relating immunization to health as well as social outcome. The comfort level of audience can also be improved by providing relevant images or stories so that Maori parents can relate to the benefits of immunization (Corbett, 2013). Taking such comprehensive approach in health literacy program can reduce the gap in immunization coverage for Maori children.
The rational for including Maori people in immunization service improvement is that they are likely to reduce language and cultural barriers that leads to poor perception towards immunization. They can help to provide culturally sensitive health education to Maori parents so that they easily understand the importance of vaccination. Having Maori staffs is also likely to increase the uptake of coverage because staffs belonging to Maori community can understand cultural values of Maori and they may consider about their convenience while fixing vaccination schedules for their child (Greenfield et al., 2015). Hence, employment and recruitment of Maori health workers can make place for Maori health within the infrastructure of the primary care organizations too. Furthermore, timeliness in coverage can be improved by providing certain tools that reminds the parents regarding timely childhood immunization. Abbott et al., (2013) took the approach of distributing calendars during first visit for early childhood immunization and this was designed in a way that it would display next immunization date on the calendar. Such tool was found to improve timeliness in early childhood vaccination. Similar strategies can also be taken by health care workers so that Maori people can easily adapt those tools to timely immunize their child.
The report gave an insight into the role of poor immunization coverage in reducing disparities in health outcomes for Maori infants compared to total children in New Zealand. The local and national statistics states that improvement in immunization coverage is seen with time however since the Maori population is small, the disparities in coverage is huge. The review of New Zealand’s government’s action in improving coverage has revealed that introduction of NIR was an effective approach by the government as it helped in real time tracking of progress in immunization. However, there are many structural and cultural barriers that need to be addressed to reduce inequities in immunization coverage. The report has recommended three strategies of increasing knowledge and confidence of health care professional in interacting with Maori people, providing health literacy to parents and including Maori in health care workforces. These three strategies are likely to reduce barriers in immunization coverage as well as empower Maori community as the strategy has been developed based on application of the principles of Te Tiriti O Waitangi.
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