What contributes to delays? The primary care determinants of immunisation timeliness in New Zealand.

INTRODUCTION: Delay in receipt of the first vaccine dose in the primary series is one of the strongest and most consistent predictors of subsequent incomplete immunisation. AIM: To describe the on-time immunisation delivery of New Zealand infant scheduled vaccines by primary care practices and identify characteristics of practices, health professionals and patients associated with delays in receipt of infant immunisations. METHODS: Timeliness of immunisation delivery and factors associated with timely immunisation were examined in 124 randomly selected primary care practices in two large regions of New Zealand. RESULTS: A multiple regression model of demographic, practice, nurse, doctor and caregiver association explained 68% of the variance in immunisation timeliness between practices. Timeliness was higher in practices without staff shortages (ß-coefficient -0.0770, p= 0.01), where nurses believed parental apathy (ß-coefficient 0.0819, p=0.008) or physicians believed parental access (ß-coefficient 0.109, p=0.002) was a barrier, and lower in practices with Maori governance (ß-coefficient -0.0868, p=0.05), higher social deprivation (ß-coefficient -0.0643, <0.001) and where caregivers received immunisation-discouraging information (ß-coefficient -0.0643, p=0.04). DISCUSSION: Interventions supporting practice teams and providers in primary care settings could produce significant improvements in immunisation timeliness.

Primary care practice and health professional determinants of immunisation coverage.

AIM: To identify primary care factors associated with immunisation coverage. METHODS: A survey during 2005-2006 of a random sample of New Zealand primary care practices, with over-sampling of practices serving indigenous children. An immunisation audit was conducted for children registered at each practice. Practice characteristics and the knowledge and attitudes of doctors, nurses and caregivers were measured. Practice immunisation coverage was defined as the percentage of registered children from 6 weeks to 23 months old at each practice who were fully immunised for age. Associations of practice, doctor, nurse and caregiver factors with practice immunisation coverage were determined using multiple regression analyses. RESULTS: One hundred and twenty-four (61%) of 205 eligible practices were recruited. A median (25th-75th centile) of 71% (57-77%) of registered children at each practice was fully immunised. In multivariate analyses, immunisation coverage was higher at practices with no staff shortages (median practice coverage 76% vs 67%, P = 0.004) and where doctors were confident in their immunisation knowledge (72% vs 67%, P= 0.005). Coverage was lower if the children's parents had received information antenatally, which discouraged immunisation (67% vs 73%, P = 0.008). Coverage decreased as socio-economic deprivation of the registered population increased (P < 0.001) and as the children's age (P = 0.001) and registration age (P = 0.02) increased. CONCLUSIONS Higher immunisation coverage is achieved by practices that establish an early relationship with the family and that are adequately resourced with stable and confident staff. Immunisation promotion should begin antenatally.

Factors associated with immunisation coverage and timeliness in New Zealand.

BACKGROUND: Immunisation coverage in New Zealand is lower than what is necessary to prevent large epidemics of pertussis. Primary care is where most immunisation delivery occurs. General practices vary in their structure and organisation, both in a general sense and specifically with respect to immunisation delivery. AIM: To identify the structural and organisational characteristics of general practices associated with higher immunisation coverage and more timely immunisation delivery. DESIGN OF STUDY: A random sample of practices during 2005 and 2006. SETTING: General practices in the Auckland and Midland regions, with over-sampling of indigenous Maori governance practices. METHOD: Practice immunisation coverage and timeliness were measured. Primary care practice characteristics relevant to immunisation delivery by the practice were described. Associations of these practice characteristics with higher practice immunisation coverage and more timely immunisation delivery were determined. RESULTS: A total of 124 (61%) of 205 eligible practices were recruited. A median (25th to 75th centile) of 71% (57-77%) of registered children at each practice were fully immunised, and 56% (40-64%) had no immunisation delay. In multivariate analyses, both practice immunisation coverage (P<0.001) and timeliness (P<0.001) decreased with increased social deprivation. After adjustment for socioeconomic deprivation, region, and governance, immunisation coverage and timeliness were better at practices that enrolled children at a younger age (coverage: P = 0.002; timeliness P = 0.007), used one of the four available practice management systems (coverage: P<0.001; timeliness: P = 0.006), and had no staff shortages (coverage: P = 0.027; timeliness: P = 0.021). CONCLUSION: Practice immunisation coverage and timeliness vary widely in New Zealand. General organisational and structural aspects of general practices are key determinants of general practice immunisation delivery.

The use and misuse of media headlines: lessons from the MeNZB immunisation campaign.

AIM: Tracking the use of headlines with single issue stories in the New Zealand print media from their source, three case studies of the MeNZB vaccination campaign's presentation in the print media were examined. METHOD: Article headlines were tracked in the three case studies. All headlines were coded between two researchers to review for accurate or misleading presentations in terms of whether the headlines matched the article content. RESULTS: In these three case studies 26 out of 51 headlines were inaccurate when compared with the article content (51%), with a further 6 being misleading (total of 61%). CONCLUSIONS: These small case studies illustrate the difficulties arising at the intersection between media and public health interests. There is an inherent tension between public health publicity needs, and the print media needs. To maintain public confidence, health planners constantly need to develop and review their health promotion messages and relationships with the media. Close and ongoing dialogue between media and public health professionals are important, with recognition on each side of the different drivers and needs in two different sectors.

Recruitment of practices in primary care research: the long and the short of it.

OBJECTIVE: To determine factors that facilitated or hindered recruitment of general practices into a large New Zealand primary care project that aimed to determine general practice characteristics of immunization coverage. METHODS: The project had a multi-level recruitment strategy requiring recruitment of randomly selected practices before randomly selecting GPs, practice nurses and caregivers of children enrolled at those practices. Detailed quantitative and qualitative recruitment data were recorded on an access database. Post-recruitment, recruiters underwent semi-structured interviews. Analysis was mixed method, with triangulation of descriptive statistics of the number of calls and time course to recruitment and general inductive thematic analysis of qualitative data. RESULTS: Identifying key decision makers and how individual practice processes work can save significant recruitment time. Factors identified as assisting practice recruitment included using a personal approach from doctor to doctor, getting buy-in from all practice staff, streamlining the research process to minimize disruption to the practice and flexibility to accommodate practices. CONCLUSIONS: The task of recruiting should not be underestimated. Adequate time and resource need to be allocated from the onset. Long periods where practices have no added burdens such as audits, mass vaccination programmes or influenza season are unlikely, therefore there are always considerable challenges in recruiting practices for research. Remaining flexible to individual practice styles and influences and acknowledging the commitment of participants is important.

Determining immunisation coverage rates in primary health care practices: a simple goal but a complex task.

PURPOSE: To explore the quality of data recording by practices and identify issues to be considered and addressed before such data can be used as a continuous measure of immunisation delivery. METHODS: One hundred and twenty-four randomly selected general practices visited to measure immunisation coverage using the various practice management systems (PMS) in use. To capture all target children it was necessary to build two queries: one generated a list of all children aged between 6 weeks and 2 years who had been to the practice, regardless of enrollment status; the other asked dates and nature of all immunisations given. Each different PMS required a unique query to extract the necessary information. RESULTS: Variability encountered included different types and versions of PMS and operating systems; variable degree of staff technical competence with their PMS; proportion of enrolled children ranging from nearly 0 to 100%; lack of consistency of the nature and location of data entry and coding; and unreliability of dates relating to some vaccination events. RECOMMENDATIONS: To improve recording of immunisation coverage we recommend a standard early age of registration and enrollment; standard definitions of the denominator and of immunisation delay; greater uniformity of PMS; improved staff training; intrinsic data quality checks; integration of PMS with changes in the immunisation schedule; incentives and interval electronic checks to improve data quality.