Tailoring Immunisation Service Delivery in a Disadvantaged Community in Australia; Views of Health Providers and Parents

In 2014, the Australian immunisation target was raised from 90% to 95% of children to be fully immunised. A national priority is to identify geographic areas of low coverage and implement strategies to improve immunisation rates. Using the World Health Organization (WHO)'s Tailoring Immunization Programmes (TIP) guidelines, the aim of this study was to identify areas of low immunisation coverage for children in the Hunter New England Local Health District, New South Wales (NSW), and to gain a deeper understanding of the factors influencing immunisation in those areas in order to develop tailored strategies for increasing immunisation coverage.

As detailed in Related Summaries, below, TIP draws on evidence from social psychology, the medical humanities, and behavioural science to assist service planners in identifying pockets of low coverage within a region and design strategies for increasing immunisation within that population. An evaluation of TIP found its strengths to be in community engagement, qualitative research methods, generation of local insights, and the relationships established through the process. TIP uses a step-by-step approach, which is illustrated in Figure 2 in the paper. The present study focused on the formative phase, which involved using available data and stakeholder interviews to identify the problem and to gain a clear understanding of the intended groups (both children and service providers).

Both quantitative and qualitative methods were used. To identify pockets of low immunisation coverage, data from the Australian Immunisation Register (AIR) were used. The regional city of Maitland in NSW, which is relatively socio-economically disadvantaged, was identified as having a persistently high number and relatively high proportion of children not fully immunised (n = 427, 15.4% in 2016). For the qualitative component, researchers first met with stakeholder groups in Maitland to share the quantitative results, discuss the planned study, and develop a trusting relationship. The researchers conducted 34 interviews and 6 focus groups with a total of 59 participants between September 2016 and January 2017. Themes from these interviews and focus groups included:

• Limited engagement with health services unless the need is urgent - One Aboriginal mother with 3 children had moved to Maitland and did not have a general practitioner (GP) or access to transport. After learning about a local Aboriginal health service, the family attended, and the children commenced a catch-up programme.
• Multi-dimensional access barriers to immunisation services in Maitland - One service provider said, "In some families, the wife is from a CALD [culturally and linguistically diverse] background and would like to be informed as well, but they're not at the language level, so that creates a barrier for them and feel they aren't part of it. With this paper [the child's Personal Health Record], they're struggling to understand the meaning of it."
• Need for a flexible, supportive, family-centred, primary health care approach, utilising strong partnerships - Participants suggested increasing the number of community child health workers (already accredited immunisers) who could immunise children within their role either opportunistically or through targeted outreach and home visiting programmes.
• Role of data in informing service providers about trends and individual children not fully immunised - Many health service participants described data quality problems with the Australian Immunisation Register (AIR) and with the timely sharing of relevant information.

In Australia, the proportion of children whose parent(s) object to immunisation has remained consistently low at around 2%. As the TIP analysis showed, children are more likely to be under immunised for other reasons, including difficulty accessing health services, missed opportunities, and logistic barriers. They are also more likely to be from the lowest socio-economic deciles, as is borne out by the Maitland population under study. The research also showed that one year after the introduction of the No Jab No Pay legislation, the number and rate of one-year-old children not fully immunised in the Maitland area remained virtually unchanged. Despite financial punishment inherent in the new legislation, children whose parents struggle with chaotic lives and conflicting priorities remain under-immunised.

A more tailored approach that is family centred, flexible, and supportive, including targeted outreach and home visiting, emerged as the most likely way to improve immunisation coverage for this group. Timely use of quality data, more collaboration amongst stakeholder groups, and better use of existing accredited immunisers could improve service delivery.

In conclusion, the researchers found that TIP guidelines proved useful for identifying areas of low coverage and providing an understanding of determining factors and the strategies most likely to be effective. Understanding the complex problems many parents face and the access barriers that contribute to low immunisation coverage is essential, they say, in developing appropriate solutions. Finding ways to support parents and remove those barriers can contribute to higher coverage.