Socially or materially marginal children are less likely to be fully immunised—a systems response
1 Department of Public Health, University of Otago Wellington School of Medicine and Health Sciences, PO Box 7343, Wellington, New Zealand,2 Service Planning and Funding Directorate, Capital and Coast District Health Board, Private Bag 7902, Wellington, New Zealand
Samad and colleagues have neatly shown what we already know: children born into circumstances that are socially or materially marginal are less likely to be fully immunised.1 At age 9 months immunisation rates in the UK are high (> 95% fully immunised); the challenges posed by Samad et al's paper are the challenges associated with reaching that last small percentage of children. This is in the context of the UK healthcare system, which is universal and doesn't impose user charges. Samad et al have shown also that children who are unimmunised fall into two groups: those from disadvantaged backgrounds and those with mothers who were on average older and more educated.
, http://www.100md.com
The first barrier to overcome is the framing and labelling barrier; the term "hard to reach," along with its semantic equivalents, is service-centric and an implicit admission of the system's failure, which in turn invites nihilism. "Hard to reach" thinking tends to transfer ownership of the problem to the victims of the problem, thereby taking the focus away from the role of the primary care system. A number of primary care approaches to immunisation have been shown to be effective.
, 百拇医药
Because poor populations tend to be more mobile, special attention needs to be paid to outreach and opportunistic immunisation. However, outreach on its own may not be sufficient: overall primary health care and social service capability are important too. Schuster et al found that home visiting alone was only partially effective and suggested that case managers may be more effective when they have resources to use to help overcome specific barriers.2 Opportunistic and outreach immunisation in turn need to be supported by a shared immunisation register.3
, 百拇医药
Opportunistic immunisation is equally important. It is likely that partial immunisation may be contributed to by missed opportunities, such as inappropriate delaying of immunisation after a hospital admission.3 It is important for hospitals to ensure that immunisations are given before discharge and that correct information is freely available as to what constitutes a contraindication. Likewise, immunisation update should be offered at all primary care contacts.
, 百拇医药 In order to address belief systems and conflicting information, tailored approaches to information are required for the unimmunised (for example, those of black Caribbean ethnicity).3 4
Finally, most importantly, the foundation for an effective immunisation system is the recognition that the most powerful and persistent barriers to timely immunisation are poverty and factors associated with poverty.3 In order to engage successfully with socially marginalised communities, and the health problems that typically occur in such communities, primary care needs to include in its remit intersectoral approaches to addressing poverty. Along with this, primary care needs to be underpinned by a community development approach which defines health in the context of social factors such as housing and the economy, acknowledges that health improvements do not necessarily start with health services, focuses on community wants, and takes a bottom-up approach.5
, http://www.100md.com
Competing interests: None declared.
References
Samad L, Tate AR, Dezateux C, Peckham C, Butler N, Bedford H. Differences in risk factors for partial and no immunisation in the first year of life: prospective cohort study. BMJ 2006;332: 1312-3.
Schuster M, Wood D, Duan N, Mazel R, Sherbourne C, Halfon N. Utilization of well-child care services for African-American infants in a low-income community: results of a randomized, controlled case management/home visitation intervention. Pediatrics 1998;101: 9991005.
, http://www.100md.com
National Vaccine Advisory Committee. Strategies to sustain success in childhood immunizations. JAMA 1999;281: 363-70.
Bond L, Nolan T. Vaccine preventable diseases and immunisations: a qualitative study of mothers' perceptions of the severity, susceptibility, benefits and barriers. Aust N Z J Public Health 1998;22: 440-6.
Haglund B. The community diagnosis concept—a theoretical framework for prevention in the health sector. Scand J Prim Health Care Suppl 1988;1: 11-21., 百拇医药(Peter Crampton, Julia Car)
Samad and colleagues have neatly shown what we already know: children born into circumstances that are socially or materially marginal are less likely to be fully immunised.1 At age 9 months immunisation rates in the UK are high (> 95% fully immunised); the challenges posed by Samad et al's paper are the challenges associated with reaching that last small percentage of children. This is in the context of the UK healthcare system, which is universal and doesn't impose user charges. Samad et al have shown also that children who are unimmunised fall into two groups: those from disadvantaged backgrounds and those with mothers who were on average older and more educated.
, http://www.100md.com
The first barrier to overcome is the framing and labelling barrier; the term "hard to reach," along with its semantic equivalents, is service-centric and an implicit admission of the system's failure, which in turn invites nihilism. "Hard to reach" thinking tends to transfer ownership of the problem to the victims of the problem, thereby taking the focus away from the role of the primary care system. A number of primary care approaches to immunisation have been shown to be effective.
, 百拇医药
Because poor populations tend to be more mobile, special attention needs to be paid to outreach and opportunistic immunisation. However, outreach on its own may not be sufficient: overall primary health care and social service capability are important too. Schuster et al found that home visiting alone was only partially effective and suggested that case managers may be more effective when they have resources to use to help overcome specific barriers.2 Opportunistic and outreach immunisation in turn need to be supported by a shared immunisation register.3
, 百拇医药
Opportunistic immunisation is equally important. It is likely that partial immunisation may be contributed to by missed opportunities, such as inappropriate delaying of immunisation after a hospital admission.3 It is important for hospitals to ensure that immunisations are given before discharge and that correct information is freely available as to what constitutes a contraindication. Likewise, immunisation update should be offered at all primary care contacts.
, 百拇医药 In order to address belief systems and conflicting information, tailored approaches to information are required for the unimmunised (for example, those of black Caribbean ethnicity).3 4
Finally, most importantly, the foundation for an effective immunisation system is the recognition that the most powerful and persistent barriers to timely immunisation are poverty and factors associated with poverty.3 In order to engage successfully with socially marginalised communities, and the health problems that typically occur in such communities, primary care needs to include in its remit intersectoral approaches to addressing poverty. Along with this, primary care needs to be underpinned by a community development approach which defines health in the context of social factors such as housing and the economy, acknowledges that health improvements do not necessarily start with health services, focuses on community wants, and takes a bottom-up approach.5
, http://www.100md.com
Competing interests: None declared.
References
Samad L, Tate AR, Dezateux C, Peckham C, Butler N, Bedford H. Differences in risk factors for partial and no immunisation in the first year of life: prospective cohort study. BMJ 2006;332: 1312-3.
Schuster M, Wood D, Duan N, Mazel R, Sherbourne C, Halfon N. Utilization of well-child care services for African-American infants in a low-income community: results of a randomized, controlled case management/home visitation intervention. Pediatrics 1998;101: 9991005.
, http://www.100md.com
National Vaccine Advisory Committee. Strategies to sustain success in childhood immunizations. JAMA 1999;281: 363-70.
Bond L, Nolan T. Vaccine preventable diseases and immunisations: a qualitative study of mothers' perceptions of the severity, susceptibility, benefits and barriers. Aust N Z J Public Health 1998;22: 440-6.
Haglund B. The community diagnosis concept—a theoretical framework for prevention in the health sector. Scand J Prim Health Care Suppl 1988;1: 11-21., 百拇医药(Peter Crampton, Julia Car)