Family practice nurse views on barriers to immunising children

Abstract

New Zealand (NZ) has low immunisation coverage for infants and children compared to many other westernised countries. Barriers to improving uptake are multifactorial, with health professional knowledge and attitudes identified as important modifiable factors. In NZ practice nurses give most childhood vaccinations in the primary health care setting. This study explored aspects of 150 family practice nurse views, knowledge and experience about immunisation. Qualitative and quantitative text data were obtained through randomised computer assisted telephone surveys and converged using a triangulated multi-method approach. Response rate was 89.3% nurses identified parents’ fear as the greatest barrier to achieving better immunisation uptake and disagreed that health professional knowledge was a barrier. However, findings showed lack of knowledge among many participants, despite many feeling confident about their knowledge base. Factors associated with lower practice coverage of infants under 2 years were poorer knowledge of contraindications to vaccination and lack of completion of vaccinator training, especially an update course. A high level of confidence, more years in practice, dedicated time to follow-ups were not associated with better coverage rates. Practice nurses may be unaware that their knowledge in some areas needs improving. A trained practice nurse appears to play a significant role in overcoming fears and maintaining high coverage rates in their practice. We conclude that strategies that focus on primary health care provider support and education are more likely to gain high coverage than those that are purely directed at overcoming access barriers.

Introduction

Childhood immunisation coverage in New Zealand (NZ) is lower than in many other westernised countries and in its Pacific neighbours. UNICEF 1998 data indicated that NZ was ranked 102nd out of the 193 listed countries for its primary infant series immunisation rates [1]. In response to the current low rates, NZ has introduced a number of initiatives. These include the development of a register to track children's immunisation status, and increasing availability of outreach services.

The NZ situation contrasts with developments in Australia and the United States, both of which have recorded improved immunisation rates in recent years. These changes have been achieved by the use of a combination of approaches [2], [3]. In both countries an increased emphasis on supporting providers and communicating vaccine safety issues has been a major component of their improved coverage strategy.

The knowledge of nurses, physicians and other health providers about immunisation and their ability to clearly communicate risk-benefit information to parents has been identified as one of the most important factors in vaccine uptake [4], [5], [6], [7]. There is an active anti-immunisation lobby in NZ [8] and while there has been national and local efforts to provide accurate immunisation messages to the public, it is evident that the activities of the lobby group contribute to the erosion of public confidence [9]. Recent research indicates that many NZ parents have low confidence in immunisation, and vaccine safety is a primary concern [10]. Access to health care services also is consistently highlighted as a major issue, particularly for parents from the lower socio-economic groups. However, evidence indicates that parental fear and active decisions not to vaccinate is in itself sufficiently high to prevent achieving the 95% target uptake rate [11]. The ability of some local primary health care initiatives to overcome the poor national coverage rates and consistently obtain coverage rates for their populations over 90% demonstrates that well integrated primary health care services with committed health professionals can make considerable difference, even without addressing the access issues with outreach services [12].

The immunisation programme for NZ infants is delivered within the primary health care setting. NZ research supports the interpersonal relationship with the health professional as being the one in which the parents have confidence and trust [13]. In contrast the other education avenues such as Ministry of Health brochures or information from pharmaceutical companies can be held in considerable suspicion [13].

In NZ family practice, family physicians (general practitioners) and practice nurses work as a team. In most practices the doctor's primary role is to educate parents about immunisation issues, and to opportunistically encourage them to have their children vaccinated when they present for other health reasons. Only in a small minority of practices do doctors actively administer vaccines. The practice nurse's role generally involves not only parental education, but all aspects of immunisation delivery including ordering, safely storing (with documented evidence of maintenance of the cold chain) and administering vaccines to children, as well as maintaining a recall system for all children registered with the practice. In group practices with two or more doctors and nurses, there is usually at least one practice nurse who is likely to have attended one of the nationally standardised vaccinator training courses, which include two-yearly updates. A small number of sole family physician practices do not employ practices nurses (7% of all practices) [14] and in these cases the doctor assumes all responsibility for immunisation administration.

The aim of this study was to understand the immunisation issues confronting practice nurses in NZ using a national randomised computer-assisted telephone survey. The questions focused on general practice organisation issues; nurse perceptions of barriers to improving immunisation; their knowledge and educational needs regarding immunisation; preferred resources, and their own practices around immunisation. This study was conducted contemporaneously with a similar survey of NZ family physicians [14].