title: Childhood immunisations in Northland, New Zealand: declining care and the journey through the immunisation pathway.
abstract: OBJECTIVE
  In a region with high rates of immunisation refusal, we examine whether refusing an immunisation at 6 weeks (the first scheduled immunisation) predicts the pattern for subsequent scheduled immunisations, and the characteristics of those who declined these immunisations.
  
  
  METHODS
  We used data from the National Immunisation Register to identify 11,972 children born between 1 January 2009 and 31 December 2013 (inclusive), and who had their first immunisation (due at 6 weeks age) in Northland, New Zealand. At each immunisation event, individual vaccines are recorded as being delivered or declined. This cohort was 'followed' to determine which of these children received or declined the scheduled 3-month and 5-month immunisations.
  
  
  RESULTS
  Immunisation providers delivered a full immunisation programme to 10,828/11,927 (90%) of the cohort. Caregivers of 897 (7%) of children declined the 6-week vaccination. Of this group, 872 (97%) also declined the 3-month and 850 (95%) declined the 5-month immunisations, constituting 872/962 (91%) and 850/923 (92%) of all declined immunisations, respectively. In the decline group, there was variability with primary care practice, and differences according to ethnic group and deprivation profile.
  
  
  CONCLUSIONS
  Increasing Northland's immunisation coverage may require primary care providers to more actively engage with declining caregivers prior to the 3-month and 5-month vaccinations. Immunisation information and decision-making programmes targeted at parents and providers in the antenatal and prenatal period may also be of benefit, in addition to considering regulatory and incentive strategies.
authors.affiliation: Public and Population Health, Northland District Health Board, Whangarei, New Zealand. juliet.rumball-smith@northlanddhb.org.nz.
authors.forename: Juliet
authors.initials: J
authors.lastname: Rumball-Smith
authors.affiliation: South Auckland Clinical School, University of Auckland, Auckland, New Zealand.
authors.forename: Timothy
authors.initials: T
authors.lastname: Kenealy
mesh_terms: D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D006801:Humans; D017589:Immunization Programs; D007223:Infant; D009520:New Zealand / Q000453:epidemiology; D011204:Poverty Areas; D011320:Primary Health Care; D012042:Registries; D014611:Vaccination / Q000706:statistics & numerical data*; D000072758:Vaccination Refusal / Q000706:statistics & numerical data*