Nikki Turner (academic general practitioner)

Much of Turner's research and outreach has focused on improving immunisation coverage and closing equity gaps for the national schedule vaccine delivery in New Zealand. In 2009, she co-authored a paper that noted immunisation coverage in New Zealand (NZ) was "mediocre...[with]...the 2005 national survey... [showing]...only 77% of children at 2 years of age had received all scheduled childhood immunizations."[5]

She has been concerned with both personnel and systems, showing that adequately trained and stable medical and nursing staff, practice management systems and early enrollment of children on a national immunisation register are key to improved vaccination levels.[5][6][7] Her joint survey research has found that New Zealand parents, family physicians and practice nurses identified the importance of educating parents about immunisation and vaccine safety.[8][9] It also identified a need for vaccination training including a better knowledge of contraindications to vaccination.[10] Further work summarising international literature on influences and policies that affect immunisation coverage identified the need to develop policies that acknowledged "social and ethnic sensitivities"; engagement with local communities; having well trained and informed medical staff, and consistent demonstration of a "high degree of consensus among medical scientists through positive messages."[11]

Turner has also examined physical processes involved in community immunisation. In 2011 Turner co-authored an Immunisation Advisory Centre (IMAC) study to assess the effectiveness of the cold chain management for delivery of childhood vaccines from national stores to delivery sites in New Zealand.[12]

Speaking to Kathryn Ryan on Radio New Zealand in 2019, Turner discussed the significance of a worldwide drop in measles vaccinations below the level needed to create herd immunity. She stressed that it was an international problem and noted again that some of the underlying causes of insufficient rates of vaccination were lack of trust in medical authorities and increasing inequalities, resulting in less equitable access to vaccines. [13]

Turner was in the research team for The Southern Hemisphere Influenza and Vaccine Effectiveness Research and Surveillance (SHIVERS) project (2012–2016) designed to measure "disease burden, epidemiology, aetiology, risk factors, immunology, effectiveness of vaccination and other prevention strategies for influenza and other respiratory infectious diseases of public health importance."[14] Annual studies from 2012 to 2014 for the first time in New Zealand, estimated how effectively trivalent inactivated influenza vaccine (TIV) prevented general practice visits and hospitalisation for patients with influenza-confirmed respiratory infections. In each year the data showed mostly moderate effectiveness of the vaccine,[15][16][17] but it was noted that future data gathered in the SHIVERS project would allow estimates for specific high-risk population groups and enable "more extensive comparisons between VE [vaccine effectiveness ] estimates in primary care (general practice) and hospital settings."[17]

The SHIVERS Project (I) continued to develop an effective population-based surveillance system for acute respiratory illness in New Zealand until 2017 producing over 17 peer-reviewed publications. In 2018 SHIVERS won a national Team Award from Science New Zealand.[18] In 2019, in recognition of their major contribution to influenza research, the SHIVERS team, including Turner, received The New Zealand Association of Scientists (NZAS) Shortland Medal. [19]

Following the hosting of a major influenza symposium involving international experts in 2018, IMAC collated a synopsis of the key topics to inform a reflection of strategies used since the 1918 influenza pandemic and deal with unanswered questions about how to manage future pandemics.[20] Data gathered from seasonal influenza epidemics indicated that the burden of the disease had been inequitably carried by vulnerable populations such as the Maori, Pacific Island and Asian communities.[20] In another research project, Turner and epidemiologists Nick Wilson and Michael Baker presented data that showed the birth rate for Maori dropped disproportionately after the 2018 pandemic and this was consistent with the general mortality rate for Maori during this period. The findings of the study confirmed the importance of pregnant women being vaccinated against seasonal influenza to reduce the rate of stillbirths, and highlighted the need to "eliminate poverty and ethnic inequalities in health in New Zealand, as well as more specific strategies to protect Māori health (eg, via eliminating tobacco, controlling the obesogenic environment and improving access to healthcare)."[21] In a later discussion about this research, Turner reiterated the importance of protecting pregnant women from any infection, and if vaccines were in short supply, prioritising them for "access to antivirals and ventilators in hospital intensive care units if they get sick."[22]

She co-authored a paper in 2019 that summarised the findings of a retrospective cohort study of New Zealand children (born 2006–2015), which identified that hospitalisation rates for infectious diseases since 1989 had increased disproportionately for Maori and Pacific children and those who were socioeconomically most deprived, but that those children who received the pneumococcal conjugate vaccine (PVC) between 2008 and 2014, were less likely to be hospitalized. The paper concluded that the use of PVC was associated with "reductions in ethnic and socioeconomic disparities in hospitalization." [23]

Another report on a research study co-authored by Turner showed that foreign-born migrant children living in New Zealand had an overall lower vaccination rate than NZ-born migrant and non-migrant children. It was acknowledged that there needed to be an improvement in the way such data were gathered, highlighting the importance of having "better national surveillance and migrant-specific data related to vaccination coverage to help uncover health inequities among children living in NZ and inform immunisation policy and practice."[24] A follow-up paper on this research highlighted that "children need to be age-appropriately vaccinated, and other individual and environmental factors addressed, to reduce the risk of infectious diseases", and to get a better understanding of migrant health, data must be disaggregated to locate hidden trends, provide information about subsets and make vulnerable groups more visible.[25]

Much of Turner's research and writing has been on the importance of people getting accurate information about immunisation particulary to reassure parents that vaccines were safe.[7][8] Turner has been actively involved in media discussions of vaccine safety including the Meningococcal vaccine in 2004 [26]and the cervical cancer vaccine Gardasil in 2009.[27][28]

Turner has highlighted the importance of building trust between the public and those delivering health programs, either government-funded,[29][30] or at the level of general practice.[7] Her research noted that the decision-making process for consent could be influenced by anti-vaccination views, often from those in the healthy population, resulting in immunisation hesitancy in the community. Coercive approaches to increase vaccine uptake were seen as likely to increase mistrust of vaccines and medical professionals, particularly by those members of the population with low levels of social inclusion and less access to systems and services. The study concluded that "vaccination advocates with similar backgrounds to the target population can help to increase trust and acceptance within health services."[11] Discussing the research, Turner said that while making vaccinations mandatory might be helpful, it could result in some families being less inclined to discuss their concerns openly and develop a strong sense of engagement with, and trust in healthcare professionals.[31]

In 2019, New Zealand had a serious outbreak of measles.[32][33][34] Turner has written, researched and commented extensively on this epidemic and how such outbreaks can be prevented.[35][36] The paper on the research, co-authored by Turner concluded that these were also factors that had contributed to the pandemic in New Zealand and suggested management strategies such as a national campaign targeting the at-risk age groups; putting in place systems to ensure adequate supplies of vaccines; provision of support for their delivery at the practice level; and creative use of community facilities to improve accessibility.[35]

Figures as at 1 December 2019 indicated that it was a challenge to get the measles vaccination to the estimated 300,000 people aged between 15 and 30 who needed in New Zealand. Turner said this left the country very vulnerable and that because most countries were focused on COVID-19 vaccinations, measles was on the rise worldwide.[37][38]

In her role as spokesperson for Child Poverty Action Group, Turner has commented in the media on the relationship between low income and poor child health,[39] and in 2008 co-authored a research report which stated that poverty was causing "devastation" in the health sector, with data showing that New Zealand children had "higher rates of preventable illness and deaths from injuries than children in almost any other OECD country."[40] The report drew attention to the fact that Maori and Pasifika children were disproportionately affected by this, being more likely to grow up in poverty and be most at risk of poor health.[40]

When the New Zealand government decided to allow schools to sell 'junk' food in 2009, Turner suggested that this was giving the wrong message to young people and ignoring the fact that "obesity is disproportionately a burden of low-income families...[who needed]...community support to combat the obesity epidemic." It was suggested that there is evidence that showed changing the school environment is a key factor in children and families making healthy food choices.[41]

In 2010 Turner noted that with one in five of New Zealand children living in poverty, the rates of preventable disease in this group were among the highest in the developed world. She said, addressing this required innovative ways to get and use funding where it was most needed as the key issue was to ensure children's access to health care at all times.[42] An article in the same year, co-authored by Turner, also noted that after-hours access was a barrier to children under six years of age receiving health care.[43]

In 2012, Turner, as a member of the New Zealand Children's Commissioner's Expert Advisory Group on Solutions to Child Poverty, contributed to a major report that explored how child poverty in New Zealand could be reduced.[44] Turner later said she was disappointed at the response by the New Zealand government and that they had only focussed on a few areas instead of taking a fully systemic approach to reducing child poverty.[45] This report supported the findings in a previous paper endorsed by the New Zealand Medical Association and co-authored by Turner, which contended that overcrowding, poor nutrition, exposure to tobacco and stress contribute to creating a social environment in which the population is vulnerable and likely to have less access to health care services.[46]

The Child Poverty Action Group continued to call on the New Zealand government at this time to invest more in children,[47] and when the annual Child Poverty Monitor was released in 2104,[48] Turner noted that it showed too many New Zealand children were still in poverty and a "substantial commitment is needed to improve incomes and housing for families with children...[because]...childhood poverty has life-long consequences for people's health and well-being."[49] A paper co-authored by Turner focussed on the cost of visits to general practitioners for New Zealand children aged between 6–17 years old concluded that the amount for both unexpected and out-of-hours trips to the doctor would be difficult for families that were struggling financially.[50]

Commenting on a report released by The Asthma Foundation[51], Turner said it confirmed concerns that poverty and deprivation impacted greatly on respiratory disease in New Zealand children, and the underlying causes need to be addressed to ensure that children and families had adequate income, good housing and easy access to health care.[52] In 2015 after the Children's Commissioner released data showing that at the time, there were 305,000 children living in poverty in New Zealand - an increase of 45,000 from the previous year - Turner said that child poverty was now a national issue, not just for individual parents, and there appeared to be an unwillingness to resource a solution to the problem.[53]

On 17 May 2017, with a General Election pending in New Zealand, The Child Poverty Action Group stated it was crucial that policies for the wellbeing of the country's children be enacted. As their health spokesperson, Turner said "Poverty makes children sick. It may cause illnesses that affect their physical and mental health for their whole lives, decreasing their chances of good educational outcomes, and future success, as well as that of future generations."[54]