Public Health Reports®

In response to public health systems and services research priorities, we examined the extent to which participation in accreditation and performance improvement programs can be expected to enhance preparedness capacities.

Using data collected by the Local Health Department Preparedness Capacities Assessment Survey, we applied a series of weighted least-squares models to examine the effect of program participation on each of the eight preparedness domain scores. Participation was differentiated across four groups: North Carolina (NC) accredited local health departments (LHDs), NC non-accredited LHDs, national comparison LHDs that participated in performance or preparedness programs, and national comparison LHDs that did not participate in any program.

Domain scores varied among the four groups. Statistically significant positive participation effects were observed on six of eight preparedness domains for NC accreditation programs, on seven domains for national comparison group LHDs that participated in performance programs, and on four domains for NC non-accredited LHDs.

Overall, accreditation and other performance improvement programs have a significant and positive effect on preparedness capacities. While we found no differences among accredited and non-accredited NC LHDs, this lack of significant difference in preparedness scores among NC LHDs is attributed to NC's robust statewide preparedness program, as well as a likely exposure effect among non-accredited NC LHDs to the accreditation program.

Numerous institutional facilitators and barriers to preparedness planning exist at the local level for vulnerable and at-risk populations. Findings of this evaluation study contribute to ongoing practice-based efforts to improve response services and address public health preparedness planning and training as they relate to vulnerable and at-risk populations.

From January 2012 through June 2013, we conducted a multilevel, mixed-methods evaluation study of the North Carolina Preparedness and Emergency Response Research Center's Vulnerable & At-Risk Populations Resource Guide, an online tool to aid local health departments' (LHDs') preparedness planning efforts. We examined planning practices across multiple local, regional, and state jurisdictions utilizing user data, follow-up surveys, and secondary data. To identify potential incongruities in planning, we compared respondents' reported populations of interest with corresponding census data to determine whether or not there were differences in planning priorities.

We used data collected from evaluation surveys to identify key institutional facilitators and barriers associated with planning for at-risk populations, including challenges to conducting assessments and lack of resources. Results identified both barriers within institutional culture and disconnects between planning priorities and evidence-based identification of vulnerable and at-risk populations, including variation in the planning process, partnerships, and perceptions.

Our results highlight the important role of LHDs in preparedness planning and the potential implications associated with organizational and bureaucratic impediments to planning implementation. A more in-depth understanding of the relationships among public institutions and the levels of preparedness that contribute to the conditions and processes that generate vulnerability is needed.

We surveyed U.S. immunization program managers (IPMs) as part of a project to improve public health preparedness against future emergencies by leveraging the immunization system. We examined immunization program policy and Immunization Information System (IIS) functionality changes as a result of the Haemophilus influenzae type B (Hib) vaccine shortage and pandemic influenza A(H1N1) (pH1N1). Evaluating changes in immunization program functionalities and policies following emergency response situations will assist in planning for future vaccine-related emergencies.

We administered three consecutive surveys to IPMs from 64 state, city, and territorial jurisdictions in 2009, 2010, and 2012. We compared IPMs' responses across either two or three years (e.g., changes in response or consistent responses across years) using McNemar's test.

Immunization programs maintained increases in functionality related to communication systems with health-care providers during this period. Immunization programs often did not maintain changes to IIS functionalities made from 2009 to 2010 (e.g., identifying high-risk and priority populations, tracking adverse events, and mapping disease risk) in the post-pandemic period (2010–2012). About half of IPMs reporting additional IIS functionality in identifying high-risk populations from 2009 to 2010 reported no longer having this function in 2012. There was an 18% decline in respondents reporting geographic information systems risk-mapping capability in IIS from 2010 to 2012.

Because of the Hib vaccine shortage and pH1N1, immunization program needs and efforts changed to address evolving situations. The lack of sustained increases in resources or system functions after the pandemic highlights the need for comprehensive, sustainable public health emergency preparedness systems and related resources.

Studies have shown that differences among individuals and social groups in accessing and using information on health and specific threats have an impact on their knowledge and behaviors. These differences, characterized as communication inequalities, may hamper the strength of a society's response to a public health emergency. Such inequalities not only make vulnerable populations subject to a disproportionate burden of adversity, but also compromise the public health system's efforts to prevent and respond to pandemic influenza outbreaks. We investigated the effect of socioeconomic status (SES) and health communication behaviors (including barriers) on people's knowledge and misconceptions about pandemic influenza A(H1N1) (pH1N1) and adoption of prevention behaviors.

The data for this study came from a survey of 1,569 respondents drawn from a nationally representative sample of American adults during pH1N1. We conducted logistic regression analyses when appropriate.

We found that (1) SES has a significant association with barriers to information access and processing, levels of pH1N1-related knowledge, and misconceptions; (2) levels of pH1N1-related knowledge are associated positively with the adoption of recommended prevention measures and negatively with the adoption of incorrect protective behaviors; and (3) people with higher SES, higher news exposure, and higher levels of pH1N1-related knowledge, as well as those who actively seek information, are less likely than their counterparts to adopt incorrect prevention behaviors.

Strategic public health communication efforts in public health preparedness and during emergencies should take into account potential communication inequalities and develop campaigns that reach across different social groups.

The Rapid Emergency Alert Communication in Health (REACH) Trial was a randomized control trial to systematically compare and evaluate the effectiveness of traditional and mobile communication modalities for public health agencies to disseminate time-sensitive information to health-care providers (HCPs). We conducted a sub-study to identify the communication channels by which HCPs preferred receiving public health alerts and advisories.

Enrolled HCPs were blindly randomized into four message delivery groups to receive time-sensitive public health messages by e-mail, fax, or short message service (SMS) or to a no-message control group. Follow-up interviews were conducted 5–10 days after the message. In the final interview, additional questions were asked regarding HCP preferences for receiving public health alerts and advisories. We examined the relationship between key covariates and preferred method of receiving public health alert and advisory messages.

Gender, age, provider type, and study site showed statistically significant associations with delivery method preference. Older providers were more likely than younger providers to prefer e-mail or fax, while younger providers were more likely than older providers to prefer receiving messages via SMS.

There is currently no evidence-based research to guide or improve communication between public health agencies and HCPs. Understanding the preferences of providers for receiving alerts and advisories may improve the effectiveness of vital public health communications systems and, in turn, may enhance disease surveillance, aid in early detection, and improve case finding and situational awareness for public health emergencies.

This study presents reliability and validity findings for the Assessment for Disaster Engagement with Partners Tool (ADEPT), an instrument that can be used to monitor the frequency and nature of collaborative activities between local health departments (LHDs) and community-based organizations (CBOs) and faith-based organizations (FBOs) for disaster preparedness, response, and recovery.

We used formative research to develop the instrument by ranking LHDs according to their disaster outreach and engagement activities. We validated the scale through a 2011 national survey of disaster preparedness coordinators (n=273) working in LHDs. We reduced the original measure of 25 items to a final measure comprising 15 items with four dimensions: (1) communication outreach and coordination, (2) resource mobilization, (3) organizational capacity building, and (4) partnership development and maintenance. We used internal consistency reliability m correlation and factor analysis to validate the measure.

Using internal consistency reliability, we found reasonable inter-item reliability for the four hypothesized dimensions (Cronbach's alpha: 0.71–0.88). These four dimensions were confirmed through correlation and factor analysis (Varimax rotation).

Higher scores on all four dimensions of ADEPT for organizational respondents suggest that more activities were conducted for inter-organizational preparedness in those organizations than in organizations whose respondents had lower scores. This finding implies that organizations with higher ADEPT scores have more active relationships with CBOs/FBOs in the realm of preparedness, a key element for creating community resilience for emergencies and disaster preparedness.

Using comparative analysis, we examined the factors that influence the engagement of academic institutions in community disaster response.

We identified colleges and universities located in counties affected by four Federal Emergency Management Agency-declared disasters (Kentucky ice storms, Hurricanes Ike and Gustav, California wildfires, and the Columbia space shuttle disintegration) and performed key informant interviews with officials from public health, emergency management, and academic institutions in those counties. We used a comparative case study approach to explore particular resources provided by academic institutions, processes for engagement, and reasons for engagement or lack thereof in the community disaster response.

Academic institutions contribute a broad range of resources to community disaster response. Their involvement and the extent of their engagement is variable and influenced by (1) their resources, (2) preexisting relationships with public health and emergency management organizations, (3) the structure and organizational placement of the school's disaster planning and response office, and (4) perceptions of liability and lines of authority. Facilitators of engagement include (1) the availability of faculty expertise or special training programs, (2) academic staff presence on public health and emergency management planning boards, (3) faculty contracts and student practica, (4) incident command system or emergency operations training of academic staff, and (5) the existence of mutual aid or memoranda of agreements.

While a range of relationships exist between academic institutions that engage with public health and emergency management agencies in community disaster response, recurrent win-win themes include co-appointed faculty and staff; field experience opportunities for students; and shared planning and training for academic, public health, and emergency management personnel.

Faculty and affiliates of the Johns Hopkins Preparedness and Emergency Response Research Center partnered with local health departments and faith-based organizations to develop a dual-intervention model of capacity-building for public mental health preparedness and community resilience. Project objectives included (1) determining the feasibility of the tri-partite collaborative concept; (2) designing, delivering, and evaluating psychological first aid (PFA) training and guided preparedness planning (GPP); and (3) documenting preliminary evidence of the sustainability and impact of the model.

We evaluated intervention effectiveness by analyzing pre- and post-training changes in participant responses on knowledge-acquisition tests administered to three urban and four rural community cohorts. Changes in percent of correct items and mean total correct items were evaluated. Criteria for model sustainability and impact were, respectively, observations of non-academic partners engaging in efforts to advance post-project preparedness alliances, and project-attributable changes in preparedness-related practices of local or state governments.

The majority (11 of 14) test items addressing technical or practical PFA content showed significant improvement; we observed comparable testing results for GPP training. Government and faith partners developed ideas and tools for sustaining preparedness activities, and numerous project-driven changes in local and state government policies were documented.

Results suggest that the model could be an effective approach to promoting public health preparedness and community resilience.

Collaboration between existing components of the public health system is important for protecting public health and promoting community resilience. We describe the factors that promote collaborative emergency preparedness and response activities between local health departments (LHDs) and school systems.

We gathered data from a multistage, stratified random sample of 750 LHDs nationwide. Utilizing a mailed invitation, we recruited respondents to participate in an online questionnaire. We calculated descriptive and inferential statistics.

The majority of LHDs collaborated with school systems for emergency preparedness and response activities and most indicated they were likely to collaborate in the future. Characteristics of the jurisdiction, general experience and perceptions of collaboration, and characteristics of the preparedness collaboration itself predicted future collaboration.

Our results help us understand the nature of collaborations between LHDs and school systems on emergency preparedness and response activities, which can be used to identify priority areas for developing successful and sustainable joint efforts in the future. By focusing on the perceived value of collaboration and building on existing non-preparedness partnering, communities can increase the likelihood of ongoing successful LHD-school system emergency preparedness collaborations.

Public health surveillance and epidemiologic investigations are critical public health functions for identifying threats to the health of a community. We conducted a survey of local health departments (LHDs) in California to describe the workforce that supports public health surveillance and epidemiologic functions during routine and emergency infectious disease situations.

The target population consisted of the 61 LHDs in California. The online survey instrument was designed to collect information about the workforce involved in key epidemiologic functions. We also examined how the public health workforce increases its epidemiologic capacity during infectious disease emergencies.

Of 61 LHDs in California, 31 (51%) completed the survey. A wide range of job classifications contribute to epidemiologic functions routinely, and LHDs rely on both internal and external sources of epidemiologic surge capacity during infectious disease emergencies. This study found that while 17 (55%) LHDs reported having a mutual aid agreement with at least one other organization for emergency response, only nine (29%) LHDs have a mutual aid agreement specifically for epidemiology and surveillance functions.

LHDs rely on a diverse workforce to conduct epidemiology and public health surveillance functions, emphasizing the need to identify and describe the types of staff positions that could benefit from public health surveillance and epidemiology training. While some organizations collaborate with external partners to support these functions during an emergency, many LHDs do not rely on mutual aid agreements for epidemiology and surveillance activities.

We tested the Analytical Hierarchy Process tool for its use in public health to identify potential gaps in emergency preparedness by local health departments (LHDs) in California and Hawaii during a radiological emergency.

We developed a dedicated tool called All-Hazards Preparedness Squared (AHP²) that can be used by those who are responsible for all-hazards preparedness planning and response to guide them while making strategic decisions both in preparing for and responding to a slow-moving incident while it is unfolding. The tool is an Internet-based survey that can be distributed among teams responsible for emergency preparedness and response. Twenty-eight participants from 16 LHDs in California and Hawaii responsible for coordinating preparedness and response in a radiological emergency participated in using the tool in 2013. We used the data to compare the perceived importance of different elements of preparedness among participants and identify gaps in preparedness of their organizations for meeting the challenges presented by a radiological incident.

Clarity of information and transfer of information (to and from agency to public, state, and federal partners) were public health officials' dominant concerns while responding to an emergency. Participants also found that there were gaps in the adequacy of training and awareness of the chain of command during a radiological emergency.

This preliminary study indicates that the AHP² tool could be used for decision making in all-hazards preparedness planning and response.

Large-scale incidents such as the 2009 H1N1 outbreak, the 2011 European Escherichia coli outbreak, and Hurricane Sandy demonstrate the need for continuous improvement in emergency preparation, alert, and response systems globally. As questions relating to emergency preparedness and response continue to rise to the forefront, the field of industrial and systems engineering (ISE) emerges, as it provides sophisticated techniques that have the ability to model the system, simulate, and optimize complex systems, even under uncertainty.

We applied three ISE techniques—Markov modeling, operations research (OR) or optimization, and computer simulation—to public health emergency preparedness.

We present three models developed through a four-year partnership with stakeholders from state and local public health for effectively, efficiently, and appropriately responding to potential public health threats: (1) an OR model for optimal alerting in response to a public health event, (2) simulation models developed to respond to communicable disease events from the perspective of public health, and (3) simulation models for implementing pandemic influenza vaccination clinics representative of clinics in operation for the 2009–2010 H1N1 vaccinations in North Carolina.

The methods employed by the ISE discipline offer powerful new insights to understand and improve public health emergency preparedness and response systems. The models can be used by public health practitioners not only to inform their planning decisions but also to provide a quantitative argument to support public health decision making and investment.

This study explored if and to what extent the laws of U.S. states mirrored the U.S. federal laws for responding to nuclear-radiological emergencies (NREs).

Emergency laws from a 12-state sample and the federal government were retrieved and translated into numeric codes representing acting agents, their partner agents, and the purposes of activity in terms of preparedness, response, and recovery. We used network analysis to explore the relationships among agents in terms of legally directed NRE activities.

States' legal networks for NREs appear as not highly inclusive, involving an average of 28% of agents among those specified in the federal laws. Certain agents are highly central in NRE networks, so that their capacity and effectiveness might strongly influence an NRE response.

State-level lawmakers and planners might consider whether or not greater inclusion of agents, modeled on the federal government laws, would enhance their NRE laws and if more agents should be engaged in planning and policy-making for NRE incidents. Further research should explore if and to what extent legislated NRE directives impose constraints on practical response activities including emergency planning.