National health governance, science and the media: drivers of COVID-19 responses in Germany, Sweden and the UK in 2020

Singapore's COVID-19 crisis decision-making through centralization, legitimacy, and agility: an empirical analysis

Background

Decision-making during health crises differs from routine decision-making and is constrained by ambiguity about evolving epidemiological situations, urgency of response, lack of evidence, and fear. Recent analyses of governance and decision-making during COVID-19, focusing on leadership qualities, involvement of specific stakeholders, and effective resource management, do not adequately address a persisting gap in understanding the determinants of decision-making during health crises at the national level.

Methods

We undertook a study to understand the processes and characteristics of decision-making during the COVID-19 pandemic in Singapore. We used a case study approach and collected empirical evidence about public health decision-making, using a combination of key informant interviews and focus group discussions with stakeholders from government, academia and civil society organizations.

Findings

We argue that administrative centralization and political legitimacy played important roles in agile governance and decision-making during the pandemic in Singapore. We demonstrate the role of the Singapore government's centralization in creating a unified and coherent governance model for emergency response and the People's Action Party's (PAP) legitimacy in facilitating people's trust in the government. Health system resilience and financial reserves further facilitated an agile response, yet community participation and prioritization of vulnerable migrant populations were insufficient in the governance processes.

Interpretation

Our analysis contributes to the theory and practice of crisis decision-making by highlighting the role of political and administrative determinants in agile crisis decision-making.

Funding

This study is funded by the U.S. Centers for Disease Control and Prevention through a Cooperative Research Agreement (NU2HGH2020000037).

Space and place for health and care - Nationalist discourses in Swedish daily press during the first year of COVID-19

Sweden's strategy during COVID-19 with restrictions but no firm closure of the society surprised the rest of the world and was questioned, not least by neighbouring countries. This article analyses public discourses on space and place for health and care in the Swedish daily press during the first year of the pandemic, 2020. Critical discourse analysis was conducted on daily press newspaper articles to approach issues of space, place, health and care during the COVID-10 pandemic. The findings suggest three main discourses. First, a powerful discourse on unity against the threat is articulated, urging citizens in Sweden to be loyal in the national space. Secondly, an affirming national reconstructing discourse is manifested, related to constructions of borders of national space but also in relation to places of family life and social contacts to 'flatten the curve' and stay healthy. Thirdly, later in the period the overarching discourse of the nation and its loyal citizens was torn apart and increasing tensions were articulated due to, as it appeared, the uncertain actions from the government. This study adds to the literature on a theoretical and practical level. Raising awareness on nationalist discourses in relation to place, space, health, and care could prove important in combating inequalities in the local society as well as when cooperating on an international level.

Governance and Public Health Decision-Making During the COVID-19 Pandemic: A Scoping Review

Objective: We provide an in-depth understanding of how governance and decision-making during the COVID-19 pandemic has been empirically characterized in the literature to identify gaps in research and highlight areas that require further inquiry. Methods: We searched peer-reviewed publications using empirical data published between Jan 1, 2020 and Jan 31, 2022 in three electronic databases to examine the process of governance and decision-making during the COVID-19 pandemic. Two authors independently screened the records and 24 publications were extracted for the review. Results: Governance is analyzed by its level at national, sub-national, community and by its aspects of process, determinants and performance. While different methodological approaches are used, governance is conceptualized in four ways 1) characteristics and elements, 2) leadership, 3) application of power and 4) models or arrangements of governance. Conclusion: For future pandemic preparedness, there is a need for more empirical research using a unified conceptual approach to governance, which integrates decision-making processes and can guide governance structures and mechanisms across different countries and contexts. We call for more inclusivity in who performs the research on governance and where.

'What we lacked was the courage to take decisions that differed from the rest of the world': expert perspectives on the role of evidence in COVID-19 policymaking in Iraq

INTRODUCTION

Iraq reported its first COVID-19 case on 24 February 2020 and formed a national committee and advisory committees to support its response. While global experts have suggested that the COVID-19 pandemic provided an exceptional opportunity for advancing evidence-informed policymaking (EIPM), no research has examined this in Iraq. Therefore, this study aimed to examine evidence use in COVID-19 policymaking in Iraq.

METHODS

This qualitative study employed semi-structured interviews with 20 Iraqi policymakers and researchers. Data were analysed thematically in Arabic using inductive coding.

FINDINGS

Participants described COVID-19 policy in Iraq as based on research conducted in other countries, with poor access and quality of routine data and lack of national research priorities and academic freedom as barriers to national research production. Most researchers influenced policy individually, with universities and other research bodies not seen as contributing to policy development. Public non-compliance could be traced to mistrust in both political and healthcare systems and became particularly problematic during the pandemic. Proposed strategies to increase national research production included dedicated funding, establishing communication and collaboration for research priority setting, and protection of academic freedom.

CONCLUSION

Sociopolitical and economic realities in Iraq were unsupportive of national or subnational evidence generation even before the COVID-19 pandemic, and government relied on international evidence and policy transfer rather than contextually informed EIPM. Strengthening evidence-informed infectious disease policymaking and policy transfer would thus require governmental focus on improving the quality and relevance of Iraqi research, engagement between researchers and policymakers, and processes of evidence use and policy transfer.

Personal protective equipment and medical students in times of COVID-19: experiences and perspectives from the final clerkship year

BACKGROUND

The availability and correct use of personal protective equipment (PPE) to prevent and control infections plays a critical role in the safety of medical students in clinical placements. This study explored their experiences and perspectives in their final clerkship year with PPE during the COVID-19 pandemic.

METHODS

This qualitative study was based on social constructivism and was conducted in 2021 at the Charité - Universitätsmedizin Berlin. In three online focus group discussions, 15 medical students in their final clerkship year reported their experiences with PPE training and use during the COVID-19 pandemic. Data were recorded, transcribed and analysed based on Kuckartz's approach to content analysis. We drew upon the a priori dimensions of the capability, opportunity, motivation - behaviour (COM-B) model as main categories as well as emergent issues raised by the study participants (subcategories).

RESULTS

In addition to the three main categories of the COM-B model, eleven subcategories were identified through inductive analysis. The study participants reported several factors that hindered the correct use of PPE. In the area of capabilities, these factors were related to learning experience with PPE in terms of both theoretical and practical learning together with later supervision in practice. In the area of opportunities, these factors included the limited availability of some PPE components, a lack of time for PPE instruction and supervision and inappropriate role modelling due to the inconsistent use of PPE by physicians and nursing staff. The area of motivation to use PPE was characterized by an ambivalent fear of infection by the SARS-CoV-2 virus and the prioritization of patient safety, i.e., the need to prevent the transmission of the virus to patients.

CONCLUSIONS

Our study revealed several limitations pertaining to the enabling factors associated with the trainable behaviour "correct use of PPE". The concept of shared responsibility for student safety was used to derive recommendations for future improvement specifically for the medical school as an organization, the teachers and supervisors, and students themselves. This study may guide and stimulate other medical schools and faculties to explore and analyse components of student safety in clinical settings in times of infectious pandemics.

Covid-19 vaccine roll-out in England: A qualitative evaluation

BACKGROUND

The UK was the first country to launch a national pandemic COVID-19 vaccination programme, which was implemented swiftly despite significant vaccine supply constraints. The delivery strategy used a combination of mass vaccination sites operated by NHS secondary care providers and local sites led by Primary Care Networks, and local pharmacies. Despite nation-wide rollout, persistent gaps in coverage continued to affect particular populations, including ethnic minority and marginalised social groups.

AIM

The study examined sub-national immunisation commissioners and providers' perspectives on how the COVID-19 vaccine programme was operationalised, and how delivery strategies impacted inequalities in access to vaccination services and uptake. The study aimed to inform national programme implementation, sustainability and future pandemic preparedness.

METHODS

Qualitative research was conducted in eight local NHS areas in 4 regions of England. Semi-structured interviews were performed with 82 sub-national NHS and public health vaccine providers and commissioners.

RESULTS

England's COVID-19 vaccination programme was described as top down, centralised and highly political. The programme gradually morphed from a predominantly mass vaccination strategy into more locally driven and tailored approaches able to respond more effectively to inequalities in uptake. Over time more flexibility was introduced, as providers adapted services by "working around" the national systems for vaccine supply and appointment booking. The constant change faced by providers and commissioners was mitigated by high staff motivation and resilience, local collaboration and pragmatism. Opportunities for efficient implementation were missed because priority was given to achieving national performance targets at the expense of a more flexible sub-national tailored delivery.

CONCLUSION

Pandemic vaccination delivery models need to be adapted for underserved and hesitant groups, working in collaboration with local actors. Learnings from the initial COVID-19 vaccine roll-out in England and elsewhere is important to inform future pandemic responses, in tailoring strategies to local communities, and improve large-scale vaccination programmes.

Patient characteristics and testing over COVID-19 waves 1 and 2 from the first German COVID-19 testing unit in Munich, Germany

BACKGROUND

In Munich, the first German case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was detected on 27 January 2020 at the Division of Infectious Diseases and Tropical Medicine of the University Hospital LMU Munich (DIDTM), and consecutively the Covid Testing Unit was established. Germany advocated several public health measures to control the outbreak. This study investigates the effects of measures on health service utilization in the public, which in turn can alter case numbers and test positivity rates.

METHOD

Our retrospective observational study was conducted to determine the effects of public health measures on the utilization of a testing facility and positivity rates from the first operational COVID-19 testing facility in Munich for waves 1 and 2 over a period of 14 months. This was accomplished by comparing trends in client characteristics including age, gender, symptoms, and socio-demographic aspects over time to non-pharmaceutical measures in Germany. To depict trend changes in testing numbers over time, we developed a negative binomial model with multiple breakpoints.

RESULTS

In total 9861 tests were conducted on 6989 clients. The clients were mostly young (median age: 34), female (60.58%), and asymptomatic (67.89%). Among those who tested positive for SARS-CoV-2, 67.72% were symptomatic while the percentage was 29.06% among those who tested negative. There are other risk factors, but a SARS-CoV-2-positive colleague at work is the most prominent factor. Trend changes in the clients' testing numbers could be attributed to the implementation of various public health measures, testing strategies, and attitudes of individuals toward the pandemic. However, test positivity rates did not change substantially during the second wave of the pandemic.

CONCLUSION

We could show that implementation or changes in public health measures have a strong effect on the utilization of testing facilities by the general public, which independently of the true epidemiological background situation can result in changing test numbers.

The Approach to the COVID-19 Pandemic in Georgia-A Health Policy Analysis

Objectives: This study aimed to analyze key COVID-19 pandemic-related policies and national strategic responses in light of Georgia’s political, socioeconomic and cultural backgrounds.

Methods: We applied a policy triangle framework for policy analysis, performed document and media content analysis, and described pandemic trends statistically.

Results: Early introduction of stringent restrictive measures largely prevented a first wave in March–May 2020. This was communicated as a success story, prompting a public success perception. With unpopular restrictions lifted and hesitancy to embrace evidence-informed policymaking ahead of nationwide parliamentary elections, SARS-CoV-2 infection spread rapidly and was met with an insufficiently coordinated effort. Facing health system capacity saturation an almost complete lockdown was re-introduced in late 2020. Factors as delayed immunization campaign, insufficient coordination and, again, little evidence-informed policymaking eventually led to another devastating COVID-19 wave in summer of 2021.

Conclusion: Georgia’s pandemic health policy response was adversely impacted by a volatile political environment. National pandemic preparedness and response might benefit from an independent body with appointment procedures and operations shielded from political influences to effectively inform and communicate evidence-based pandemic policy.

The mechanism of governments' and individuals' influence on protective behaviours during the second wave of COVID-19: a multiple mediation model

Background: The SARS-CoV-2 virus continues to spread and resurge globally with signs of a second wave, despite actions by governments to curb the COVID-19 pandemic. However, evidence-based strategies to combat COVID-19 recurrence are poorly documented. Objective: To reveal how governments and individuals should act to effectively cope with future waves, this study proposed a preventive model of COVID-19 resurgence. Method: A questionnaire survey was conducted among 1,137 residents of Beijing, where the epidemic reoccurred. Structural equation model was used to explore the mechanism among government intervention, perceived efficacy, positive emotions, posttraumatic growth (PTG) and protective behaviours. Results: Data analysis revealed that during COVID-19 resurgence, government intervention could directly and indirectly influence protective behaviours through individual factors (i.e. perceived efficacy, positive emotions), and PTG could mediate the indirect pathway to protective behaviours. Conclusions: These findings implied that government intervention needs to be integrated with individual factors to effectively control repeated COVID-19 outbreaks.