Using exercises to improve public health preparedness in Asia, the Middle East and Africa

Simulation training on respectful emergency obstetric and neonatal care in north-western Madagascar: a mixed-methods evaluation of an innovative training program

BACKGROUND

The rates of maternal and neonatal deaths in Madagascar are among the highest in the world. In response to a request for additional training from obstetrical care providers at the Ambanja district hospital in north-eastern Madagascar, a partnership of institutions in Switzerland and Madagascar conducted innovative training on respectful emergency obstetric and newborn care using e-learning and simulation methodologies. The training focused on six topics: pre-eclampsia, physiological childbirth, obstetric maneuvers, postpartum hemorrhage, maternal sepsis, and newborn resuscitation. Cross-cutting themes were interprofessional communication and respectful patient care. Ten experienced trainers participated in an e-training-of-trainers course conducted by the Swiss partners. The newly-trained trainers and Swiss partners then jointly conducted the hybrid remote/in-person training for 11 obstetrical care providers in Ambanja.

METHODS

A mixed methods evaluation was conducted of the impact of the training on participants' knowledge and practices. Trainees' knowledge was tested before, immediately after, and 6 months after the training. Focus group discussions were conducted to elicit participants' opinions about the training, including the content and pedagogical methods.

RESULTS

Trainees' knowledge of the six topics was higher at 6 months (with an average of 71% correct answers) compared to before the training (62%), although it was even higher (83%) immediately after the training. During the focus group discussions, participants highlighted their positive impressions of the training, including its impact on their sense of professional effectiveness. They reported that their interprofessional relationships and focus on respectful care had improved. Simulation, which was a new methodology for the participants native to Madagascar, was appreciated for its engaging and active format, and they enjoyed the hybrid delivery of the training. Participants (including the trainers) expressed a desire for follow-up engagement, including additional training, and improved access to more equipment.

CONCLUSION

The evaluation showed improvements in trainees' knowledge and capacity to provide respectful emergency care to pregnant women and newborns across all training topics. The hybrid simulation-based training method elicited strong enthusiasm. Significant opportunity exists to expand the use of hybrid onsite/remote simulation-based training to improve obstetrical care and health outcomes for women and newborns in Madagascar and elsewhere.

Developing Public Health Emergency Response Leaders in Incident Management: A Scoping Review of Educational Interventions

During emergency responses, public health leaders frequently serve in incident management roles that differ from their routine job functions. Leaders' familiarity with incident management principles and functions can influence response outcomes. Therefore, training and exercises in incident management are often required for public health leaders. To describe existing methods of incident management training and exercises in the literature, we queried 6 English language databases and found 786 relevant articles. Five themes emerged: (1) experiential learning as an established approach to foster engaging and interactive learning environments and optimize training design; (2) technology-aided decision support tools are increasingly common for crisis decision-making; (3) integration of leadership training in the education continuum is needed for developing public health response leaders; (4) equal emphasis on competency and character is needed for developing capable and adaptable leaders; and (5) consistent evaluation methodologies and metrics are needed to assess the effectiveness of educational interventions.These findings offer important strategic and practical considerations for improving the design and delivery of educational interventions to develop public health emergency response leaders. This review and ongoing real-world events could facilitate further exploration of current practices, emerging trends, and challenges for continuous improvements in developing public health emergency response leaders.

Educating, training, and exercising for infectious disease control with emphasis on cross-border settings: an integrative review

INTRODUCTION

Points of entry and other border regions educate, train, and exercise (ETEs) their staff to improve preparedness and response to cross-border health threats. However, no conclusive knowledge of these ETEs' effectiveness exists. This study aimed to review the literature on ETEs in infectious disease control concerning their methods and effect, with an emphasis on cross-border settings and methods that enlarge ETEs' reach.

METHODOLOGY

We systematically searched for studies in the databases Embase, Medline, Web of Science, PsycInfo, ERIC, and Cinahl. After successively screening titles and abstracts, full-texts, and citations, 62 studies were included using in- and exclusion criteria. Data were extracted using a data-extraction form. Quality assessment was performed. We developed a theoretical framework based on which we analyzed the ETE context (target group, recruitment, autonomy, training needs), input (topic, trainers, development and quality of materials), process (design, duration, interval, goals), evaluation (pre-, post- follow-up tests), and outcome (reaction, learning, behavior, and system).

RESULTS

We found a limited number of published evaluations of ETEs in general (n = 62) and of cross-border settings (n = 5) in particular. The quality assessment resulted in seven ETE methodologies and 23 evaluations with a 'good' score. Both general studies and those in a cross-border setting contain a low-moderate detail level on context, input, and process. The evaluations were performed on reaction (n = 45), learning (n = 45), behavior (n = 9) and system (n = 4), mainly using pre- and post-tests (n = 22). Online learning methods have a high potential in enlarging the reach and are effective, particularly in combination with offline training. Training-of-trainer approaches are effective for learning; new ETEs were developed by 20-44% of participants until six months after the initial training.

CONCLUSION

Our study reveals a limited number of publications on ETEs in infectious disease control. Studies provide few details on methodology, and use mainly short-term evaluations and low level outcomes. We call for more extensive, higher-level evaluation standards of ETEs, and an easy and sustainable way to exchange evaluations within the workforce of infectious disease control in cross-border settings. The theoretical framework developed in this study could guide future development and evaluation of ETEs in infectious disease control.

Disaster Exercises to Prepare Hospitals for Mass-Casualty Incidents: Does it Contribute to Preparedness or is it Ritualism?

IntroductionThe central question this study sought to answer was whether the team members of Strategic Crisis Teams (SCTs) participating in mass-casualty incident (MCI) exercises in the Netherlands learn from their participation.

METHODS

Evaluation reports of exercises that took place at two different times were collected and analyzed against a theoretical model with several dimensions, looking at both the quality of the evaluation methodology (three criteria: objectives described, link between objective and items for improvement, and data-collection method) and the learning effect of the exercise (one criterion: the change in number of items for improvement).

RESULTS

Of all 32 evaluation reports, 81% described exercise objectives; 30% of the items for improvement in the reports were linked to these objectives, and 22% of the 32 evaluation reports used a structured template to describe the items for improvement. In six evaluation categories, the number of items for improvement increased between the first (T1) and the last (T2) evaluation report submitted by hospitals. The number of items remained equal for two evaluation categories and decreased in six evaluation categories.

CONCLUSION

The evaluation reports do not support the ideal-typical disaster exercise process. The authors could not establish that team members participating in MCI exercises in the Netherlands learn from their participation. More time and effort must be spent on the development of a validated evaluation system for these simulations, and more research into the role of the evaluator is needed.Verheul MLMI, Dückers MLA, Visser BB, Beerens RJJ, Bierens JJLM. Disaster exercises to prepare hospitals for mass-casualty incidents: does it contribute to preparedness or is it ritualism? Prehosp Disaster Med. 2018;33(4):387-393.

Preparedness and response against diseases with epidemic potential in the European Union: a qualitative case study of Middle East Respiratory Syndrome (MERS) and poliomyelitis in five member states

Background

EU Decision 1082/2013/EU on serious cross-border health threats provides a legal basis for collaboration between EU Member States, and between international and European level institutions on preparedness, prevention, and mitigation in the event of a public health emergency. The Decision provides a context for the present study, which aims to identify good practices and lessons learned in preparedness and response to Middle East Respiratory Syndrome (MERS) (in UK, Greece, and Spain) and poliomyelitis (in Poland and Cyprus).

Methods

Based on a documentary review, followed by five week-long country visits involving a total of 61 interviews and group discussions with experts from both the health and non-health sectors, this qualitative case study has investigated six issues related to preparedness and response to MERS and poliomyelitis: national plans and overall preparedness capacity; training and exercises; risk communication; linking policy and implementation; interoperability between the health and non-health sectors; and cross-border collaboration.

Results

Preparedness and response plans for MERS and poliomyelitis were in place in the participating countries, with a high level of technical expertise available to implement them. Nevertheless, formal evaluation of the responses to previous public health emergencies have sometimes been limited, so lessons learned may not be reflected in updated plans, thereby risking mistakes being repeated in future. The nature and extent of inter-sectoral collaboration varied according to the sectors involved, with those sectors that have traditionally had good collaboration (e.g. animal health and food safety), as well as those that have a financial incentive for controlling infectious diseases (e.g. agriculture, tourism, and air travel) seen as most likely to have integrated public health preparedness and response plans. Although the formal protocols for inter-sectoral collaboration were not always up to date, good personal relations were reported within the relevant professional networks, which could be brought into play in the event of a public health emergency. Cross-border collaboration was greatly facilitated if the neighbouring country was a fellow EU Member State.

Conclusions

Infectious disease outbreaks remain as an ongoing threat. Efforts are required to ensure that core public health capacities for the full range of preparedness and response activities are sustained.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3326-0) contains supplementary material, which is available to authorized users.

Planning and preparing for public health threats at airports

The ever-increasing speed and scope of human mobility by international air travel has led to a global transport network for infectious diseases with the potential to introduce pathogens into non-endemic areas, and to facilitate rapid spread of novel or mutated zoonotic agents.

Robust national emergency preparedness is vital to mitigate the transmission of infectious diseases agents domestically and to prevent onward spread to other countries. Given the complex range of stakeholders who respond to an infectious disease threat being transmitted through air travel, it is important that protocols be tested and practised extensively in advance of a real emergency. Simulation exercises include the identification of possible scenarios based on the probability of hazards and the vulnerability of populations as a basis for planning, and provide a useful measure of preparedness efforts and capabilities.

In October 2016, a live simulation exercise was conducted at a major airport in Ireland incorporating a public health threat for the first time, with the notification of a possible case of MERS-CoV aboard an aircraft plus an undercarriage fire. Strengths of the response to the communicable disease threat included appropriate public health risk assessment, case management, passenger information gathering, notification to relevant parties, and communication to passengers and multiple agencies.

Lessons learned include:

o Exercise planning should not be overly ambitious. In testing too many facets of emergency response, the public health response could be deprioritised.

o The practical implementation of communication protocols in a real-time exercise of this scope proved challenging. These protocols should continue to be checked and tested by desk-top exercises to ensure that all staff concerned are familiar with them, especially in the context of staff turn-over.

o The roles and responsibilities of the various agencies must be clear to avoid role confusion.

o Equipment and infrastructure capacities must be considered and in place in advance of an actual incident or test, for example whether or not cell phone signals require boosting during a major event.

Importantly, exercises bring together individuals representing organisations with different roles and perspectives allowing identification of capabilities and limitations, and problem solving about how to address the gaps and overlaps in a low-threat collaborative setting.

A Systematic Review of Literature on Effectiveness of Training in Emergency Risk Communication

Although disaster preparedness training is regularly conducted for a range of health-related professions, little evidence-based guidance is available about how best to actually develop capacity in staff for conducting emergency risk communication. This article presents results of a systematic review undertaken to inform the development of World Health Organization guidelines for risk communication during public health and humanitarian emergencies. A total of 6,720 articles were screened, with 24 articles identified for final analysis. The majority of research studies identified were conducted in the United States, were either disaster general or focused on infectious disease outbreak, involved in-service training, and used uncontrolled quantitative or mixed method research designs. Synthesized findings suggest that risk communication training should include a focus on collaboration across agencies, training in working with media, and emphasis on designing messages for specific audience needs. However, certainty of findings was at best moderate due to lack of methodological rigor in most studies.

Development of an Online Toolkit for Measuring Performance in Health Emergency Response Exercises

Introduction

Exercises that simulate emergency scenarios are accepted widely as an essential component of a robust Emergency Preparedness program. Unfortunately, the variability in the quality of the exercises conducted, and the lack of standardized processes to measure performance, has limited the value of exercises in measuring preparedness.

Methods

In order to help health organizations improve the quality and standardization of the performance data they collect during simulated emergencies, a model online exercise evaluation toolkit was developed using performance measures tested in over 60 Emergency Preparedness exercises. The exercise evaluation toolkit contains three major components: (1) a database of measures that can be used to assess performance during an emergency response exercise; (2) a standardized data collection tool (form); and (3) a program that populates the data collection tool with the measures that have been selected by the user from the database. The evaluation toolkit was pilot tested from January through September 2014 in collaboration with 14 partnering organizations representing 10 public health agencies and four health care agencies from eight states across the US. Exercise planners from the partnering organizations were asked to use the toolkit for their exercise evaluation process and were interviewed to provide feedback on the use of the toolkit, the generated evaluation tool, and the usefulness of the data being gathered for the development of the exercise after-action report.

Results

Ninety-three percent (93%) of exercise planners reported that they found the online database of performance measures appropriate for the creation of exercise evaluation forms, and they stated that they would use it again for future exercises. Seventy-two percent (72%) liked the exercise evaluation form that was generated from the toolkit, and 93% reported that the data collected by the use of the evaluation form were useful in gauging their organization’s performance during the exercise. Seventy-nine percent (79%) of exercise planners preferred the evaluation form generated by the toolkit to other forms of evaluations.

Conclusion

Results of this project show that users found the newly developed toolkit to be user friendly and more relevant to measurement of specific public health and health care capabilities than other tools currently available. The developed toolkit may contribute to the further advancement of developing a valid approach to exercise performance measurement.

AgboolaF, BernardD, SavoiaE, BiddingerPD. Development of an online toolkit for measuring performance in health emergency response exercises. Prehosp Disaster Med. 2015;30(5):503–508.