Gauging U.S. Emergency Medical Services workers' willingness to respond to pandemic influenza using a threat- and efficacy-based assessment framework

Emergency medical service interventions and experiences during pandemics: A scoping review

BACKGROUND

The global impact of COVID-19 has been profound, with efforts to manage and contain the virus placing increased pressure on healthcare systems and Emergency Medical Services (EMS) in particular. There has been no previous review of studies investigating EMS interventions or experiences during pandemics. The aim of this scoping review was to identify and present published quantitative and qualitative evidence of EMS pandemic interventions, and how this translates into practice.

METHODS

Six electronic databases were searched from inception to July 2022, supplemented with internet searches and forward and backward citation tracking from included studies and review articles. A narrative synthesis of all eligible quantitative studies was performed and structured around the aims, key findings, as well as intervention type and content, where appropriate. Data from the qualitative studies were also synthesised narratively and presented thematically, according to their main aims and key findings.

RESULTS

The search strategy identified a total of 22,599 citations and after removing duplicates and excluding citations based on title and abstract, and full text screening, 90 studies were included. The quantitative narrative synthesis included seven overarching themes, describing EMS pandemic preparedness plans and interventions implemented in response to pandemics. The qualitative data synthesis included five themes, detailing the EMS workers' experiences of providing care during pandemics, their needs and their suggestions for best practices moving forward.

CONCLUSIONS

Despite concerns for their own and their families' safety and the many challenges they are faced with, especially their knowledge, training, lack of appropriate Personal Protective Equipment (PPE) and constant protocol changes, EMS personnel were willing and prepared to report for duty during pandemics. Participants also made recommendations for future outbreak response, which should be taken into consideration in order for EMS to cope with the current pandemic and to better prepare to respond to any future ones.

TRIAL REGISTRATION

The review protocol was registered with the Open Science Framework (osf.io/2pcy7).

An assessment of nurses' perceived and actual household emergency preparedness

Nurses' household preparedness is critical if they are to avoid role conflict and report for duty during an emergency. To date, the alignment between nurses' perceived and actual household preparedness remains under examined. Investigating one of these variables in isolation fails to consider that perceived and actual household preparedness must be high and aligned. If misaligned, vulnerabilities could surface during emergencies, like concerns about family safety, potentially impacting a nurse's commitment to duty during a crisis, or nurses may lack the actual preparedness to continue working long hours during an emergency. An online questionnaire was distributed to registered nurses in Ireland. The questionnaire was informed by a review of the literature and captured nurses' perceived and actual household preparedness, attitudes towards and exposure to a range of emergencies, and pertinent demographic characteristics. The results showed a relationship between how nurses view their household preparedness and their actual preparedness. Regression analyses indicate that while there is an overlap, the factors associated with how prepared nurses think they are and how prepared they are can differ. This means that strategies to boost actual preparedness may differ from those needed to boost perceived preparedness. This finding underscores the importance of psychosocial preparedness. Feeling prepared is crucial as it can influence how one responds in an emergency. Considering both the perceived and actual aspects of household preparedness can lead to a more effective response during emergencies.

Assessment of Physicians' Willingness to Work with Patients Not Yet Diagnosed with COVID-19 in a Romanian Sample

BACKGROUND

The risk to physicians who worked with patients without confirmed COVID-19 testing during the pandemic has been little studied. However, they were at high risk.

METHODS

In the summer of 2020, 1285 Romanian physicians participated in a single-center study. Participants (mean age = 48.21 years; 302 males and 982 females, all specialties) completed a series of single-item measures adapted from previous studies on work ethics and responsibility. This study used Mann-Whitney comparisons between physicians who reported that they knowingly had direct contact with COVID patients and those who did not regarding their willingness to work.

RESULTS

Compared with their colleagues, physicians who reported not knowingly having direct contact with COVID patients reported less access to protective equipment, less overall willingness to respond when asked to work with infected patients, more likely to work out of fear of losing their jobs, and fear of legal repercussions. They received less training in the use of protective equipment.

CONCLUSIONS

Physicians who worked with patients not yet diagnosed with COVID-19 were significantly less willing to work. The perception of invisible risk may explain the observed differences.

Navigating a Pandemic: Leadership Dynamics and Challenges within Infection Prevention and Control Units in Israel

This study investigates the impact of the coronavirus disease 2019 (COVID-19) pandemic on leadership within infection prevention and control (IPC) units across public hospitals in Israel. Through qualitative interviews with ten IPC managers from nine hospitals, equivalent to 30% of the country's acute care facilities, the research uncovers significant changes in managerial approaches due to the health crisis. The results reveal four main themes: (1) Enhanced managerial autonomy and leadership skills, with a noted rise in self-efficacy against the pandemic's backdrop; (2) Shifted perceptions of IPC units by upper management, recognizing their strategic value while identifying the need for a more profound understanding of IPC operations; (3) The increased emphasis on adaptability and rapid decision-making for effective crisis management; (4) The dual effect on job satisfaction and well-being, where greater commitment coincides with risks of burnout. The study underscores the essential nature of effective IPC leadership during emergencies, highlighting the need for clear communication, prompt action, and empathetic leadership. The conclusions point to the necessity for continuous research into IPC leadership, promoting strategic advancements in management to bolster IPC units against future health threats.

Are the healthcare providers willing and able to respond to disasters: An assessment of tertiary health care system of Khyber Pakhtunkhwa

For the tertiary health care system to provide adequate care during disasters, willing and able healthcare providers must be available to respond to the abnormal surge of the patients. Health care professionals (HCPs) constantly face a dilemma because of their profession to either respond to disasters or protect themselves. This study was conducted to assess the willingness and ability of HCPs working in the tertiary healthcare system of Khyber Pakhtunkhwa to respond to disasters. This cross-sectional survey was conducted in all the 8 tertiary care hospitals of the Khyber Pakhtunkhwa province of Pakistan. For different disaster scenarios, between 6% and 47% of HCP indicated their unwillingness, and between 3% & 41% of HCPs indicated that they were unable to respond to the given disaster scenarios. HCPs with childcare obligation indicated significantly lower willingness (p<0.05) to respond to earthquakes, MCIs, and an outbreak of Influenza, and SARS. Male HCPs showed a significantly (p<0.05) higher willingness to respond to earthquakes, MCIs, and an outbreak of Influenza as compared to their female counterparts. The overall ability indicated by HCPs for various disaster scenarios ranged between 54.1% [95% CI 0.503,0.578] for responding to victims of nuclear war and 96.4% [95% CI 0.947,0.976] for responding to conventional war. The HCPs who indicated childcare obligation showed a significantly lower ability (p<0.05) to respond to environmental disaster, influenza outbreak, and responding to victims of nuclear war. Female HCPs indicated significantly higher ability (p<0.05) as compared to their male counterparts. This survey provides an opportunity for the tertiary healthcare system to build on the findings and develop disaster mitigation plans to address the barriers to improving the HCPs' availability during disasters.

Physicians' Trust in Relevant Institutions during the COVID-19 Pandemic: A Binary Logistic Model

Little research has been done on professionals' perceptions of institutions and governments during epidemics. We aim to create a profile of physicians who feel they can raise public health issues with relevant institutions during a pandemic. A total of 1285 Romanian physicians completed an online survey as part of a larger study. We used binary logistic regression to profile physicians who felt they were able to raise public health issues with relevant institutions. Five predictors could differentiate between respondents who tended to agree with the trust statement and those who tended to disagree: feeling safe at work during the pandemic, considering the financial incentive worth the risk, receiving training on the use of protective equipment, having the same values as colleagues, and enjoying work as much as before the pandemic. Physicians who trusted the system to raise public health issues with the appropriate institutions were more likely to feel that they shared the same values as their colleagues, to say they were trained to use protective equipment during the pandemic, to feel that they were safe at work during the pandemic, to enjoy their work as much as before the pandemic, and to feel that the financial bonus justified the risk.

Synthesis of Evidence to Support EMS Personnel's Mental Health During Disease Outbreaks: A Scoping Review

Emergency medical services (EMS) personnel are at high risk for adverse mental health outcomes during disease outbreaks. To support the development of evidence-informed mitigation strategies, we conducted a scoping review to identify the extent of research pertaining to EMS personnel's mental health during disease outbreaks and summarized key factors associated with mental health outcomes. We systematically searched three databases for articles containing keywords within three concepts: EMS personnel, disease outbreaks, and mental health. We screened and retained original peer-reviewed articles that discussed, in English, EMS personnel's mental health during disease outbreaks. Where inferential statistics were reported, the associations between individual and work-related factors and mental health outcomes were synthesized. Twenty-five articles were eligible for data extraction. Our findings suggest that many of the contributing factors for adverse mental health outcomes are related to inadequacies in fulfilling EMS personnel's basic safety and informational needs. In preparation for future disease outbreaks, resources should be prioritized toward ensuring adequate provisions of personal protective equipment and infection prevention and control training. This scoping review serves as a launching pad for further research and intervention development.

Duty to Work During the COVID-19 Pandemic: A Cross-Sectional Study of Perceptions of Health Care Providers in Jordan

Introduction

This study aimed to assess perceptions of duty to work among health care providers during the coronavirus disease 2019 response and to identify factors that may influence their perceptions.

Methods

This was a cross-sectional study conducted from April 1, 2020, to April 20, 2020, using an online survey distributed to health care providers in Jordan. Descriptive statistics were used, as well as chi-square test for independence to assess relationships between variables.

Results

A total of 302 questionnaires were included. Commitment to serve the community was the primary reason for coming to work (36%), followed by commitment to faith (29.6%). The major perceived barriers for coming to work were lack of appropriate personal protective equipment and appropriate training (62.6% and 53.5%, respectively). Males perceived higher work obligations than females in all potential barriers (P < .05), except for the lack of appropriate training. Nurses perceived higher work obligations than other health care providers despite the lack of appropriate training (χ² = 11.83, P = .005), lack of effective vaccine or treatment (χ² = 21.76, P < .001), or reported infection among coworkers (χ² = 10.18, P = .03).

Discussion

While the majority of health care providers perceive an obligation to work during the coronavirus disease 2019 pandemic, specific conditions, mainly lack of protective gear and training, may significantly alter their perception of work obligation. Providing training and proper personal protective equipment are among the vital measures that could improve the work environment and work obligation during pandemic conditions.

State emergency medical services guidance and protocol changes in response to the COVID-19 pandemic: A national investigation

OBJECTIVES

The COVID-19 pandemic has had an impact on emergency medical services (EMS) and its guidelines, which aid in patient care. This study characterizes state and territory EMS office recommendations to EMS statewide operational and clinical guidelines and describes the mechanisms of distribution and implementation during the COVID-19 pandemic.

METHODS

A mixed-methods study was conducted in 2 phases. In phase 1, changes and development of COVID-19 guidance and protocols for EMS clinical management and operations were identified among 50 states, the District of Columbia, and 5 territories in publicly available online documents and information. In phase 2, structured interviews were conducted with state/territory EMS officials to confirm the protocol changes or guidance and assess dissemination and implementation strategies for COVID-19.

RESULTS

In phase 1, publicly available online documents for 52 states/territories regarding EMS protocols and COVID-19 guidance were identified and reviewed. Of 52 (33/52) states/territories, 33 had either formal protocol changes or specific guidance for the pandemic. In phase 2, 2 state and territory EMS officials were interviewed regarding their protocols or guidance for COVID-19 and the dissemination and implementation practices they used to reach EMS agencies (response rate = 65%). Of the 34 state/territory officials interviewed, 22 had publicly available online COVID-19 protocols or guidance. Of the 22 officials with online COVID-19 protocols, all reported providing operational direction, and 19 of 22 officials reported providing clinical direction.

CONCLUSIONS

Most states provided guidance to EMS agencies and/or updated protocols in response to the COVID-19 pandemic.

[First wave of COVID-19 in Quebec: Healthcare workers' motivation to treat infected patients]

INTRODUCTION

Retention of healthcare workers (HCWs) in the healthcare system during the COVID-19 pandemic could become a challenge. It is therefore important to better understand what are the motivational elements that could explain a greater or lesser motivation to care for infected patients.

OBJECTIVES

To evaluate factors modulating HCWs' willingness to treat COVID-19 infected patients.

METHODS

HCWs from Québec, Canada, were invited to complete an online survey during the first wave of the COVID-19 pandemic between the months of April and July 2020. The survey focused on the intention to avoid treating infected patients, prior experiences in treating COVID-19 patients and anxiety levels. Descriptive statistics and multiple regression analysis were used to assess which factors explained differences in HCWs intention to avoid treating patients.

RESULTS

A total of 430 HCW completed the survey. A majority were women (87%) and nurses (50%). Of those, 12% indicated having considered measures to avoid working with COVID-19 infected patients and 5% indicated having taken actions to avoid working with infected patients. A further 18% indicated that they would use a hypothetical opportunity to avoid working with infected patients. Having previously treated infected patients was associated with a significant reduction in the intention to avoid work (OR: 0.56 CI 0.36-0.86). Amongst HCWs, physicians had a significantly reduced intention to avoid treating infected patients (OR: 0.47 CI 0.23-0.94). We also found that an increase in anxiety score was associated with a greater intention to avoid treating COVID-19 infected patients (OR: 1.06 CI 1.04-1.08).

CONCLUSION

Study results suggest that previous experience in treating COVID-19 infected patients is protective in terms of work-avoidance intentions. We also found that amongst HCWs, physicians had a significantly lower intention to avoid working with COVID-19 infected patients. Finally, our results show that increase in anxiety is associated with a higher intention to avoid treating infected patients. Characterization of factors associated with low anxiety levels and low reluctance to work during the COVID-19 pandemic could be useful in staffing facilities during the present and future healthcare crisis.

Factors Associated with Turnover Intention Among Healthcare Workers During the Coronavirus Disease 2019 (COVID-19) Pandemic in China

PURPOSE

This study assessed the prevalence of turnover intention and explored associated factors on turnover intention among healthcare workers during the COVID-19 pandemic in China.

METHODS

An institutional-based cross-sectional study was conducted from July to February 13th to 20th, 2020, in 31 provinces of mainland China. A total of 1403 healthcare workers were recruited. Hierarchical logistic regressions were used to identify potential factors associated with turnover intention among Chinese health care workers.

RESULTS

The prevalence of turnover intention among healthcare workers was 10.1% during the COVID-19 pandemic in China. Results of hierarchical regression revealed that working in Grade II hospital (OR = 1.78), technician (OR = 0.30), daily working hours over 12 h (OR = 2.92), frequency of mask replacement between 4 and 8 h (OR = 3.51), refuse volunteer to frontline (OR = 1.68), patient-physician relation unchanged (OR = 1.73), depression (OR = 2.21) and lower social support (OR = 1.75) were significantly associated with the risk of turnover intention. Additionally, healthcare worker's psychosocial syndemic (OR = 6.13) was positively associated with turnover intention.

CONCLUSION

Turnover intention is relatively prevalent among healthcare workers during the COVID-19 pandemic in China, and the factors contributing to turnover intention were complex and varied. Early screening of high-risk groups for turnover intention among healthcare workers and more psychosocial health care and physical protection are needed during the COVID-19 pandemic in China.

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.

Attitudes and stressors related to the SARS-CoV-2 pandemic among emergency medical services workers in Germany: a cross-sectional study

BACKGROUND

The aim was to investigate attitudes and stressors related to the SARS-CoV-2 outbreak among emergency medical services (EMS) workers in Germany. We further aimed to detect possible changes within a 5-week period and potential determinants of attitudes and stressors.

METHODS

We conducted two cross-sectional studies using an online questionnaire in early April 2020 (i.e., the first peak of the SARS-CoV-2 outbreak in Germany) and five weeks later. The study instrument comprised sociodemographic items, self-devised items on pandemic-related attitudes, stressors and work outcomes, and established instruments assessing depressive symptoms and symptoms of anxiety. Logistic regression was performed to identify possible determinants.

RESULTS

Data of 1537 participants was included in the analysis (April: n = 1124, May: n = 413, 83.1% male, median age 32). Most participants agreed that their personal risk of infection was higher compared to the general population (April: 87.0% agreement, May: 78.9%). The greatest stressor was uncertainty about the pandemic's temporal scope (82.0 and 80.9%, respectively). Most participants (69.9, 79.7%) felt sufficiently prepared for the pandemic and only few felt burdened by their financial situation (18.8, 13.3%). Agreement to all stressors decreased from April to May except related to the childcare situation. Regression analysis identified subgroups to be burdened more frequently such as older employees, those with SARS-CoV-2 cases among their colleagues, and those with lower paramedic training levels.

CONCLUSIONS

We identified key SARS-CoV-2-related stressors whose levels generally decreased within a 5-week period. Our results indicate that EMS workers are less affected by existential fears and rather worry about their personal infection risk.

Management of COVID-19-related challenges faced by EMS personnel: a qualitative study

BACKGROUND

As the first link in the chain of providing healthcare services in the frontline of the battle against COVID-19, emergency medical services (EMS) personnel are faced with various challenges, which affect their professional performance. The present study aimed to identify some strategies to manage the COVID-19-related challenges faced by the pre-hospital emergency care personnel in the south of Iran.

METHODS

In this qualitative descriptive study, 27 pre-hospital emergency care personnel who were selected through the purposeful sampling method. Data were collected through 27 semi-structured, in-depth, individual interviews. The collected data were then analyzed based on the Granheim and Lundman's method.

RESULTS

Analysis of the data resulted in the identification of 3 main themes and eight sub-themes. These three main themes were as follows: comprehensive and systematic planning, provision of medical equipment, and reduction of professional challenges.

CONCLUSION

The findings of the present study showed that, during the COVID-19 crisis, emergency medical services personnel should be provided with a comprehensive and systematic protocol to provide pre-hospital care and their performance should be assessed in terms of a set of scientific standards. Due to lack of equipment and work overload in the current crisis, emergency medical services personnel are faced with many psychological challenges, which adversely affect their quality of pre-hospital emergency care. Furthermore, emergency care senior managers should develop comprehensive protocols, provide more equipment, and eliminate professional challenges to pave the ground for improving the quality and safety of the healthcare services in pre-hospital emergency care during the current COVID-19 crisis.

Factors Influencing Health Care Workers' Willingness to Respond to Duty during Infectious Disease Outbreaks and Bioterrorist Events: An Integrative Review

BACKGROUND

Infectious disease emergencies are increasingly becoming part of the health care delivery landscape, having implications to not only individuals and the public, but also on those expected to respond to these emergencies. Health care workers (HCWs) are perhaps the most important asset in an infectious disease emergency, yet these individuals have their own barriers and facilitators to them being willing or able to respond.

AIM

The purpose of this review was to identify factors affecting HCW willingness to respond (WTR) to duty during infectious disease outbreaks and/or bioterrorist events.

METHODS

An integrative literature review methodology was utilized to conduct a structured search of the literature including CINAHL, Medline, Embase, and PubMed databases using key terms and phrases. PRISMA guidelines were used to report the search outcomes and all eligible literature was screened with those included in the final review collated and appraised using a quality assessment tool.

RESULTS

A total of 149 papers were identified from the database search. Forty papers were relevant following screening, which highlighted facilitators of WTR to include: availability of personal protective equipment (PPE)/vaccine, level of training, professional ethics, family and personal safety, and worker support systems. A number of barriers were reported to prevent WTR for HCWs, such as: concern and perceived risk, interpersonal factors, job-level factors, and outbreak characteristics.

CONCLUSIONS

By comprehensively identifying the facilitators and barriers to HCWs' WTR during infectious disease outbreaks and/or bioterrorist events, strategies can be identified and implemented to improve WTR and thus improve HCW and public safety.

SARS-CoV-2 IgG Seropositivity and Acute Asymptomatic Infection Rate among Firefighter First Responders in an Early Outbreak County in California

Objective: Firefighter first responders and other emergency medical services (EMS) personnel have been among the highest risk healthcare workers for illness during the SARS-CoV-2 pandemic. We sought to determine the rate of seropositivity for SARS-CoV-2 IgG antibodies and of acute asymptomatic infection among firefighter first responders in a single county with early exposure in the pandemic. Methods: We conducted a cross-sectional study of clinically active firefighters cross-trained as paramedics or EMTs in the fire departments of Santa Clara County, California. Firefighters without current symptoms were tested between June and August 2020. Our primary outcomes were rates of SARS-CoV-2 IgG antibody seropositivity and SARS-CoV-2 RT-PCR swab positivity for acute infection. We report cumulative incidence, participant characteristics with frequencies and proportions, and proportion positive and associated relative risk (with 95% confidence intervals). Results: We enrolled 983 out of 1339 eligible participants (response rate: 73.4%). Twenty-five participants (2.54%, 95% CI 1.65-3.73) tested positive for IgG antibodies and 9 (0.92%, 95% CI 0.42-1.73) tested positive for SARS-CoV-2 by RT-PCR. Our cumulative incidence, inclusive of self-reported prior positive PCR tests, was 34 (3.46%, 95% CI 2.41-4.80). Conclusion: In a county with one of the earliest outbreaks in the United States, the seroprevalence among firefighter first responders was lower than that reported by other studies of frontline health care workers, while the cumulative incidence remained higher than that seen in the surrounding community.

Factors Associated With Emergency Medical Services Providers' Acceptance of the Seasonal Influenza Vaccine

OBJECTIVE

Influenza vaccination remains the most effective primary prevention strategy for seasonal influenza. This research explores the percentage of emergency medical services (EMS) clinicians who received the seasonal flu vaccine in a given year, along with their reasons for vaccine acceptance and potential barriers.

METHODS

A survey was distributed to all EMS clinicians in Virginia during the 2018-2019 influenza season. The primary outcome was vaccination status. Secondary outcomes were attitudes and perceptions toward influenza vaccination, along with patient care behaviors when treating an influenza patient.

RESULTS

Ultimately, 2796 EMS clinicians throughout Virginia completed the survey sufficiently for analysis. Participants were mean 43.5 y old, 60.7% male, and included the full range of certifications. Overall, 79.4% of surveyed EMS clinicians received a seasonal flu vaccine, 74% had previously had the flu, and 18% subjectively reported previous side effects from the flu vaccine. Overall, 54% of respondents believed their agency has influenza or respiratory specific plans or procedures.

CONCLUSIONS

In a large, state-wide survey of EMS clinicians, overall influenza vaccination coverage was 79.4%. Understanding the underlying beliefs of EMS clinicians remains a critical priority for protecting these frontline clinicians. Agencies should consider practical policies, such as on-duty vaccination, to increase uptake.

Understanding the Impact of COVID-19 on Physician Moms

Objective:

This study evaluates the personal and professional experiences of physician mothers during the coronavirus disease 2019 (COVID-19) pandemic and the impact of the pandemic on the lives of physician mothers.

Methods:

Using social media to reach a broad range of physicians, a convenience sample of physician mothers completed an on-line survey posted between April 27 and May 11. Members were encouraged to repost on social media and share with personal contacts resulting in a passive snowball sampling effect.

Results:

A total of 2709 physician mothers from 48 states, Puerto Rico, and 19 countries representing more than 25 medical specialties completed the survey. Most were between 30 and 39 y of age, 67% self-identified as white, 17% as Asian, 4% as African American. Most had been working for 11-16 y. A total of 91% had a spouse/partner of the opposite sex. Over half were practicing in an area they identified as high COVID-19 density, while 50% had personally cared for a person with COVID-19. Physician mothers were most concerned about exposing their children to COVID-19 and about the morale and safety of their staff.

Conclusions:

This is one of the first studies to explore the personal and professional challenges facing physician mothers during a pandemic. Physician mothers were most concerned about exposing their families to COVID-19. Mothers continued to work and at times increased their work, despite having domestic, childcare, and schooling responsibilities.

Emergency Medical Services Personnel Awareness and Training about Personal Protective Equipment during the COVID-19 Pandemic

Background: With the emergence of the 2019 novel coronavirus disease (COVID-19), appropriate training for emergency medical services (EMS) personnel on personal protective equipment (PPE) is essential. We aimed: 1) to examine the change in proportions of EMS personnel reporting awareness of and training in PPE during the COVID-19 pandemic; and 2) to determine factors associated with reporting these outcomes.We conducted a cross-sectional analysis of data collected from October 1, 2019 to June 30, 2020 from currently working, nationally certified EMS personnel (n = 15,339), assessing N95 respirator fit testing; training in air purified respirators (APR) or powered APR (PAPR) use; and training on PPE use for chemical, biological, and nuclear (CBN) threats. We used an interrupted time series analysis to determine changes in proportions of EMS personnel reporting training per week, using the date of Centers for Disease Control and Prevention's (CDC) initial EMS guidance (February 6, 2020) as the interruption. We fit multivariable logistic regression models to understand factors associated with each outcome.Results: We found high awareness of N95 respirators (99%) and APR/PAPR (91%), but only 61% reported N95 fit testing and 64% reported training on PPE for CBN threats in the prior 12 months. There was a significant, positive slope change after CDC guidance for N95 respirator fit testing, and significant post-interruption mean increases for fit testing (0.9%, 95% CI 0.6-1.1%), APR/PAPR training (0.3%, 95% CI 0.2-0.5%), and PPE for CBN threats training (0.6%, 95% CI 0.3-0.9%). Factors consistently associated with lower odds of awareness/training included part-time employment, providing 9-1-1 response service, working at a non-fire-based EMS agency, and working in a rural setting.Conclusions: CDC guidance on COVID-19 for EMS may have increased N95 fit testing and training, but there remain substantial gaps in training on PPE use among EMS personnel. As the pandemic continues in our communities, EMS agencies should be supported in efforts to adequately prepare their staff.

The Current State of Infectious Disasters Preparedness Around the World: A Qualitative Systematic Review (2007-2019)

Infectious disasters have specific features which require special approaches and facilities. The main challenge is the rate of spread, and their ability to traverse the Earth in a short time. The preparedness of hospitals to face these events is therefore of the utmost importance. This study was designed to assess the preparedness of countries facing biological events worldwide. A qualitative systematic review was done from PubMed (National Library of Medicine, Bethesda, MD), Scopus (Elsevier, Amsterdam, Netherlands), Web of Science (Thomson Reuters, New York, NY), ProQuest (Ann Arbor, MI), and Google Scholar (Google Inc, Mountain View, CA). Two journals were searched as key journals. The search period was from January 1, 2007 to December 30, 2018. Twenty-one (21) documents were selected including 7 (33%) from Asia, 7 (33%) from Europe, 4 (19%) from USA, 2 (10%) from Africa, and 1 (5%) multi-continental. Forty-six (46) common sub-themes were obtained and categorized into 13 themes (infection prevention control, risk perception, planning, essential support services, surveillance, laboratory, vulnerable groups, education and exercise and evaluation, human resource, clinical management of patients, risk communication, budget, and coordination). Not all articles discussed all the identified categories. There is an extended process required to reach complete preparedness for confronting biological events, including adequate and well-managed budget. Medical centers may have trouble dealing with such events, at least in some respects, but most developed countries seem to be more prepared in this regard.

Applying the Ready, Willing, and Able Framework to Assess Agency Public Health Emergency Preparedness: The CDC Perspective

Public health emergencies in the United States have been complex, frequent, and increasingly costly in the past decade, at times overwhelming government agencies that are primarily resourced for routine, nonemergency health functions. Emergencies are not always predictable, and adequate resources are not always available to prepare staff in advance for emergency response roles and to mobilize them quickly when a new threat emerges. Additionally, real-world data that connect preparedness levels to response outcomes may be difficult to obtain, further limiting continuous quality improvement efforts by public health officials. In this article, we apply the Ready, Willing, and Able (RWA) framework to identify areas for improvement related to organizational and staff readiness, willingness, and ability to respond during a public health emergency. We share emergency response deployment, training, and personnel data collected as part of emergency response activations (2008 to 2018) at the Centers for Disease Control and Prevention to illustrate how the framework may be applied at government agencies to improve response processes and effectiveness. Additionally, we propose potential metrics aligned with the framework constructs that may help emergency managers consistently assess agency preparedness and, over time, be incorporated into broader standardized measurement methods. We conclude that the RWA framework is a practical tool that can complement other preparedness approaches currently in use at government public health agencies.

Emergency Medical Services Personnel's Pandemic Influenza Training Received and Willingness to Work during a Future Pandemic

Objective: Identify determinants of emergency medical service (EMS) personnel's willingness to work during an influenza pandemic. Background: Little is known about the willingness of EMS personnel to work during a future influenza pandemic or the extent to which they are receiving pandemic training. Methods: EMS personnel were surveyed in July 2018 - Feb 2019 using a cross-sectional approach; the survey was available both electronically and on paper. Participants were provided a pandemic scenario and asked about their willingness to respond if requested or required; additional questions assessed their attitudes and beliefs and training received. Chi-square tests assessed differences in attitude/belief questions by willingness to work. Logistic regressions were used to identify significant predictors of response willingness when requested or required, controlling for gender and race. Results: 433 individuals completed the survey (response rate = 82.9%). A quarter (26.8%, n = 116) received no pandemic training; 14.3% (n = 62) participated in a pandemic exercise. Significantly more EMS personnel were willing to work when required versus when only requested (88.2% vs 76.9%, X2 = 164.1, p < .001). Predictors of willingness to work when requested included believing it is their responsibility to work, believing their coworkers were likely to work, receiving prophylaxis for themselves and their family members, and feeling safe working during a pandemic. Discussion: Many emergency medical services personnel report lacking training or disaster exercises related to influenza pandemics, and a fair percentage are unwilling to work during a future event. This may limit healthcare surge capacity and could contribute to increased morbidity and mortality. Findings from this study indicate that prehospital staff's attitudes and beliefs about pandemics influence their willingness to work. Pre-event training and planning should address these concerns.

Working During Pandemic Disasters: Views and Predictors of EMS Providers

OBJECTIVES

This study aims to assess the perception and attitude of emergency medical services (EMS) providers toward working during disease outbreaks, and the factors that may influence their decisions to ultimately work or not.

METHODS

This is a cross-sectional study assessing the attitude of EMS providers to work during disease outbreaks. Descriptive statistics and regression analyses were performed to assess attitudes toward reporting for duty and factors that influence providers' decisions.

RESULTS

Of the 500 surveys distributed, 466 (93.2%) were complete and included for analysis. The majority of participants (70.2%) are male with a mean age of 27 (SD 4.3) years. The study found that the majority (71.1%) of participants are willing to come to work during disease outbreaks. The study found 7 predictors of reporting for duty. Confidence that employer will provide adequate protective gear was the most significant predictor (odds ratio [OR], 3.95; 95% confidence interval [CI] = 2.31-5.42). Concern for family safety was the most important barrier against coming to work (OR, 0.40; 95% CI = 0.21-0.73).

CONCLUSIONS

Providing adequate supplies of protective gear along with knowledge and training for disease outbreak are the main factors that enhance providers to fulfill their work expectations.

Responding to natural disasters vs. disease outbreaks: Do emergency medical service providers have different views?

INTRODUCTION

Our planet has been experiencing a huge burden of natural disasters and public health emergencies in the last three decades. Emergency medical service providers are expected to be in the frontlines during such emergencies. Yet, this system is badly understudied when it comes to its roles and performance during disasters and public health emergencies. This study is designed to enhance understanding by assessing a sample U.S EMS providers' views about working during natural disasters and disease outbreaks and explores whether they are coming to work during such conditions.

METHODS

This study utilized a qualitative approach using face-to-face interviews with EMS workers from the State of Delaware, USA. Participants were asked about their views, insights, and potential behavior of working during natural disasters and disease outbreaks. Data collected were transcribed and coded using ATLAS.ti software to develop themes of the study using an inductive approach.

RESULTS

Three themes were emerged from interviews regarding working during natural disasters; respondents expressed excitement, concern, or no real differences. For disease outbreaks, however, the two themes were concerned and no additional risk. While participants expressed varying concerns about working during disasters and pandemic conditions, everyone felt willing and obligated to come to work despite the perceived high risk for some of them to work in some conditions.

CONCLUSION

This study helps to provide the base upon which EMS, public health, and emergency management agencies can formulate actions that emerged from the views of EMS providers concerning work during disasters and public health emergencies.

Characterization of nurses’ duty to care and willingness to report

Background:

Nurses must balance their perceived duty to care against their perceived risk of harm to determine their willingness to report during disaster events, potentially creating an ethical dilemma and impacting patient care.

Research aim:

The purpose of this study was to investigate nurses’ perceived duty to care and whether there were differences in willingness to respond during disaster events based on perceived levels of duty to care.

Research design:

A cross-sectional survey research design was used in this study.

Participants and research context:

Using a convenience sample with a snowball technique, data were collected from 289 nurses throughout the United States in 2017. Participants were recruited through host university websites, Facebook, and an American Nurses Association discussion board.

Ethical considerations:

Institutional review board approval was obtained from the University of Texas at Tyler and the University of Arkansas.

Findings:

Analysis of willingness to report to work based on levels of perceived duty to care resulted in the emergence of two groups: “lower level of perceived duty to care group” and “higher level of perceived duty to care group.” The most discriminating characteristics differentiating the groups included fear of abandonment by co-workers, reporting because it is morally the right thing to, and because of imperatives within the Nursing Code of Ethics.

Discussion:

The number of nurses in the lower level of perceived duty to care group causes concern. It is important for nursing management to develop strategies to advance nurses’ safety, minimize nurses’ risk, and promote nurses’ knowledge to confidently work during disaster situations.

Conclusion:

Level of perceived duty to care affects nurses’ willingness to report to work during disasters. Primary indicators of low perceived duty to care are amenable to actionable strategies, potentially increasing nurses’ perceived duty to provide care and willingness to report to work during disasters.

Anesthesiologists and Disaster Medicine: A Needs Assessment for Education and Training and Reported Willingness to Respond

BACKGROUND

Anesthesiologists provide comprehensive health care across the emergency department, operating room, and intensive care unit. To date, anesthesiologists' perspectives regarding disaster medicine and public health preparedness have not been described.

METHODS

Anesthesiologists' thoughts and attitudes were assessed via a Web-based survey at 3 major academic institutions. Frequencies, percentages, and odds ratios (ORs) were used to assess self-reported perceptions of knowledge and skills, as well as attitudes and beliefs regarding education and training, employee development, professional obligation, safety, psychological readiness, efficacy, personal preparedness, and willingness to respond (WTR). Three representative disaster scenarios (natural disaster [ND], radiological event [RE], and pandemic influenza [PI]) were investigated. Results are reported as percent or OR (95% confidence interval).

RESULTS

Participants included 175 anesthesiology attendings (attendings) and 95 anesthesiology residents (residents) representing a 47% and 51% response rate, respectively. A minority of attendings indicated that their hospital provides adequate pre-event preparation and training (31% [23-38] ND, 14% [9-21] RE, and 40% [31-49] PI). Few residents felt that their residency program provided them with adequate preparation and training (22% [14-33] ND, 16% [8-27] RE, and 17% [9-29] PI). Greater than 85% of attendings (89% [84-94] ND, 88% [81-92] RE, and 87% [80-92] PI) and 70% of residents (81% [71-89] ND, 71% [58-81] RE, and 82% [70-90] PI) believe that their hospital or residency program, respectively, should provide them with preparation and training. Approximately one-half of attendings and residents are confident that they would be safe at work during response to a ND or PI (55% [47-64] and 58% [49-67] of attendings; 59% [48-70] and 48% [35-61] of residents, respectively), whereas approximately one-third responded the same regarding a RE (31% [24-40] of attendings and 28% [18-41] of residents). Fewer than 40% of attendings (34% [26-43]) and residents (38% [27-51]) designated who would take care of their family obligations in the event they were called into work during a disaster. Regardless of severity, 79% (71-85) of attendings and 73% (62-82) of residents indicated WTR to a ND, whereas 81% (73-87) of attendings and 70% (58-81) of residents indicated WTR to PI. Fewer were willing to respond to a RE (63% [55-71] of attendings and 52% [39-64] of residents). In adjusted logistic regression analyses, those anesthesiologists who reported knowing one's role in response to a ND (OR, 15.8 [4.5-55.3]) or feeling psychologically prepared to respond to a ND (OR, 6.9 [2.5-19.0]) were found to be more willing to respond. Similar results were found for RE and PI constructs. Both attendings and residents were willing to respond in whatever capacity needed, not specifically to provide anesthesia.

CONCLUSIONS

Few anesthesiologists reported receiving sufficient education and training in disaster medicine and public health preparedness. Providing education and training and enhancing related employee services may further bolster WTR and help to build a more capable and effective medical workforce for disaster response.

The Role of Fear-Related Behaviors in the 2013-2016 West Africa Ebola Virus Disease Outbreak

The 2013-2016 West Africa Ebola virus disease pandemic was the largest, longest, deadliest, and most geographically expansive outbreak in the 40-year interval since Ebola was first identified. Fear-related behaviors played an important role in shaping the outbreak. Fear-related behaviors are defined as "individual or collective behaviors and actions initiated in response to fear reactions that are triggered by a perceived threat or actual exposure to a potentially traumatizing event. FRBs modify the future risk of harm." This review examines how fear-related behaviors were implicated in (1) accelerating the spread of Ebola, (2) impeding the utilization of life-saving Ebola treatment, (3) curtailing the availability of medical services for treatable conditions, (4) increasing the risks for new-onset psychological distress and psychiatric disorders, and (5) amplifying the downstream cascades of social problems. Fear-related behaviors are identified for each of these outcomes. Particularly notable are behaviors such as treating Ebola patients in home or private clinic settings, the "laying of hands" on Ebola-infected individuals to perform faith-based healing, observing hands-on funeral and burial customs, foregoing available life-saving treatment, and stigmatizing Ebola survivors and health professionals. Future directions include modeling the onset, operation, and perpetuation of fear-related behaviors and devising strategies to redirect behavioral responses to mass threats in a manner that reduces risks and promotes resilience.

Impact of an Education Intervention on Missouri K-12 School Disaster and Biological Event Preparedness

BACKGROUND

A 2011 nationwide school pandemic preparedness study found schools to be deficient. We examined the impact of a school nurse educational intervention aimed at improving K-12 school biological event preparedness.

METHODS

Missouri Association of School Nurses (MASN) members were e-mailed a survey link in fall 2013 (ie, preintervention), links to online education modules (ie, intervention) in late fall, and a postintervention survey link in spring, 2014. School biological event readiness was measured using 35 indicators, for a possible score range of 0-35. A paired t-test compared pre- to postintervention preparedness scores.

RESULTS

A total of 133 school nurses (33.6% response rate) completed a survey; 35.3% of those (N = 47) completed both pre- and postintervention survey that could be matched. Pre- and postintervention preparedness scores ranged from 5 to 28.5 (x‾ = 13.3) and 6.5 to 25 (x‾ = 14.8), respectively. Postintervention scores were significantly higher than preintervention scores for those who watched at least 1 module (t = -2.3, p < .05).

CONCLUSION

The education intervention was effective at improving school preparedness, though the impact was small. The education intervention needs to be reassessed, especially in regard to providing a longer intervention period.

Vaccination Against Seasonal or Pandemic Influenza in Emergency Medical Services

INTRODUCTION

Influenza is a major concern for Emergency Medical Services (EMS); EMS workers' (EMS-Ws) vaccination rates remain low despite promotion. Determinants of vaccination for seasonal influenza (SI) or pandemic influenza (PI) are unknown in this setting.

HYPOTHESIS

The influence of the H1N1 pandemic on EMS-W vaccination rates, differences between SI and PI vaccination rates, and the vaccination determinants were investigated.

METHODS

A survey was conducted in 2011 involving 65 Swiss EMS-Ws. Socio-professional data, self-declared SI/PI vaccination status, and motives for vaccine refusal or acceptation were collected.

RESULTS

Response rate was 95%. The EMS-Ws were predominantly male (n=45; 73%), in good health (87%), with a mean age of 36 (SD=7.7) years. Seventy-four percent had more than six years of work experience. Self-declared vaccination rates were 40% for both SI and PI (PI+/SI+), 19% for PI only (PI+/SI-), 1.6% for SI only (PI-/SI+), and 39% were not vaccinated against either (PI-/SI-). Women's vaccination rates specifically were lower in all categories but the difference was not statistically significant. During the previous three years, 92% of PI+/SI+ EMS-Ws received at least one SI vaccination; it was 8.3% in the case of PI-/SI- (P=.001) and 25% for PI+/SI- (P=.001). During the pandemic, SI vaccination rate increased from 26% during the preceding year to 42% (P=.001). Thirty percent of the PI+/SI+ EMS-Ws declared that they would not get vaccination next year, while this proportion was null for the PI-/SI- and PI+/SI- groups. Altruism and discomfort induced by the surgical mask required were the main motivations to get vaccinated against PI. Factors limiting PI or SI vaccination included the option to wear a mask, avoidance of medication, fear of adverse effects, and concerns about safety and effectiveness.

CONCLUSION

Average vaccination rate in this study's EMS-Ws was below recommended values, particularly for women. Previous vaccination status was a significant determinant of PI and future vaccinations. The new mask policy seemed to play a dual role, and its net impact is probably limited. This population could be divided in three groups: favorable to all vaccinations; against all, even in a pandemic context; and ambivalent with a "pandemic effect." These results suggest a consistent vaccination pattern, only altered by exceptional circumstances.

The analysis of factors affecting municipal employees' willingness to report to work during an influenza pandemic by means of the extended parallel process model (EPPM)

Background

The management of pandemics with highly infectious diseases in modern urban habitats depends largely on the maintenance of public services. Understanding the factors that influence municipal employees’ willingness to come to work during a pandemic is therefore a basic requirement for adequate public health preparedness. In this study the extended parallel process model (EPPM) is applied to investigate how the readiness of municipal employees to report to work during an influenza pandemic (IP) is affected by individual attitudes and environmental conditions.

Methods

1.566 employees of a major German city participated in a cross-sectional online survey. The questions of the survey covered the dimensions of risk perception, role competence, self-efficacy, role importance, sense of duty, and willingness to report to work in the case of an IP. Data were analysed by means of path analyses.

Results

Data suggest that up to 20 % of the public service workers were not willing to come to work during an IP. Willingness to report to work was increased by the perception of a high working role competence, a high assessment of role importance, high self-efficacy expectations, and a high sense of duty. Negative effects on willingness to report to work were identified as the perception of a high risk to become infected at work and the perceived risk to infect family members. The decomposition of direct and indirect effects provided important insights into the interrelationships between model variables.

Conclusions

Measures to increase municipal workers’ willingness to report to work in case of an infectious pandemic should include communication strategies to inform employees clearly about their particular tasks during such critical events and training exercises to increase their confidence in their competences and skills to fulfil these tasks.

Healthcare workers' willingness to work during an influenza pandemic: a systematic review and meta-analysis

To estimate the proportion of healthcare workers (HCWs) willing to work during an influenza pandemic and identify associated risk factors, we undertook a systematic review and meta-analysis compliant with PRISMA guidance. Databases and grey literature were searched to April 2013, and records were screened against protocol eligibility criteria. Data extraction and risk of bias assessments were undertaken using a piloted form. Random-effects meta-analyses estimated (i) pooled proportion of HCWs willing to work and (ii) pooled odds ratios of risk factors associated with willingness to work. Heterogeneity was quantified using the I(2) statistic, and publication bias was assessed using funnel plots and Egger's test. Data were synthesized narratively where meta-analyses were not possible. Forty-three studies met our inclusion criteria. Meta-analysis of the proportion of HCWs willing to work was abandoned due to excessive heterogeneity (I(2) = 99.2%). Narrative synthesis showed study estimates ranged from 23.1% to 95.8% willingness to work, depending on context. Meta-analyses of specific factors showed that male HCWs, physicians and nurses, full-time employment, perceived personal safety, awareness of pandemic risk and clinical knowledge of influenza pandemics, role-specific knowledge, pandemic response training, and confidence in personal skills were statistically significantly associated with increased willingness. Childcare obligations were significantly associated with decreased willingness. HCWs' willingness to work during an influenza pandemic was moderately high, albeit highly variable. Numerous risk factors showed a statistically significant association with willingness to work despite significant heterogeneity between studies. None of the included studies were based on appropriate theoretical constructs of population behaviour.

Emergency preparedness law and willingness to respond in the EMS workforce

INTRODUCTION

For effective responses to emergencies, individuals must have the ability to respond and also be willing to participate in the response. A growing body of research points to gaps in response willingness among several occupational cohorts with response duties, including the Emergency Medical Services (EMS) workforce. Willingness to respond is particularly important during an influenza or other pandemic, due to increased demands on EMS workers and the potential for workforces to be depleted if responders contract influenza or stay home to care for sick dependents. State emergency preparedness laws are one possible avenue to improve willingness to respond. Hypothesis Presence of certain state-level emergency preparedness laws (ie, ability to declare a public health emergency; requirement to create a public health emergency plan; priority access to health resources for responders) is associated with willingness to respond among EMS workers.

METHODS

Four hundred twenty-one EMS workers from the National Registry of Emergency Medical Technicians' (NREMT's) mid-year Longitudinal EMT Attributes and Demographics Study (LEADS) were studied. The survey, which included questions about willingness to respond during an influenza pandemic, was fielded from May through June 2009. Survey data were merged with data about the presence or absence of the three emergency preparedness laws of interest in each of the 50 US states. Unadjusted logistic regression analyses were performed with the presence/absence of each law and were adjusted for respondents' demographic/locale characteristics.

RESULTS

Compared to EMS workers in states that did not allow the government to declare a public health emergency, those in states that permitted such declarations were more likely to report that they were willing to respond during an influenza pandemic. In adjusted and unadjusted analyses, this difference was not statistically significant. Similar results were found for the other state-level emergency preparedness laws of interest.

CONCLUSION

While state-level emergency preparedness laws are not associated with willingness to respond, recent research suggests that inconsistencies between the perceived and objective legal environments for EMS workers could be an alternative explanation for this study's findings. Educational efforts within the EMS workforce and more prominent state-level implementation of emergency preparedness laws should be considered as a means to raise awareness of these laws. These types of actions are important steps toward determining whether state-level emergency preparedness laws have the potential to promote response willingness among EMS workers.

Willingness of the local health department workforce to respond to infectious disease events: empirical, ethical, and legal considerations

According to the Institute of Medicine, the local health department workforce is at the hub of the public health emergency preparedness system. A growing body of research has pointed to troubling attitudinal gaps among local health department workers, a vital response cohort, regarding willingness to respond to emergent infectious disease threats, ranging from naturally occurring pandemics to bioterrorism events. A summary of relevant literature on the empirical evidence, ethical norms, and legal standards applicable to the willingness of public health professionals to respond to an infectious disease emergency is presented. Recommendations are proposed for future work to be done to bring the relevant empirical, ethical, and legal considerations together to develop practical guidance for the local response to infectious disease emergencies.

External cues to action and influenza vaccination among post-graduate trainee physicians in Toronto, Canada

BACKGROUND

Understanding factors affecting trainee physician choices about vaccination may permit the design of more effective vaccination programmes.

METHODS

To identify factors associated with seasonal and pandemic influenza vaccination, an online questionnaire based on the health belief model was sent to trainee physicians registered at the post-graduate medical education office at the University of Toronto in September 2011.

RESULTS

963 complete responses were received from 1884 trainee physicians (51%); 28 (2.9%) reported an allergy to vaccine components and were excluded from further analysis. Reported seasonal influenza vaccination rates in 2008, 2009 and 2010 were 69% (648/935), 75% (708/935) and 76% (703/935), respectively; 788 (84%) reported receiving the A(H1N1)pdm09 vaccine. In multivariable analysis, number of years of post-graduate training (OR for 4+ versus 1-3 post-graduate years 2.2 (95% CL 1.3, 3.8)) was associated with receipt of the 2009 pandemic vaccine, as were four components of the health belief model: odds ratios were 4.7 (95% CL 3.0, 7.5) for perceived severity, 1.9 (95% CL 1.2, 2.9) for perceived benefits, .35 (95% CL .21, .59) for perceived barriers, and 5.8 (95% CLI 3.6, 9.1) for external cues to action. Both vaccinated and unvaccinated respondents reported that their decisions were significantly influenced by encouragement from their colleagues, families and employers.

CONCLUSION

Self-reported vaccination coverage among trainee physicians was high. External cues to action appear to be particularly important in trainee physician vaccination decisions: active institutional promotion may increase influenza vaccination rates in trainees.

When and why health care personnel respond to a disaster: the state of the science

OBJECTIVE

Emergency response relies on the assumption that essential health care services will continue to operate and be available to provide quality patient care during and after a patient surge. The observed successes and failures of health care systems during recent mass-casualty events and the concern that these assumptions are not evidence based prompted this review.

METHOD

The aims of this systematic review were to explore the factors associated with the intention of health care personnel (HCP) to respond to uncommon events, such as a natural disaster or pandemic, determine the state of the science, and bolster evidence-based measures that have been shown to facilitate staff response.

RESULTS

Authors of the 70 studies (five mixed-methods, 49 quantitative, 16 qualitative) that met inclusion criteria reported a variety of variables that influenced the intent of HCP to respond. Current evidence suggests that four primary factors emerged as either facilitating or hindering the willingness of HCP to respond to an event: (1) the nature of the event; (2) competing obligations; (3) the work environment and climate; and (4) the relationship between knowledge and perceptions of efficacy.

CONCLUSIONS

Findings of this study could influence and strengthen policy making by emergency response planners, staffing coordinators, health educators, and health system administrators.

EPPM and willingness to respond: the role of risk and efficacy communication in strengthening public health emergency response systems

This study examines the attitudinal impact of an Extended Parallel Process Model (EPPM)-based training curriculum on local public health department (LHD) workers' willingness to respond to representative public health emergency scenarios. Data are from 71 U.S. LHDs in urban and rural settings across nine states. The study explores changes in response willingness and EPPM threat and efficacy appraisals between randomly assigned control versus intervention health departments, at baseline and 1 week post curriculum, through an EPPM-based survey/resurvey design. Levels of response willingness and emergency response-related attitudes/beliefs are measured. Analyses focus on two scenario categories that have appeared on a U.S. government list of scenarios of significant concern: a weather-related emergency and a radiological "dirty" bomb event (U.S. Department of Homeland Security, 2007). The greatest impact from the training intervention on response willingness was observed among LHD workers who had low levels of EPPM-related threat and efficacy perceptions at baseline. Self-efficacy and response efficacy and response willingness increased in intervention LHDs for both scenarios, with greater response willingness increases observed for the radiological "dirty" bomb terrorism scenario. Findings indicate the importance of building efficacy versus enhancing threat perceptions as a path toward greater response willingness, and suggest the potential applicability of such curricular interventions for boosting emergency response willingness among other cadres of health providers.

A Threat- and Efficacy-Based Framework to Understand Confidence in Vaccines among the Public Health Workforce

The Extended Parallel Process Model (EPPM) is an established threat- and efficacy-based behavioral framework for understanding health behaviors in the face of uncertain risk. A growing body of research has applied this model to understand these behaviors among the public health workforce. In this manuscript, we aim to explore the application of this framework to the public health workforce, with a novel focus on their confidence in vaccines and perceptions of vaccine injury compensation mechanisms. We characterize specific connections between EPPM’s threat and efficacy dimensions and relevant vaccine policy frameworks and highlight how these connections can usefully inform training interventions for public health workers to enhance their confidence in these vaccine policy measures.

Assessment of medical reserve corps volunteers' emergency response willingness using a threat- and efficacy-based model

The goal of this study was to investigate the willingness of Medical Reserve Corps (MRC) volunteers to participate in public health emergency-related activities by assessing their attitudes and beliefs. MRC volunteers responded to an online survey organized around the Extended Parallel Process Model (EPPM). Respondents reported agreement with attitude/belief statements representing perceived threat, perceived efficacy, and personal/organizational preparedness in 4 scenarios: a weather-related disaster, a pandemic influenza emergency, a radiological ("dirty bomb") emergency, and an inhalational anthrax bioterrorism emergency. Logistic regression analyses were used to evaluate predictors of volunteer response willingness. In 2 response contexts (if asked and regardless of severity), self-reported willingness to respond was higher among those with a high perceived self-efficacy than among those with low perceived self-efficacy. Analyses of the association between attitude/belief statements and the EPPM profiles indicated that, under all 4 scenarios and with few exceptions, those with a perceived high threat/high efficacy EPPM profile had statistically higher odds of agreement with the attitude/belief statements than those with a perceived low threat/low efficacy EPPM profile. The radiological emergency consistently received the lowest agreement rates for the attitude/belief statements and response willingness across scenarios. The findings suggest that enrollment with an MRC unit is not automatically predictive of willingness to respond in these types of scenarios. While MRC volunteers' self-reported willingness to respond was found to differ across scenarios and among different attitude and belief statements, the identification of self-efficacy as the primary predictor of willingness to respond regardless of severity and if asked highlights the critical role of efficacy in an organized volunteer response context.

Applying the Extended Parallel Process Model to workplace safety messages

The extended parallel process model (EPPM) proposes fear appeals are most effective when they combine threat and efficacy. Three studies conducted in the workplace safety context examine the use of various EPPM factors and their effects, especially multiplicative effects. Study 1 was a content analysis examining the use of EPPM factors in actual workplace safety messages. Study 2 experimentally tested these messages with 212 construction trainees. Study 3 replicated this experiment with 1,802 men across four English-speaking countries-Australia, Canada, the United Kingdom, and the United States. The results of these three studies (1) demonstrate the inconsistent use of EPPM components in real-world work safety communications, (2) support the necessity of self-efficacy for the effective use of threat, (3) show a multiplicative effect where communication effectiveness is maximized when all model components are present (severity, susceptibility, and efficacy), and (4) validate these findings with gory appeals across four English-speaking countries.

Factors associated with the willingness of health care personnel to work during an influenza public health emergency: an integrative review

INTRODUCTION

The first decade of the 21st century has witnessed three major influenza public health emergencies: (1) the severe acute respiratory syndrome of 2002-2003; (2) the avian flu of 2006; and (3) the 2009 H1N1 pandemic influenza. An effective public health response to an influenza public health emergency depends on the majority of uninfected health care personnel (HCP) continuing to report to work. The purposes of this study were to determine the state of the evidence concerning the willingness of HCP to work during an influenza public health emergency, to identify the gaps for future investigation, and to facilitate evidence-based influenza public health emergency planning.

METHODS

A systemic literature review of relevant, peer-reviewed, quantitative, English language studies published from January 1, 2001 through June 30, 2010 was conducted. Search strategies included the Cochrane Library, PubMed, PubMed Central, EBSCO Psychological and Behavioral Sciences Collection, Google Scholar, ancestry searching of citations in relevant publications, and information from individuals with a known interest in the topic.

RESULTS

Thirty-two studies met the inclusion criteria. Factors associated with a willingness to work during an influenza public health emergency include: being male, being a doctor or nurse, working in a clinical or emergency department, working full-time, prior influenza education and training, prior experience working during an influenza emergency, the perception of value in response, the belief in duty, the availability of personal protective equipment (PPE), and confidence in one's employer. Factors found to be associated with less willingness were: being female, being in a supportive staff position, working part-time, the peak phase of the influenza emergency, concern for family and loved ones, and personal obligations. Interventions that resulted in the greatest increase in the HCP's willingness to work were preferential access to Tamiflu for the HCP and his/her family, and the provision of a vaccine for the individual and his/her family.

CONCLUSIONS

Understanding the factors that contribute to the willingness of HCP to report to work during an influenza public health emergency is critical to emergency planning and preparedness. Information from this review can guide emergency policy makers, planners, and implementers in both understanding and influencing the willingness of HCP to work during an influenza public health emergency.

Determinants of emergency response willingness in the local public health workforce by jurisdictional and scenario patterns: a cross-sectional survey

Background

The all-hazards willingness to respond (WTR) of local public health personnel is critical to emergency preparedness. This study applied a threat-and efficacy-centered framework to characterize these workers' scenario and jurisdictional response willingness patterns toward a range of naturally-occurring and terrorism-related emergency scenarios.

Methods

Eight geographically diverse local health department (LHD) clusters (four urban and four rural) across the U.S. were recruited and administered an online survey about response willingness and related attitudes/beliefs toward four different public health emergency scenarios between April 2009 and June 2010 (66% response rate). Responses were dichotomized and analyzed using generalized linear multilevel mixed model analyses that also account for within-cluster and within-LHD correlations.

Results

Comparisons of rural to urban LHD workers showed statistically significant odds ratios (ORs) for WTR context across scenarios ranging from 1.5 to 2.4. When employees over 40 years old were compared to their younger counterparts, the ORs of WTR ranged from 1.27 to 1.58, and when females were compared to males, the ORs of WTR ranged from 0.57 to 0.61. Across the eight clusters, the percentage of workers indicating they would be unwilling to respond regardless of severity ranged from 14-28% for a weather event; 9-27% for pandemic influenza; 30-56% for a radiological 'dirty' bomb event; and 22-48% for an inhalational anthrax bioterrorism event. Efficacy was consistently identified as an important independent predictor of WTR.

Conclusions

Response willingness deficits in the local public health workforce pose a threat to all-hazards response capacity and health security. Local public health agencies and their stakeholders may incorporate key findings, including identified scenario-based willingness gaps and the importance of efficacy, as targets of preparedness curriculum development efforts and policies for enhancing response willingness. Reasons for an increased willingness in rural cohorts compared to urban cohorts should be further investigated in order to understand and develop methods for improving their overall response.

Characterizing hospital workers' willingness to respond to a radiological event

Introduction

Terrorist use of a radiological dispersal device (RDD, or “dirty bomb”), which combines a conventional explosive device with radiological materials, is among the National Planning Scenarios of the United States government. Understanding employee willingness to respond is critical for planning experts. Previous research has demonstrated that perception of threat and efficacy is key in the assessing willingness to respond to a RDD event.

Methods

An anonymous online survey was used to evaluate the willingness of hospital employees to respond to a RDD event. Agreement with a series of belief statements was assessed, following a methodology validated in previous work. The survey was available online to all 18,612 employees of the Johns Hopkins Hospital from January to March 2009.

Results

Surveys were completed by 3426 employees (18.4%), whose demographic distribution was similar to overall hospital staff. 39% of hospital workers were not willing to respond to a RDD scenario if asked but not required to do so. Only 11% more were willing if required. Workers who were hesitant to agree to work additional hours when required were 20 times less likely to report during a RDD emergency. Respondents who perceived their peers as likely to report to work in a RDD emergency were 17 times more likely to respond during a RDD event if asked. Only 27.9% of the hospital employees with a perception of low efficacy declared willingness to respond to a severe RDD event. Perception of threat had little impact on willingness to respond among hospital workers.

Conclusions

Radiological scenarios such as RDDs are among the most dreaded emergency events yet studied. Several attitudinal indicators can help to identify hospital employees unlikely to respond. These risk-perception modifiers must then be addressed through training to enable effective hospital response to a RDD event.