Integrating a framework for conducting public health systems research into statewide operations-based exercises to improve emergency preparedness

ABSTRACT: BACKGROUND: Due to the uncommon nature of large-scale disasters and emergencies, public health practitioners often turn to simulated emergencies, known as "exercises", for preparedness assessment and improvement. Under the right conditions, exercises can also be used to conduct original public health systems research. This paper describes the integration of a research framework into a statewide operations-based exercise program in California as a systems-based approach for studying public health emergency preparedness and response. METHODS: We developed a research framework based on the premise that operations-based exercises conducted by medical and public health agencies can be described using epidemiologic concepts. Using this framework, we conducted a survey of key local and regional medical and health agencies throughout California following the 2010 Statewide Medical and Health Exercise. The survey evaluated: (1) the emergency preparedness capabilities activated and functions performed in response to the emergency scenario, and (2) the major challenges to inter-organizational communications and information management. RESULTS: Thirty-five local health departments (LHDs), 24 local emergency medical services (EMS) agencies, 121 hospitals, and 5 Regional Disaster Medical and Health Coordinators/Specialists (RDMHC) responded to our survey, representing 57%, 77%, 26% and 83%, respectively, of target agencies in California. We found two sets of response capabilities were activated during the 2010 Statewide Exercise: a set of core capabilities that were common across all agencies, and a set of agency-specific capabilities that were more common among certain agency types. With respect to one response capability in particular, inter-organizational information sharing, we found that the majority of respondents' comments were related to the complete or partial failure of communications equipment or systems. CONCLUSIONS: Using the 2010 Statewide Exercise in California as an opportunity to develop our research framework, we characterized several aspects of the public health and medical system's response to a standardized emergency scenario. From a research perspective, this study provides a potential new framework for conducting exercise-based research. From a practitioner's perspective, our results provide a starting point for preparedness professionals' dialogue about expected and actual organizational roles, responsibilities, and resource capacities within the public health system. Additionally, the identification of specific challenges to inter-organizational communications and information management offer specific areas for intervention.     

Empathy: towards a conceptual framework for health professionals

Effective provider-patient communication and the relationships that it supports are located at the centre of quality health-care delivery. The patient-centred approach is increasingly seen as an effective way to provide effective patient care, being more sensitive and responsive to the needs of the individual. Empathy has been identified as a core component of "patient-centredness" but definitions often lack conceptual clarity. This paper proposes to clarify the definition of empathy keeping the discussion true to Rogers' original definitions of the concept whilst integrating the work of other writers. A major thrust is the development of an innovative conceptual model of empathy which has the potential to both integrate previous research findings and provide a framework for future research and training. The model is based in social psychological conceptions of attitude.     

Preparedness and response to terrorism: a framework for public health action

Political group violence in the form of terrorist actions has become a reality worldwide, affecting the health and economies of populations. As a consequence, preparedness and response are becoming an integral part of public health action. Risk appraisal, preservation of human and civil rights and communications within and between countries are all issues to be considered in the process. The combination of the natural history of terrorist actions and the epidemiological triangle model has been adapted in this paper and suggested as a comprehensive approach for preparedness and action. It covers preparedness (pre-event), response (event) and the consequences (post-event) of a terrorist attack. It takes into account the human factor, vectors and environment involved in each one of the phases. KEY POINTS: Terrorism is a global reality with varying underlying causes, manifestations and impact on the health of the public. Preparedness, response and rehabilitation are an integral part of public health action. Consideration of the pre-event, event and post-event phases in terrorist actions, together with the human factor, vector/agent and environment in each of these phases, offers a framework for public health preparedness, response and rehabilitation. Planning should consider risk assessment, risk communication, inter-sectorial cooperation, enactment of laws and regulations which consider protection of the public's health and civil liberties. Allocation of resources would need to make allowance for maintenance and development of ongoing public health activities.     

Globalization and health: a framework for analysis and action

Globalization is a key challenge to public health, especially in developing countries, but the linkages between globalization and health are complex. Although a growing amount of literature has appeared on the subject, it is piecemeal, and suffers from a lack of an agreed framework for assessing the direct and indirect health effects of different aspects of globalization. This paper presents a conceptual framework for the linkages between economic globalization and health, with the intention that it will serve as a basis for synthesizing existing relevant literature, identifying gaps in knowledge, and ultimately developing national and international policies more favourable to health. The framework encompasses both the indirect effects on health, operating through the national economy, household economies and health-related sectors such as water, sanitation and education, as well as more direct effects on population-level and individual risk factors for health and on the health care system. Proposed also is a set of broad objectives for a programme of action to optimize the health effects of economic globalization. The paper concludes by identifying priorities for research corresponding with the five linkages identified as critical to the effects of globalization on health.     

From parallel practice to integrative health care: a conceptual framework

Background

"Integrative health care" has become a common term to describe teams of health care providers working together to provide patient care. However this term has not been well-defined and likely means many different things to different people. The purpose of this paper is to develop a conceptual framework for describing, comparing and evaluating different forms of team-oriented health care practices that have evolved in Western health care systems.

Discussion

Seven different models of team-oriented health care practice are illustrated in this paper: parallel, consultative, collaborative, coordinated, multidisciplinary, interdisciplinary and integrative. Each of these models occupies a position along the proposed continuum from the non-integrative to fully integrative approach they take to patient care. The framework is developed around four key components of integrative health care practice: philosophy/values; structure, process and outcomes.

Summary

This framework can be used by patients and health care practitioners to determine what styles of practice meet their needs and by policy makers, healthcare managers and researchers to document the evolution of team practices over time. This framework may also facilitate exploration of the relationship between different practice models and health outcomes.     

Jamesian pragmatism: a framework for working towards unified diversity in nursing knowledge development

Nursing is frequently described as practical or pragmatic and there are many parallels between nursing and pragmatism, the school of thought. Pragmatism is often glancingly referenced by nursing authors, but few have conducted in‐depth discussions about its applicability to nursing; and few have identified it as a significant theoretical basis for nursing research. William James's pragmatism has not been discussed substantially in the nursing context, despite obvious complementarities. James's theme of pluralism fits with nursing's diversity and plurality; his emphasis on social conscience in our actions matches nursing's fundamental purpose of improving the lives of others; his continuous testing of pluralistic truths in critically reflective practice pairs well with nursing's focus on developing best‐available, holistic evidence; and his conceptualization of truth as being born in practice and becoming an instrument in practice is entirely compatible with nursing's theory–practice identity. The oft‐discussed theory–practice gap is seen to hinder the development of nursing knowledge. If nursing is to find its identity in knowledge development and potentiate the knowledge developed, it is imperative to identify and address that which is impeding progress. By way of the pragmatic tenets of William James, I will argue that a significant part of the theory–practice gap lies in how nursing knowledge development is operationalized, creating a false dichotomy between practice and research. I will also argue that the research–practice schism has been widened by continued philosophical and methodological infighting in the research community. I will describe how Jamesian pragmatism can be ‘what works’ for rebuilding relationships and supporting an engaged plurality within nursing research and bring research and practice together into a collaborative and iterative process of developing nursing knowledge.     

Integrating women's human rights into global health research: an action framework

This article uses Scale of Change theory as a framework to guide global health researchers to synergistically target women's health outcomes in the context of improving their right to freedom, equity, and equality of opportunities. We hypothesize that health researchers can do so through six action strategies. These strategies include (1) becoming fully informed of women's human rights directives to integrate them into research, (2) mainstreaming gender in the research, (3) using the expertise of grass roots women's organizations in the setting, (4) showcasing women's equity and equality in the organizational infrastructure, (5) disseminating research findings to policymakers in the study locale to influence health priorities, and (6) publicizing the social conditions that are linked to women's diseases. We explore conceptual and logistical dilemmas in transforming a study using these principles and also provide a case study of obstetric fistula reduction in Nigeria to illustrate how these strategies can be operationalized. Our intent is to offer a feasible approach to health researchers who, conceptually, may link women's health to social and cultural conditions but are looking for practical implementation strategies to examine a women's health issue through the lens of their human rights.     

Rebuilding health systems to improve health and promote statebuilding in post-conflict countries: A theoretical framework and research agenda

Violent conflicts claim lives, disrupt livelihoods, and halt delivery of essential services, such as health care and education. Health systems are often devastated in conflicts as health professionals flee, infrastructure is destroyed, and the supply of drugs and supplies is halted. We propose that early reconstruction of a functioning, equitable health system in countries recovering from conflict is an investment with a range of benefits for post-conflict countries. Building on the growing literature about health systems as social and political institutions, we elaborate a logic model that outlines how health systems may contribute not only to improved health status but also potentially to broader statebuilding and enhanced prospects for peace. Specifically, we propose that careful design of the core elements of the health system by national governments and their development partners can promote reliable provision of essential health services while demonstrating a commitment to equity, strengthening government accountability to citizens, and building the capacity of government to manage core social programs. We review the conceptual basis and extant empirical evidence for these mechanisms, identify knowledge gaps, and suggest a research agenda.     

Interpretation of radiological images: towards a framework of knowledge and skills

The knowledge and skills that are required for radiological image interpretation are not well documented, even though medical imaging is gaining importance. This study aims to develop a comprehensive framework of knowledge and skills, required for two-dimensional and multiplanar image interpretation in radiology. A mixed-method study approach was applied. First, a literature search was performed to identify knowledge and skills that are important for image interpretation. Three databases, PubMed, PsycINFO and Embase, were searched for studies using synonyms of image interpretation skills or visual expertise combined with synonyms of radiology. Empirical or review studies concerning knowledge and skills for medical image interpretation were included and relevant knowledge and skill items were extracted. Second, a preliminary framework was built and discussed with nine selective experts in individual semi-structured interviews. The expert team consisted of four radiologists, one radiology resident, two education scientists, one cognitive psychologist and one neuropsychologist. The framework was optimised based on the experts comments. Finally, the framework was applied to empirical data, derived from verbal protocols of ten clerks interpreting two-dimensional and multiplanar radiological images. In consensus meetings adjustments were made to resolve discrepancies of the framework with the verbal protocol data. We designed a framework with three main components of image interpretation: perception, analysis and synthesis. The literature study provided four knowledge and twelve skill items. As a result of the expert interviews, one skill item was added and formulations of existing items were adjusted. The think-aloud experiment showed that all knowledge items and three of the skill items were applied within all three main components of the image interpretation process. The remaining framework items were apparent only within one of the main components. After combining two knowledge items, we finally identified three knowledge items and thirteen skills, essential for image interpretation by trainees. The framework can serve as a guideline for education and assessment of two- and three-dimensional image interpretation. Further validation of the framework in larger study groups with different levels of expertise is needed.     

美国州公共卫生法律示范项目对我国立法启示

  目的  评价京沪两地法律体系对妇女保健的保障程度及其与孕产妇死亡率的关系,验证适宜的法律保障程度的定位及其于京沪的意义。  方法  系统收集两地所有妇女保健相关的规范性法律文件,综合法律体系完备程度、法律地位保障程度、刚性约束程度以及主动完善相关法律的程度,量化计算法律体系的保障程度,并使用Spearman秩相关和线性回归模型分析法律体系的保障程度与孕产妇死亡率的关系。  结果  京沪两地妇女保健的法律体系保障程度均呈现逐步上升的趋势,北京由1990年的30.2 %上升至2017年的69.8 %,上海由1990年的43.5 %上升至2017年的70.6 %。两地的妇保法律体系保障程度与孕产妇死亡率均呈负相关（相关系数均大于0.75）。拟合回归方程显示,京沪法律体系保障程度对孕产妇死亡率变化的解释程度分别为57.5 %和82.8 %。  结论  完备的法律体系对引领、规范妇女保健体系的运行与发展的作用不可替代。两地已逐步形成较为完善的法律体系,但在法律的刚性约束程度方面均需要进一步加强。     

Supporting government policies to embed and expand rehabilitation in health systems in Europe: A framework for action

Investment in action is vital to confront the challenges associated with chronic diseases and disability facing European health systems. Although relevant policy responses are being increasingly developed, most of them fail to recognize the role of rehabilitation services in achieving public health and social goals. Comprehensive guidance is thus urgently needed to support rehabilitation policy development and expand access to rehabilitation care to meet population needs effectively. This paper describes a framework to guide policy action for rehabilitation in Europe. The framework was developed in collaboration with the European Academy of Rehabilitation Medicine based on a focused literature review and expert consultations. A review in PubMed and grey literature sources identified 458 references and resulted in 135 relevant documents published between 2006 and 2019. Thematic analysis of extracted information helped summarize the findings and develop the draft policy action framework. This was circulated to a wider group of experts and discussed in three workshops in 2018-2019. The framework was revised according to their feedback.The proposed framework contains 48 options for policy action organized in six domains and twelve subdomains that address several areas of health programming. The proposed framework provides a structure to understand the policy terrain related to rehabilitation in Europe and the measures required for translating aspirational political pronouncements into targeted programmatic action and tangible health and social outcomes.     

Strengthening vaccination programmes and health systems in the European Union: A framework for action

Vaccination is one of the most cost-effective public health interventions. However, the EU is facing increasing outbreaks of vaccine preventable diseases, with some fatal cases of measles. This paper reviews the main factors influencing vaccination uptake, and assesses measures expected to improve vaccination coverage. Obstacles to vaccination include concerns about vaccine safety and side effects, lack of trust, social norms, exposure to rumours and myths, and access barriers. Responses fall into three broad categories. Regulation, including the introduction of mandatory vaccination, can be justified but it is important to be sure that it is an appropriate solution to the existing problem and does not risk unintended consequences. Facilitation involves ensuring that there is an effective vaccination programme, comprehensive in nature, and reducing the many barriers, in terms of cost, distance, and time, to achieving high levels of uptake, especially for marginalised or vulnerable populations. Information is crucial, but whether in the form of public information campaigns or interactions between health workers and target populations, must be designed very carefully to avoid the risk of backfire. There is no universal solution to achieving high levels of vaccine uptake but rather a range or combinations of options. The choice of which to adopt in each country will depend on a detailed understanding of the problem, including which groups are most affected.     

Knowledge for better health: a conceptual framework and foundation for health research systems

Health research generates knowledge that can be utilized to improve health system performance and, ultimately, health and health equity. We propose a conceptual framework for health research systems (HRSs) that defines their boundaries, components, goals, and functions. The framework adopts a systems perspective towards HRSs and serves as a foundation for constructing a practical approach to describe and analyse HRSs. The analysis of HRSs should, in turn, provide a better understanding of how research contributes to gains in health and health equity. In this framework, the intrinsic goals of the HRS are the advancement of scientific knowledge and the utilization of knowledge to improve health and health equity. Its four principal functions are stewardship, financing, creating and sustaining resources, and producing and using research. The framework, as it is applied in consultation with countries, will provide countries and donor agencies with relevant inputs to policies and strategies for strengthening HRSs and using knowledge for better health.     

Developing a marketing function in public healthcare systems: a framework for action

The scope of this paper is to analyse the contribution that a marketing function can bring to the wide variety of healthcare organizations operating in public health systems (PHSs). While extensive research on marketing applied to healthcare services has been elaborated in competitive and managed care contexts, marketing is a rather new issue in PHSs and little research has been conducted to assess its relevance and benefits in these environments. This study tackles that gap and is based on a review of the current literature in order to provide answers to the following points: - definition of the scopes of marketing and of the elements that affect its incorporation in the healthcare sector; - conceptualization of the possible approaches to marketing by health organizations operating in PHSs; - discussion of the resulting framework for action.     

Managing clinical integration in integrated delivery systems: a framework for action

An integrated delivery system (IDS) in healthcare must coordinate patient care across multiple functions, activities, and operating units. To achieve this clinical integration, senior management confronts many challenges. This paper uses a cross-functional-process (CFP) framework to discuss these challenges. There are ten CFPs that fall into three categories: planning processes (strategy formulation, program adaptation, budget formulation), organizational processes (authority and influence, client management, conflict resolution, motivation, and cultural maintenance), and measurement and reporting processes (financial and programmatic). Each process typically spans several functional units. Senior management must consider how to improve both the functioning of each CFP, as well as its "fit" with the other nine. The result can be greater clinical integration, improved cost management, and more coordinated care for enrollees.