Local health workers might stay home in pandemic

New research indicates staff in local health departments might not be prepared to report to work during an influenza pandemic, potentially threatening the ability of local health departments to adequately respond to such an emergency.

The findings are based on self-administered anonymous surveys sent to all health department personnel in three Maryland counties — Carroll, Dorchester, and Harford. Researchers from Ben Gurion University of the Negev, Be'er Sheva, Israel, and the Johns Hopkins Bloomsburg School of Public Health, Baltimore, said those three departments were chosen because of their location in communities ranging from 30,000 people on Maryland's Eastern Shore (Dorchester County) to 235,000 in the greater Baltimore/ Towson metropolitan area (Harford County), thus reflecting 95% of the nation's local public health agencies serving communities with 500,000 or fewer residents. Staff sizes in the three departments ranged from 132 to 225 employees.

The survey included questions on personal characteristics such as job classification, gender, and age, and then asked respondents to use a five-point Likert scale on questions relating to a possible flu pandemic: probability of them reporting to work, possibility of being asked by the health department to respond to an emergency, how knowledgeable they thought they were about the potential health impact of pandemic influenza, how confident they were about being safe in their work roles, how likely was their family prepared to function in their absence, how likely they felt their health department would provide them with timely updates, how familiar they were with their role-specific response requirements, how well they thought they could address the questions of a concerned member of the public, how significant a role they thought they would play in their agency's overall response, how important would be pre-event preparation and training, how important it was for them to have psychological support available during the event, and how important it was for them to have psychological support available after the event.

The overall survey response rate was 58%, with no statistically significant difference in age and gender distribution between respondents and all health department personnel.

Of the 303 people who responded to the question about their likelihood of reporting during a pandemic influenza related emergency, 163 (53.8%) indicated they would likely come to work during such an emergency. Age and gender were not associated with likelihood of reporting. Clinical staff indicated a higher likelihood of reporting than did technical/support staff.

Staff don't expect call for duty

Only 40% of all respondents (45.1% professional staff and 26.1% technical/support staff) felt it was likely they would be asked by their health department to respond to a pandemic influenza related emergency. Perception of the likelihood of being asked by the department to respond was associated with self-described likelihood of reporting. Only 33.4% of respondents considered themselves knowledgeable about the public health impact of pandemic influenza. Perception of one's existing knowledge about pandemic influenza and perception of having an important role in the agency's overall response were significantly higher among professional staff than technical/support staff.

Those who said they were likely to report to work during a flu pandemic were more likely to report a higher capacity to be able to communicate risk effectively, say they have a more important role in the agency's overall response, and say they were more familiar with their role-specific response requirements in a pandemic flu emergency.

The vast majority of respondents (81%) felt they would benefit from additional training activities. A lower perceived level of familiarity with one's role was not significantly associated with a higher perceived need for additional training. Most of the respondents also perceived psychological support both during and after an event as important, with the need for psychological support deemed even more important by those who considered themselves likely to be asked to report to duty during an event.

Some 66% of respondents perceived themselves to be at personal risk when performing their duties during such an emergency. Confidence in personal safety was associated with several issues independent of one's job classification, including perception of existing knowledge about the public health impact of pandemic influenza, family preparation, health department perceived ability to provide timely information, perception of the capacity to effectively communicate risk, perception of the importance of one's role in the agency's overall response, and familiarity with one's role-specific response requirements.

The associations between self-identified likelihood of reporting to work and perception of one's capacity to effectively communicate risk were substantially stronger for technical/support staff compared to professional staff.

The researchers said they found the willingness to report to duty during a pandemic varies considerably according to individuals' job classifications. Thus, clinical staff say they are significantly more likely to report to duty, compared with other workers. That difference correlates well, according to the researchers, with the single most influential construct associated with willingness to report to duty — the perception of the importance of one's role in the agency's overall response.

Less than one-third of the respondents believe they will have an important role in the agency's response to local outbreaks of pandemic influenza, but within this subgroup, willingness to report to duty was as high as 86.8%. Belief in the importance of one's role was lowest among technical/support staff, environmental health staff, and other nonclinical professional staff, groups in which willingness to report was seen to be lowest.

"We believe further efforts must be directed at ensuring that all local public health workers, but most notably nonclinical professional staff, understand in advance the importance of their role during an influenza pandemic," the researchers said. "Otherwise, they will fail to show up when they are most needed."

The findings are important because local health departments are considered the backbone of public health response plans for any and all infectious disease outbreaks. The U.S. pandemic influenza plan released last November laid out a critical role for local and state public health agencies during a pandemic, including providing regular situational updates for providers, providing guidance on infection control measures for health care and nonhealth care settings, conducting or facilitating testing and investigation of pandemic influenza cases, and investigating and reporting special pandemic situations.

The researchers said such activities would require an extensive prompt response by local health departments, a response that is called into question by the survey results.

The study said that while none of the health departments surveyed serve a large metropolitan areas, and all three had fewer than 250 employees, it should also be recognized that only 4% of the nation's local health departments serve populations of 500,000 or more, and that local public health agencies tend to have small staff sizes.

Findings similar to post-9/11 NYC

And the findings show similar patterns to data on the willingness of urban health care workers from nonpublic health settings to respond to emergencies. A survey of 6,248 employees of 47 health care facilities in the New York City area found that the workers were least willing (48%) to report to duty during an untreatable naturally occurring infectious disease outbreak affecting their facility (SARS), compared to other disaster scenarios.

"In the face of a pandemic influenza threat," the report concluded, "local health department employees' unwillingness to report to duty may pose a threat to the nation's emergency response infrastructure. Addressing the specific factors associated with this unwillingness is necessary to help ensure that existing local health department preparedness competencies will translate into the scope of response described in the nation's pandemic influenza plans. Interventions suggested to enhance the willingness of health care workers in nonpublic health department settings to report to duty in disasters include work force preparedness education, provision of appropriate personal protective equipment, crisis counseling, family preparedness, and social support. These recommendations fit well within the framework of our findings, and we further recommend that such education programs include specialized training emphasizing the specific nature of, and guidelines for, one's role in response to pandemic influenza, the relevance of each worker's role in the effectiveness of an overall public health response, and the workers' ability to provide effective risk communications."

(Editor's note: The study was published by BMC Public Health, a BioMed Central journal. Download it from www.biomedcentral.com/1471-2458/6/99.)