Development And Application Of Assessment Tools For Response Capacity Of Public Health Emergency Response System And Exploratory Research Of Capacity Assessment Models

BackgroundThe outbreak of severe acute respiratory syndrome(SARS),in the first 6 months in 2003,was not only a huge disaster to people's life and health,but also a heavy attack to China's economy,which disclosed the weakness of the public health system, including the poor infrastructures,scarce human resources and inadequate capacity. How to respond to public health emergencies swiftly and properly has become an unprecedented challenge to China's public health.An important lesson from SARS outbreak is that inadequate surveillance and response capacity can result in disease epidemic all over the country,and cause mass panics in communities,furthermore, endanger the national public health security.To meet the long-term needs of public health and social development of China,it is in urgency to establish a comprehensive response system and crisis management mechanism for public health emergencies.ObjectiveThe general objective of this study is to develop tailored assessment tool for public health emergency response system in China.Specifically,through field investigation and qualitative interviews1.to create framework and indicators for the assessment of public health emergency response system using literature review,key informatics interview and theme forum;2.to develop tailored tools and models for the assessment of public health emergency response system;3.to apply the assessment tools for describing and understanding the capability of public health emergency response system in county level health facilities of rural China;4.to identify the weaknesses and pitfalls of current public health emergency response system,and to provide policy recommendations for its improvement.MethodologyQualitative methods including literatures review,key informatics interview and experts' forum were applied to set up the framework of the assessment and index system for Public Health Emergency Response System,and to develop the assessment tools including questionnaires and interview guideline.Field investigations using structured questionnaires were carried out to understand the current situation of Public Health Emergency Response System with regard to function,composition,infrastructure,capacity,and system assurance,etc.at county level.The questionnaires were designed specifically for this study,and the eliability and validity of the questionnaires were tested before field survey.National experts and health/public health professionals from local health bureau,center of disease control and prevention,county hospital,township hospital were interviewed during study period.Models for capacity evaluation were generated based on the data collected from the field investigation.All the quantitative data were entered into the database created through Epi-data 3.1,and were analyzed with SPSS 11.0.Content analysis,with an inductive approach, was used in qualitative data analysis.Results1.The structure of the index system for public health emergency response systemThe capability assessment set the county-level unit of the Public Health Emergency Response System as the starting point and target.The development of assessment tools had based on the duties,responsibilities and functions of each sector in the Public Health Emergency Response System in county.Data were collected from the responsible person in the relevant sections.The index system of capability assessment for county-level Public Health Emergency Response System had been designed to cover the system assurance,early warning(ability to identify and judge), emergency response(emergency,on-site treatment,rescue and control) and the mechanism of assessment.For the center for disease control and prevention at county-level and county hospitals,the ccomprehensive assessment index system was constructed with eight dimensions,i.e.,(1) protocols,rules,regulations,operating manuals,(2) surveillance and alert,(3) laboratory confirmation,(4) emergency response team and experts,(5) information communication,dissemination and coordination,(6) training and drills,(7) rightness in action and(8) reserve.For the township-level hospitals,the index system was designed to focus on the capability of essential health care service,disease surveillance and early warning,laboratory testing,and response.The questionnaires for county CDC,county hospital and township-level hospitals consisted of 211,184 and 54 indicators respectively.The internal consistency of each questionnaire was high and the overall Cronbach'sαcoefficients was higher than 0.95.Except for dimension of information communication and dissemination,Cronbach'sαcoefficient of other dimensions was higher than 0.60.For the questionnaire developed CDC and general hospitals,5 (62.15%) and 7(86.75%)Cronbach'sαcoefficients were higher than 0.8 respectively. Spearman correlation coefficients test showed that the correlation between dimensions of the questionnaire was also high.3.Capability of the studied Public Health Emergency Response System3.1 County CDCTotally 18 county CDCs were be investigated of which the mean of maximum service distance was 81.36 km.The average number of employees of CDC was 61 with 79.8%being healthcare-related technicians.Majority of the employees had an education of secondary school,and did not have a chief or associate chief title.The proportion of the staff working in the laboratory varied from 6.84%to 25.00%.All the sampled CDCs had developed and announced at least one Public Health Emergency Preparedness Plan in which only about 25%plans met the requirements of the "national regulation".However,these plans did not be well development since the structure of the plan was uncompleted and the coverage of the contents was incomprehensive.Although in the studied counties,a disease surveillance system has already been set up,the application of the data was limited.About 89.9%of the CDCs could do epidemiological description,and 75%could apply for trend analyses,but only two CDCs could do some kind of risk assessment when a public health emergency actually happened.There were the missed or delayed reports in surveillance,The promptness of infectious disease report could be low to 4.23%and the omission rates for infectious disease could be high to 27.10%in the sampled study sites.The main laboratore tests carried out in county CDC were bacterial culture and ELISA using blood samples.All of the investigated counties had set up their own department of public health emergency management and 66.7%of them being standing bodies.It was found that the Public Health Emergency Response System at county level was able to organize emergency team.Of the 18 counties,12 had resource backup for experts.The system was strong in responding to major infectious disease emergencies,including surveillance,case identification,on-site handling,but weak to unknown disease, chemical poison,radioactive material leak and injury.Results from the interviews showed that public health staffs were not very much confident in the capability of response to public health emergency of their own health sectors.The function of information communication and exchange for public health emergency response had been well established not only within disease control and prevention system,but also betweeh CDCs and other health sectors.The regulations for information release were also set up in the study areas.Although the long-term rules for training and practicing had been developed,the content was constrained mainly for the major infectious diseases.When measuring the capability of the system using score,the highest score was given to the capability of surveillance and early warning(90.65),and the lowest score was seen at capability of reserving(49.14 of 100).There was no significant difference in scores for each dimension between areas with different economic status.3.2 County hospitalOf all the employees in the 17 investigated county hospitals,the average proportion of healthcare professionals was 82.30%varied from 65.09%to 92.20%. The mean ratio of doctors to nurses was 1 to 1.06.About two-third of the sampled hospitals had an over-use of hospital beds.All the county general hospitals had contingency plans for public health emergencies,on-site treatment guideline for major infectious disease and other public health emergency events.One-third of the hospitals had set up symptom surveillance spot and 83.3%of the hospitals requested that the clinical physician should complete the log for outpatient visits,and registration for patients with major infectious diseases.All the county hospitals had installed internct-based infectious diseases surveillance and public health emergency reporting system.However,only 71.40%of the hospitals could analyze data regularly.All the hospitals were able to respond to the emergencies in major infectious disease,regional priority disease and food poisoning,in terms of laboratory tests, medical personnel gathering and on-site rescue.However,the capacity for responding to emergencies due to chemical substances,radiation and natural disasters were not as good as to above events.The capacity for response to infectious disease varied between provinces.Overall,15 hospitals had established labor resources pool,of which only one(5.56%) had reserved for psychiatrist and two(11.12%) for family nurses.The possibility of providing extra hospital beds in emergency was low,at an average of 10%.None of the county hospital laboratories had joined the regional public health laboratory network.The communication between county hospitals and local health bureau,and up-level hospitals were fine,actually much better than that between county hospital and CDC,health inspection,as well as other medical institutions.Long-term training and practicing mechanism had also been regulated in county hospitals.With regard to dimentions,in county hospitals,the scores for dimention of trainging,surveillance and early warning,and reserve were 73.50,65.37and 44.93 respectively.3.3 Township hospitalThe employees had relatively poor education and low position title in all 54 township hospitals.Of them,67.69%and 76.15%had an education of secondary school and primary title respectively.The three-tier network from village to town to county for expanded planned immunization(EPI) had already been built in all the study sites with a coverage rate of 90%and higher for the EPI vaccines.All the township-level hospitals had had a infectious disease management system,however only 59.23%of these hospitals used internet based report.It was obvious that the township-level hospitals were weak in medical rescue for emergency.The main problems were poor infrastructure,insufficient human resources,and weak surveillance network.4.Capacity assessment modelsBased on the quantitative data collected in this study,capacity assessment models were established through factor analysis.Emergency,identification and protection,these 3 factors constitutes the triangular model to describe and evaluate the capability of county-level Public Health Emergency Response System.F_CDC=0.608F_emergency+0.242F_{identification}+0.15F_assureanceF_hospital=0.718F_emergency+0.156F_assurance+0.126F_{identification}5.Capacity development strategyThe basic framework of public health emergency response system had been built up in China.However,the unbalanced development between regions,the undefined and varied functions,unclear responsibilities of each sector,and uncompleted mechanism of the system were observed from both the qualitative interviews and quantitative investigations.Cluster analysis showed that both CDCs and county hospitals could be classified as four clusters with different capacity characters.The first is the units that had good integrated capacity,balanced score for all dimentions but each dimention is not outstanding,The other 3 clusters are the unites with special strengths in one or more dimentions Such as comprehensive in system composition, excellent in identification cases or evens,or strong capacity in on-site emergency handling.Therefore,it is of great importance to identify the problems and weaknesses of the system first when develop regional policies and strategies,to improve the general capability of the public health emergency response system.ConclusionThe index system of capability for county-level Public Health Emergency Response System,developed by this study,covers the capability of system assurance, early warning(ability to identify and judge),emergency response(emergency,on-site treatment,rescue and control) and the mechanism of assessment,etc.The questionnaire consisted of eight dimensions including 1)plans,rules,regulations, operating manuals,2)surveillance and alert,3) laboratory testing,4) emergency team and experts,5)communication,dissemination,and coordination,6)training and drills, 7)capability of response and 8)reserve.The questionnaires are reliable and valid for public health emergency system at county level.Emergency,identification and protection,these 3 factors constitutes the triangular model to describe and evaluate the capability of county-level Public Health Emergency Response System.At present,the three-tier Public Health Emergency Response System has been available in rural counties of China with documented preparedness plan and basic function on responses to public health emergency,which to some extent can handle the emergencies and secure the publics.Nevertheless,the capability or function of the Public Health Emergency Response System is largely influenced by Public health budgets,human resources,laboratory equipment,and surveillance network.Weakness of the system recognized in this study should have huge impacts on the improvement of capability of the system.For the units having stronger integrated capability,balance should be maintained during the development of the whole system. For the units having poor assurance capability,legislations and preparedness should be the key component for further development.For the units having poor identification capability,more resources should be allocated to the surveillance network and laboratory,and capacity in data analysis and application should also be strengthened.For the units having poor response capacity,training and practicing are extremely important to enhance the awareness and accelerate the responses for public health emergencies.