Evidence-Based Practice for Public Health Emergency Preparedness and Response (2020) / Chapter Skim
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8 Improving and Expanding the Evidence Base for Public Health Emergency Preparedness and Response
8 Improving and Expanding the Evidence Base for Public Health Emergency Preparedness and Response
Pages 205-250
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From page 205... ...
The quantitative impact category, accounting for only about 6 percent of all articles, includes studies that evaluate specific PHEPR practices. This distribution of study designs presents challenges for identifying evidence-based practices, and in Chapter 2, the committee presents the following conclusion: Conclusion: With the increasing complexity of both public health emergencies and the PHEPR system, policy makers and practitioners have a crucial need for access to guidance based on robust evidence to support their decisions on practices, policies, and programs for saving lives during future public health emergencies.
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A NATIONAL PHEPR SCIENCE FRAMEWORK The generation of a PHEPR evidence base has been hindered by the inherent challenges of conducting research on public health emergencies, which can limit the opportunities to observe and proactively study the effects of practices used to mitigate harm before, during, and after such an event (see Chapter 2 for additional details)
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Robust and sustained Recognition of PHEPR commitment to PHEPR science as a unique researcher and practitioner academic discipline within training and education public health PHEPR evidence-based Capacity building for guidelines group to translation, develop guidelines for dissemination, and PHEPR practice and implementation of communicate key research to practice evidence gaps System leadership to transform how PHEPR research is coordinated, sustainably funded, and conducted Cross-cutting, forward-looking Common evidence research agenda with a focus guidelines and standards on innovation and with a focus on rigorous systems-level approaches research and evaluation Mechanisms to build and maintain durable and trusting partnerships among practitioners, communities, and researchers FIGURE 8-2 Key components of a National PHEPR Science Framework.
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An interagency and multidisciplinary effort led by the Centers for Disease Control and Prevention (CDC) will be necessary to develop and implement a National PHEPR Science Framework; establish an authority and process for supporting research before, during, and following public health emergencies; and ensure that adequate research funding, capacities, and infrastructure are in place.
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-- is not always feasible. Researching public health emergencies requires specific knowledge and understanding of how the systems involved work, and public health scientists may lack the knowledge, experience, and credibility to conduct research before, during, or following a public health emergency.
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and the committee's evidence reviews for practices within the Community Preparedness, E mergency Operations Coordination, Information Sharing, and Non-Pharmaceutical Interventions Capabilities (see the sections on future research priorities in Chapters 4–7)
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The community also has many resources to offer the PHEPR research enterprise, including its experiences and knowledge of its needs and existing networks that can be leveraged. Overall, PHEPR research requires the collaboration, insight, and trust of professionals from public health, other response a gencies, academia, private entities, and members of the community prior to a public health emergency, and an effective National PHEPR Science Framework will support strategies for strengthening and maintaining these partnerships to promote successful PHEPR research.
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These issues are explored in depth in the sections on workforce capacity development for PHEPR research and practitioners and on translation of research into practice and dissemination and implementation of evidence-based PHEPR practices later in this chapter. Ensuring Adequate Infrastructure and Supporting Mechanisms to Facilitate the Conduct of PHEPR Research To conduct research effectively before, during, and following a public health emergency, additional capacities, infrastructure, policies, and other elements must be strengthened or created.
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Given the inherent challenges of conducting research during public health emergencies, it is important to give careful consideration to opportunities for advancing PHEPR science during nonemergency times and to the pre-event planning needed to enable research during and following future public health emergencies. Types of PHEPR research that could be supported in nondisaster times include modeling, simulations and exercises, and research on public health implementation issues that would likely translate in the event of a public health emergency.
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214 EVIDENCE-BASED PRACTICE FOR PHEPR TABLE 8-1 Key Components of Research Response in the Context of Public Health Emergencies Component Actions Before the Event Actions During the Event Identify questions that will need Identify experts in research design Convene experts, and review and to be addressed for common and in key topic areas amend protocols as needed scenarios and develop generic study protocols Develop and gain approval from institutional review boards for key study protocols Ensure that appropriate cadres of Roster experts in research design Convene experts (and potentially scientists are available to respond and in topical areas of concern others with concerns) to identify to events areas for priority research Develop an on-call research "ready reserve" of clinicians, scientists, and other experts in government, academia, and industry Develop a process for activating Incorporate the concept of an Identify an "incident commander research response "incident commander for research" for research" and representatives into response plans from relevant science agencies that will be charged with supporting Determine criteria for activation of and conducting research research response Notify prerostered experts Identify and prioritize research Identify potential knowledge gaps Convene experts and others, such needs and research questions as those in affected communities, to review previously identified gaps, identify unforeseen and emerging knowledge gaps, prioritize research and baseline data collection needs, and recommend to researchers and funders which to pursue in the short term Ensure conditions for rapid data Develop and preapprove generic Modifying preexisting survey and collection protocols and survey instruments other data collection tools for so that only changes to them event-specific conditions require review when the event occurs Develop protocols for collecting and storing biospecimens Ensure rapid and appropriate Establish a Public Health Facilitate rapid review of protocols human subjects review Emergency Research Review Board by national or local institutional review boards Promote a commitment to expedite review by grantee institutions and prepositioned research networks Ensure mechanisms for rapid Use prefunded research networks Convene potential governmental funding and preawarded but just-in-time and nongovernmental funders funded research contracts Share prioritized research agenda Incorporate research response to public health emergencies in specific aims on grant awards to better facilitate administrative supplements Identify nongovernmental funders, both regionally and by sector, with an interest in addressing knowledge gaps
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Additionally, partnerships with foundations that are interested in addressing the needs of communities and health-related research could help fill gaps in funding. Rapid funding to support research in the event of a public health emergency is not enough, however; efforts are also needed to enhance capacities to conduct the research and improve data collection capabilities.
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Science Framework To enhance and expand the evidence base for PHEPR practices and translation of the science to the practice community, the Centers for Disease Control and Prevention should work with other relevant funding agencies; state, local, tribal, and territorial public health agencies; academic researchers; professional associations; and other stake 1 See https://dr2.nlm.nih.gov/tools-resources (accessed March 10, 2020)
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Such infrastructure should include • sustained funding for practice-based and investigator-driven research that allows for the progression from exploratory to effectiveness to scale-up research and encour ages researcher diversity; • upport for partnerships (e.g., with academic institutions, hospital systems, and s state, local, tribal, and territorial public health agencies) to facilitate collaboration in research on the preparedness, response, and recovery phases of a public health emergency; • development of a rapid research funding mechanism and interdisciplinary rapid response teams with applied research expertise (similar to CDC's Epidemic Intel ligence Service)
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To help ensure that future studies yield results from which stronger conclusions can be drawn about the effectiveness of PHEPR practices, future investments in PHEPR research will need to remedy these common methodological shortcomings. Standards, guidance, and incentives can help raise the quality and evidentiary value of research in the PHEPR field.
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. While acknowledging the value of randomization for demonstrating a causal link between interventions and outcomes, the committee recognizes that it is difficult, if not infeasible or inappropriate, to implement RCTs for some PHEPR practices, particularly in the context of a real public health emergency.
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In cases in which the adoption of other PHEPR practices or staff it is possible to measure outcomes for turnover. For some outcomes, there is likely multiple time periods prior to and after to be considerable variation that cannot be implementation of the PHEPR practice, it is explained by contextual factors, and it may possible to compare not only differences in be difficult or impossible to obtain reliable outcomes immediately before and after the and consistent measures of the outcomes of event but also differences in trends before interest through existing records or recall and and after.
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. Furthermore, as PHEPR research is trans isciplinary, design d methodologies used in such fields as public health services and systems research, operations research, behavioral and social sciences, organizational research, and quality improvement can also provide evidence for understanding PHEPR practices.
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3 » Barriers and » Coalitions expressed a desire for more participation from at- facilitators risk populations but struggled to include them. 3 FIGURE 8-3 Los Angeles County Community Disaster Resilience mixed-method research study.
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Research The Centers for Disease Control and Prevention, the Office of the Assistant Secretary for Preparedness and Response, the National Institutes of Health, the U.S. Department of Homeland Security, the National Science Foundation, and other relevant PHEPR research funders should use funding requirements to drive needed improvements in the conduct and reporting of research on the effectiveness and implementation of PHEPR practices.
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IMPROVING SYSTEMS TO GENERATE HIGH-QUALITY EXPERIENTIAL EVIDENCE FOR PHEPR Public health agencies typically conduct after action reviews following real or simulated (exercise) public health emergencies in an effort to identify lessons learned and strengths and weaknesses of the response, and ultimately to improve emergency preparedness and response capabilities (Davies et al., 2019)
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. To inform efforts focused on improvements needed to enhance the evidentiary 1 1-ITEM TOOL FOR ASSESSING THE METHODOLOGICAL BOX 8-2 RIGOR OF AFTER ACTION REPORTS • Prolonged engagement with the subject of inquiry -- Has the review included lengthy and perhaps repeated interviews with respondents, and/or days and weeks of engagement within a case study site or group?
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6 This section draws heavily on a report commissioned by the committee on "Quality Assessment of After Action Reports: Findings and Recommendations," by Sneha Patel. 7 The committee included 38 AARs in its evidence reviews.
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. The PHEPR field could benefit from drawing on the broader public health field to apply more rigorous evaluation processes when assessing lessons learned from public health emergencies.
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228 FIGURE 8-4 Root-cause analysis: Steps and examples. NOTE: AAR = after action report; IHR = International Health Regulations; PHEP = public health emergency preparedness; RCA = root-cause analysis SOURCE: Reprinted with permission from Stoto et al., 2019.
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Essential Core Elements of a PHEPR AAR To enable aggregation and analysis of AAR data for use as a potential source of evidence on the effectiveness of PHEPR practices, it is essential to define the core elements of a PHEPR AAR that builds on the existing HSEEP format but embraces more of a public health perspective. These elements would include a standardized core dataset and rootcause analysis framework that ultimately could be used not only by one jurisdiction, but also across jurisdictions for purposes of aggregation, trend analysis, and systemwide comparison (see Box 8-3 for the committee's suggested elements for such an AAR template)
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With the proper incentives and standards in place to encourage submission of AARs (e.g., formal recognition from the user community or appropriate agencies or qualification for additional exercise funding) , an enhanced national AAR repository could be a useful tool for improving PHEPR (Kearns, 2010; Piltch-Loeb et al., 2014a; Turner et al., 2018)
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Conclusion: Unless protection is ensured for sensitive data collected in AARs, informa tion on shortcomings during public health emergency responses will remain hidden, and similar errors will be repeated. Improved systems for public sharing of AARs that specifically preclude their use for punitive purposes would foster access to more accurate and reliable information, supporting the utility of the reports in evidence reviews and guidance for practical decision making.
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This process should foster a culture of improvement in public health emergency response and include, but not be limited to, discussions aimed at • raising standards and expectations regarding the quality of information reported in AARs by defining the essential core elements of a PHEPR AAR; • establishing an independent review panel with a standardized after action reporting process, with the aims of reducing bias and increasing the utility of AARs produced following public health emergency responses; • establishing and maintaining a national repository of AARs or of reports based on analysis of AARs that is readily accessible to support the dissemination of key find ings, lessons learned, and best practices for public health emergency response; and • xploring the relevant privacy issues and the protection of information in AARs e from use in legal proceedings or other punitive actions against practitioners and organizations, as has been done for "peer-review" data in other fields (medicine, aviation, and occupational health)
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In general, the public health workforce varies greatly in terms of job descriptions, education requirements, and experience, which are not standardized across public health agencies. A recent study found that having a public health degree was significantly associated with reduced odds of reporting a skill gap in identifying and applying evidence-based approaches to address a public health issue (Maddock, 2018; Taylor and Yeager, 2019)
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and the Office of the Assistant Secretary for Preparedness and Response should work with professional and academic organizations that represent multiple disciplines to guide and support the creation of the workforce capacity development and technical assistance programs necessary to ensure the conduct of quality PHEPR research and evaluation and improve the implementation capacity of state, local, tribal, and territorial public health agencies. Such efforts should include • eveloping a research training infrastructure and career development grants -- d institutional and individual predoctoral, postdoctoral, loan repayment, and career awards -- to develop and support researchers in PHEPR in order to address research gaps in the field; • providing training grants so that PHEPR researcher and practitioner teams can learn how to develop PHEPR practices that are grounded in science and theory and to evaluate the effectiveness and implementation of PHEPR practices using rigorous and appropriate designs; • roviding ongoing technical assistance and peer networking for both PHEPR p researchers and practitioners; and
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Despite these efforts, however, barriers to the adoption of evidence-based PHEPR practices persist, related largely to capacity issues. Building Implementation Capacity Successful implementation requires that public health agencies have sufficient capacity to identify and translate scientific knowledge into practice (Brownson et al., 2018)
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• Peer-to-peer learning through existing networks • State health departments, which receive information and resources from CDC and share them with local health departments • Health care coalitions that exist within various states and localities Implementation • Ensure that products and tools can be implemented by different agency and organization types (health care, public health, emergency management agencies, others) • Provide implementation support for a new tool or resource, as it can be challenging for public health agencies to gain momentum for implementation • Identify an advocate within the agency who will ensure that the tool remains a priority during planning and implementation • Provide support to bring staff together to review and practice implementing evidence based practices • Create products that are ready to use, because practitioners have limited time to review, modify, and adapt resources for local use • Build in-person trainings into existing grant structures SOURCES: Adapted from NORC at the University of Chicago, 2017; Qari et al., 2018.
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Additional research into the identification of core components of PHEPR practices would improve understanding of which components are essential for evidence-based practices to produce desired outcomes and how this is moderated by differences in population, setting, and other contextual factors, thus enabling practitioners to better operationalize interventions in their local setting. Encouraging the inclusion of core components in descriptions of evidence-based practices could also help ensure ongoing fidelity over time (ASPE, 2013)
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Ensuring the translation, dissemination, and implementation of evidence-based PHEPR practices will require the infrastructure not only to produce evidence but also to summarize, synthesize, and disseminate it and ensure its effective use. RECOMMENDATION 8: Ensure the Translation, Dissemination, and Implementation of Public Health Emergency Preparedness and Response (PHEPR)
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, to disseminate evidence-based practices; • ncorporating the requirement of utilizing evidence-based PHEPR practices into i such processes as the Public Health Accreditation Board accreditation and such recognition programs as NACCHO's Project Public Health Ready; and • incorporating implementation science principles, such as the conduct of research to understand core components required for intervention effectiveness, into PHEPR research.
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These studies can that together indicate the also provide evidence of need for intervention? Qualitative studies (focus relationships between groups, interviews, emergency events and What PHEPR practices are observations, documentary consequences in a particular needed, and what would analysis)
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Perspectives Design and To inform the design and What is the PHEPR practice, Qualitative studies (focus Development, development of new or how is it intended to work, groups, interviews, Including improved PHEPR practices and what outcomes is it observations) Feasibility and that will address particular designed to achieve and Pilot Testing problems in PHEPR.
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Perspectives Quantitative To determine whether Is activating public health Randomized controlled Impact Evaluation PHEPR practices are emergency operations trials, quasi-experimental effective or work as centers [specify studies (matched intended to achieve the components] more comparison group studies, desired outcomes; to effective than the status interrupted time series, understand the benefits and quo approach (commonly regression discontinuity harms of PHEPR practices.
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Perspectives Systems and To use quantitative In what circumstances (e.g., Statistical and mathematical Operations approaches to analyze based on biologic factors, modeling, simulation Research strategic, tactical, and risks, resource availability, modeling, queueing theory, operational aspects of public legal authorities, social optimization health emergency response context) is quarantine to improve preparedness effective at reducing or policies or practices.
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2015. Development of an online toolkit for measuring performance in health emergency response exercises.
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2019. Public health emergency preparedness (PHEP)
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2020. Public health emergency research review board (PHERRB)
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2013. Research as a part of public health emergency response.
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Paper commissioned by the Committee on Evidence-Based Practices for Public Health Emergency Preparedness and Response. Patsopoulos, N
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American Journal of Community Psychology 41(3–4)
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