Americans' Attitudes Toward COVID-19 Preventive and Mitigation Behaviors and Implications for Public Health Communication.

PURPOSE: Identifying drivers of behavior is essential to develop effective messaging around COVID-19 prevention and mitigation. Our study assessed for behavioral antecedents of social distancing, wearing face coverings, and sheltering in place during the onset of the COVID-19 pandemic. Although ours is an early assessment, understanding motivation for behavior will remain critical as U.S. vaccination uptake has stalled and variants continue to pose a health threat. DESIGN: Cross-sectional survey; Setting: Online assessments in April 10-13 and 17-20, 2020; Subjects: 2,279 U.S. adults identified through a national, probability-based web panel (34% response rate). Measures: self-reported behavior, perceived effectiveness and risk, worry, social norms, and knowledge. ANALYSIS: Multivariable regression analyses. RESULTS: Most Americans reported social distancing (91%) and sheltering in place (86%). Just over half reported wearing face coverings (51%), whereas more (77%) said they intended to do so. Perceived effectiveness of the behavior was consistently associated with each outcome (OR = 2.34, 1.40, 2.11, respectively; all P < .01). Perceptions about the extent to which others should comply with behavior (social norms) were strongly associated with intentions to wear a face covering only (OR = 6.30, 95% CI 4.34-9.15; P < .001) and worry about getting COVID-19 was associated with sheltering in place and social distancing (OR = 2.63, 95% CI 1.15-5.00; 4.91, 95% CI 1.66, 14.50, respectively; all P < .05). CONCLUSION: Behavioral constructs were strongly associated with COVID-19 preventive and mitigation behaviors and have implications for communication.

Predictors of willingness to get a COVID-19 vaccine in the U.S.

BACKGROUND: As COVID-19 vaccine distribution efforts continue, public health workers can strategize about vaccine promotion in an effort to increase willingness among those who may be hesitant. METHODS: In April 2020, we surveyed a national probability sample of 2279 U.S. adults using an online panel recruited through address-based sampling. Households received a computer and internet access if needed to participate in the panel. Participants were invited via e-mail and answered online survey questions about their willingness to get a novel coronavirus vaccine when one became available. The survey was completed in English and Spanish. We report weighted percentages. RESULTS: Most respondents were willing to get the vaccine for themselves (75%) or their children (73%). Notably, Black respondents were less willing than White respondents (47% vs. 79%, p < 0.001), while Hispanic respondents were more willing than White respondents (80% vs. 75%, p < 0.003). Females were less likely than makes (72% vs. 79%, p < 0.001). Those without insurance were less willing than the insured (47% vs. 78%, p < 0.001). Willingness to vaccinate was higher for those age 65 and older than for some younger age groups (85% for those 65 and older vs. 75% for those 50-64, p < 0.017; 72% for those 35-49, p < 0.002; 70% for those 25-34, p = NS and 75% for ages 18-24, p = NS), but other groups at increased risk because of underlying medical conditions or morbid obesity were not more willing to get vaccinated than their lower risk counterparts. CONCLUSIONS: Most Americans were willing to get a COVID-19 vaccine, but several vulnerable populations reported low willingness. Public health efforts should address these gaps as national implementation efforts continue.

Improving referrals and integrating family planning and HIV services through organizational network strengthening.

BACKGROUND: The service needs of people with human immunodeficiency virus (HIV) in low-income settings are wide-ranging. Service provision in a community is often disjointed among a variety of providers. We sought to reduce unmet patient needs by increasing referral coordination for HIV and family planning, measured as network density, with an organizational network approach. METHODS: We conducted organizational network analysis on two networks in sub-cities of Addis Ababa, Ethiopia. There were 25 organizations in one sub-city network and 26 in the other. In one of them we sought to increase referrals through three network strengthening meetings. We then conducted the network analysis again in both sub-cities to measure any changes since baseline. We also quantitatively measured reported client service needs in both sub-cities before and after the intervention with two cross-sectional samples of face-to-face interviews with clients (459 at baseline and 587 at follow-up). RESULTS: In the sub-city with the intervention, the number of referral connections between organizations, measured as network density, increased 55%. In the control community, the density decreased over the same period. Reported unmet client service needs declined more consistently across services in the intervention community. DISCUSSION: This quasi experiment demonstrated that (1) an organizational network analysis can inform an intervention, (2) a modest network strengthening intervention can enhance client referrals in the network, (3) improvement in client referrals was accompanied by a decrease in atient-reported unmet needs and (4) a series of network analyses can be a useful evaluation tool.

Patterns in PARTNERing across Public Health Collaboratives.

Inter-organizational networks represent one of the most promising practice-based approaches in public health as a way to attain resources, share knowledge, and, in turn, improve population health outcomes. However, the interdependencies and effectiveness related to the structure, management, and costs of these networks represents a critical item to be addressed. The objective of this research is to identify and determine the extent to which potential partnering patterns influence the structure of collaborative networks. This study examines data collected by PARTNER, specifically public health networks (n = 162), to better understand the structured relationships and interactions among public health organizations and their partners, in relation to collaborative activities. Combined with descriptive analysis, we focus on the composition of public health collaboratives in a series of Exponential Random Graph (ERG) models to examine the partnerships between different organization types to identify the attribute-based effects promoting the formation of network ties within and across collaboratives. We found high variation within and between these collaboratives including composition, diversity, and interactions. The findings of this research suggest common and frequent types of partnerships, as well as opportunities to develop new collaborations. The result of this analysis offer additional evidence to inform and strengthen public health practice partnerships.

New perspectives on the "silo effect": initial comparisons of network structures across public health collaboratives.

OBJECTIVES: We explored to what extent "silos" (preferential partnering) persist in interorganizational boundaries despite advances in working across boundaries. We focused on organizational homophily and resulting silo effects within networks that might both facilitate and impede success in public health collaboratives (PHCs). METHODS: We analyzed data from 162 PHCs with a series of exponential random graph models to determine the influence of uniform and differential homophily among organizations and to identify the propensity for partnerships with similar organizations. RESULTS: The results demonstrated a low presence (8%) of uniform homophily among networks, whereas a greater number (30%) of PHCs contained varying levels of differential homophily by 1 or more types of organization. We noted that the higher frequency among law enforcement, nonprofits, and public health organizations demonstrated a partner preference with similar organizations. CONCLUSIONS: Although we identified only a modest occurrence of partner preference in PHCs, overall success in efforts to work across boundaries might be problematic when public health members (often leaders of PHCs) exhibit the tendency to form silos.

Effects of performance improvement programs on preparedness capacities.

OBJECTIVE: In response to public health systems and services research priorities, we examined the extent to which participation in accreditation and performance improvement programs can be expected to enhance preparedness capacities. METHODS: Using data collected by the Local Health Department Preparedness Capacities Assessment Survey, we applied a series of weighted least-squares models to examine the effect of program participation on each of the eight preparedness domain scores. Participation was differentiated across four groups: North Carolina (NC) accredited local health departments (LHDs), NC non-accredited LHDs, national comparison LHDs that participated in performance or preparedness programs, and national comparison LHDs that did not participate in any program. RESULTS: Domain scores varied among the four groups. Statistically significant positive participation effects were observed on six of eight preparedness domains for NC accreditation programs, on seven domains for national comparison group LHDs that participated in performance programs, and on four domains for NC non-accredited LHDs. CONCLUSIONS: Overall, accreditation and other performance improvement programs have a significant and positive effect on preparedness capacities. While we found no differences among accredited and non-accredited NC LHDs, this lack of significant difference in preparedness scores among NC LHDs is attributed to NC's robust statewide preparedness program, as well as a likely exposure effect among non-accredited NC LHDs to the accreditation program.

Institutional facilitators and barriers to local public health preparedness planning for vulnerable and at-risk populations.

OBJECTIVE: Numerous institutional facilitators and barriers to preparedness planning exist at the local level for vulnerable and at-risk populations. Findings of this evaluation study contribute to ongoing practice-based efforts to improve response services and address public health preparedness planning and training as they relate to vulnerable and at-risk populations. METHODS: From January 2012 through June 2013, we conducted a multilevel, mixed-methods evaluation study of the North Carolina Preparedness and Emergency Response Research Center's Vulnerable & At-Risk Populations Resource Guide, an online tool to aid local health departments' (LHDs') preparedness planning efforts. We examined planning practices across multiple local, regional, and state jurisdictions utilizing user data, follow-up surveys, and secondary data. To identify potential incongruities in planning, we compared respondents' reported populations of interest with corresponding census data to determine whether or not there were differences in planning priorities. RESULTS: We used data collected from evaluation surveys to identify key institutional facilitators and barriers associated with planning for at-risk populations, including challenges to conducting assessments and lack of resources. Results identified both barriers within institutional culture and disconnects between planning priorities and evidence-based identification of vulnerable and at-risk populations, including variation in the planning process, partnerships, and perceptions. CONCLUSIONS: Our results highlight the important role of LHDs in preparedness planning and the potential implications associated with organizational and bureaucratic impediments to planning implementation. A more in-depth understanding of the relationships among public institutions and the levels of preparedness that contribute to the conditions and processes that generate vulnerability is needed.

Declining trends in local health department preparedness capacities.

OBJECTIVES: We examined local health department (LHD) preparedness capacities in the context of participation in accreditation and other performance improvement efforts. MetHODS: We analyzed preparedness in 8 domains among LHDs responding to a preparedness capacity instrument from 2010 through 2012. Study groups included LHDs that (1) were exposed to a North Carolina state-based accreditation program, (2) participated in 1 or more performance improvement programs, and (3) had not participated in any performance improvement programs. We analyzed mean domain preparedness scores and applied a series of nonparametric Mann-Whitney Wilcoxon tests to determine whether preparedness domain scores differed significantly between study groups from 2010 to 2012. RESULTS: Preparedness capacity scores fluctuated and decreased significantly for all study groups for 2 domains: surveillance and investigation and legal preparedness. Significant decreases also occurred among participants for plans and protocols, communication, and incident command. Declines in capacity scores were not as great and less likely to be significant among North Carolina LHDs. CONCLUSIONS: Decreases in preparedness capacities over the 3 survey years may reflect multiple years of funding cuts and job losses, specifically for preparedness. An accreditation program may have a protective effect against such contextual factors.

Integration opportunities for HIV and family planning services in Addis Ababa, Ethiopia: an organizational network analysis.

BACKGROUND: Public health resources are often deployed in developing countries by foreign governments, national governments, civil society and the private health clinics, but seldom in ways that are coordinated within a particular community or population. The lack of coordination results in inefficiencies and suboptimal results. Organizational network analysis can reveal how organizations interact with each other and provide insights into means of realizing better public health results from the resources already deployed. Our objective in this study was to identify the missed opportunities for the integration of HIV care and family planning services and to inform future network strengthening. METHODS: In two sub-cities of Addis Ababa, we identified each organization providing either HIV care or family planning services. We interviewed representatives of each of them about exchanges of clients with each of the others. With network analysis, we identified network characteristics in each sub-city network, such as referral density and centrality; and gaps in the referral patterns. The results were shared with representatives from the organizations. RESULTS: The two networks were of similar size (25 and 26 organizations) and had referral densities of 0.115 and 0.155 out of a possible range from 0 (none) to 1.0 (all possible connections). Two organizations in one sub-city did not refer HIV clients to a family planning organization. One organization in one sub-city and seven in the other offered few HIV services and did not refer clients to any other HIV service provider. Representatives from the networks confirmed the results reflected their experience and expressed an interest in establishing more links between organizations. CONCLUSIONS: Because of organizations not working together, women in the two sub-cities were at risk of not receiving needed family planning or HIV care services. Facilitating referrals among a few organizations that are most often working in isolation could remediate the problem, but the overall referral densities suggests that improved connections throughout might benefit conditions in addition to HIV and family planning that need service integration.

Accreditation and emergency preparedness: linkages and opportunities for leveraging the connections.

BACKGROUND: Public health officials must frequently demonstrate the quality and value of public health services, especially during challenging fiscal climates. One of the ways that public health quality and accountability have been demonstrated is through the use of accreditation and standard setting initiatives. OBJECTIVE: The objective of this analysis was to identify existing alignment opportunities between standards established by the Public Health Accreditation Board (PHAB) and the Centers for Disease Control and Prevention's (CDC's) public health preparedness (PHP) capabilities in order to optimize and leverage the connections for state and local public health professionals. DESIGN: During March-May 2012, a PHAB/PHP crosswalk was developed by a research team from the CDC's Office for State, Tribal, Local and Territorial Support and Office of Public Health Preparedness and Response's Division of State and Local Readiness to examine the intersection of the PHP capabilities and the PHAB standards. The PHAB/PHP crosswalk used the CDC Public Health Preparedness Capabilities: National Standards for State and Local Planning (PHP Capabilities) and the PHAB Standards and Measures, Version 1.0 (PHAB Standards) as its source documents. To help illustrate the results of the crosswalk, alignment was also depicted through a network graph to transform the results into a visual depiction of the linkages between PHP capabilities and PHAB standards. RESULTS: The most direct links to emergency preparedness were found in PHAB Domains 2 and 5. Opportunities for improved alignment were found throughout the standard documents, particularly in PHAB Domains 3, 8, and 11. The most direct links to accreditation were found in PHP capabilities 1, 2, 3, and 4. CONCLUSIONS: The results highlight the synergy between the infrastructure and foundational elements represented by accreditation and targeted programmatic activities supported by preparedness funding.

Improving public health preparedness capacity measurement: development of the local health department preparedness capacities assessment survey.

OBJECTIVE: To address limitations in measuring the preparedness capacities of health departments, we developed and tested the Local Health Department Preparedness Capacities Assessment Survey (PCAS). METHODS: Preexisting instruments and a modified 4-cycle Delphi panel process were used to select instrument items. Pilot test data were analyzed using exploratory factor analysis. Kappa statistics were calculated to examine rater agreement within items. The final instrument was fielded with 85 North Carolina health departments and a national matched comparison group of 248 health departments. RESULTS: Factor analysis identified 8 initial domains: communications, surveillance and investigation, plans and protocols, workforce and volunteers, legal infrastructure, incident command, exercises and events, and corrective action. Kappa statistics and z scores indicated substantial to moderate agreement among respondents in 7 domains. Cronbach α coefficients ranged from 0.605 for legal infrastructure to 0.929 for corrective action. Mean scores and standard deviations were also calculated for each domain and ranged from 0.41 to 0.72, indicating sufficient variation in the sample to detect changes over time. CONCLUSION: The PCAS is a useful tool to determine how well health departments are performing on preparedness measures and identify opportunities for future preparedness improvements. Future survey implementation will incorporate recent Centers for Disease Control and Prevention's Public Health Preparedness Capabilities: National Standards for State and Local Planning.

Assessing the roles of brokerage: an evaluation of a hospital-based Public Health epidemiologist program in North Carolina.

CONTEXT: The North Carolina Division of Public Health established an innovative program in 2003 that placed public health epidemiologists (PHEs) in hospitals around the state to improve communication between hospitals and local public health departments (LHDs) and bolster public health surveillance and response. OBJECTIVE: To use social network analysis to assess how the hospital-based PHE program in North Carolina facilitates the exchange of public health surveillance information. DESIGN: Using a Gould-Fernandez brokerage analysis, this study examines communication among organizational actors and their dependence on third parties to broker information and knowledge. PARTICIPANTS: Survey and interview data were collected to identify the interorganizational network among 220 organizational actors and their public health surveillance-related activities, including 11 PHEs, 100 county-level offices of North Carolina's 85 LHDs, and 109 hospitals. MAIN OUTCOME MEASURES: Social network analysis is used to calculate the frequency with which an actor serves as an intermediary in each of the 5 brokerage roles as well as total brokerage equal to the sum of the number of times an actor occupies each role. RESULTS: Results identify a frequent tendency for PHEs to serve as an intermediary between LHDs and hospitals. Interactions between these entities are frequently facilitated by PHEs, with a high measure of degree centrality by LHDs and a low frequency of brokerage among hospitals. CONCLUSIONS: Results validate PHEs' mission to enhance communication between LHDs and hospitals around communicable disease surveillance, reporting, and management.

Linking public health agencies and hospitals for improved emergency preparedness: North Carolina's public health epidemiologist program.

BACKGROUND: In 2003, 11 public health epidemiologists were placed in North Carolina's largest hospitals to enhance communication between public health agencies and healthcare systems for improved emergency preparedness. We describe the specific services public health epidemiologists provide to local health departments, the North Carolina Division of Public Health, and the hospitals in which they are based, and assess the value of these services to stakeholders. METHODS: We surveyed and/or interviewed public health epidemiologists, communicable disease nurses based at local health departments, North Carolina Division of Public Health staff, and public health epidemiologists' hospital supervisors to 1) elicit the services provided by public health epidemiologists in daily practice and during emergencies and 2) examine the value of these services. Interviews were transcribed and imported into ATLAS.ti for coding and analysis. Descriptive analyses were performed on quantitative survey data. RESULTS: Public health epidemiologists conduct syndromic surveillance of community-acquired infections and potential bioterrorism events, assist local health departments and the North Carolina Division of Public Health with public health investigations, educate clinicians on diseases of public health importance, and enhance communication between hospitals and public health agencies. Stakeholders place on a high value on the unique services provided by public health epidemiologists. CONCLUSIONS: Public health epidemiologists effectively link public health agencies and hospitals to enhance syndromic surveillance, communicable disease management, and public health emergency preparedness and response. This comprehensive description of the program and its value to stakeholders, both in routine daily practice and in responding to a major public health emergency, can inform other states that may wish to establish a similar program as part of their larger public health emergency preparedness and response system.

Mapping convergence points in the initial emergency response to 9/11.

In response to extreme events, researchers have recognised the convergence of volunteers, emergency responders, and other individuals and organisations. In 2000, geographer Paul Routledge presented the concept of convergence spaces as a theoretical means to explain social movements. In applying this concept, this paper explores the geographic space in which organisations and individuals converged immediately following the 11 September 2001 attacks on the World Trade Center. The paper begins to answer the question of whether there were in fact any patterns of convergence among the locations utilised by organisations responding to the attacks. Using data collected from field documents, these geographic locations are mapped over 12 days to help identify possible patterns of clustering. Results of this analysis will begin to provide researchers, policy makers and practitioners with a better understanding of how emergency response evolves geographically following an event.