Use of Digital COVID-19 Exposure Notifications at a Large Gathering: Survey Analysis of Public Health Conference Attendees.

BACKGROUND: WA Notify was Washington State's smartphone-based COVID-19 digital exposure notification (EN) tool, which was used to help limit the spread of COVID-19 between November 30, 2020, and May 11, 2023. Following the 2022 Washington State Public Health Association Annual Conference, attendees who had WA Notify activated began receiving ENs alerting them to a possible COVID-19 exposure during the conference. A survey was emailed to all conference attendees to measure WA Notify adoption, mechanisms through which attendees received ENs, and self-reported engagement in protective behaviors postexposure. OBJECTIVE: This study aimed to learn more about the experiences of WA Notify adopters and nonadopters who may have been exposed to COVID-19 at a large group gathering. METHODS: A web-based survey administered through REDCap (Research Electronic Data Capture; Vanderbilt University) was sent to all attendees of the Washington State Public Health Association conference. Self-reported demographic information and characteristics of respondents were summarized. Regression models were used to estimate relative risks to compare WA Notify adoption and testing behaviors between groups. RESULTS: Of the 464 total registered attendees who were sent the survey, 205 (44%) responses were received; 201 eligible attendees were included in this analysis. Of those, 149 (74%) respondents reported having WA Notify activated on their phones at the time of the conference. Among respondents with WA Notify activated, 54% (n=77) reported learning of their potential exposure from a WA Notify EN. Respondents who reported that they did not have WA Notify activated and learned of their potential exposure via the event-wide email from conference organizers were 39% less likely to test for COVID-19 compared to respondents with WA Notify activated who learned of their potential exposure from the email (relative risk 0.61, 95% CI 0.40-0.93; P=.02), and this gap was even larger when compared to respondents who learned of their exposure from a WA Notify EN. The most commonly cited reason for not having WA Notify activated was privacy concerns (n=17, 35%), followed by not wanting to receive ENs (n=6, 12%) and being unaware of WA Notify (n=5, 10%). CONCLUSIONS: Digital EN systems are an important tool to directly and anonymously notify close contacts of potential exposures and provide guidance on the next steps in a timely manner. Given the privacy concerns, there is still a need for increasing transparency surrounding EN technology to increase uptake by the public if this technology were to be used in the future to slow the spread of communicable diseases.

Development and Evaluation of an Online Toolkit for Managers of 9-1-1 Emergency Communications Centers to Reduce Occupational Stress.

This article describes the development and evaluation of an online workplace stress reduction toolkit for use by managers of 9-1-1 emergency communication centers (ECCs). A three-step process for development and testing of digital learning resources was used: (1) establishing need and focus through ECC manager stakeholder engagement, (2) pretesting of the toolkit with the target ECC manager audience, and (3) toolkit utilization and evaluation. The toolkit was developed in close partnership with stakeholders throughout the entire process. Toolkit usage was documented via registration data. The evaluation utilized an online survey that included closed and open-ended questions, which were analyzed using descriptive statistics and qualitative thematic analysis. Over a 20-month period, 274 people registered for the toolkit and, of those, 184 (67%) accessed the content. Respondents to the evaluation survey (N = 156) scored the toolkit highly on satisfaction, self-efficacy, and perceived utility measures. Survey respondents reported intent to apply toolkit content through the following: providing organizational resources to help workers take better care of themselves (41%); creating a lower stress worksite environment (35%) and sharing resources with staff to (1) reduce stress (19%), (2) support conflict resolution (21%), and (3) prevent and/or stop bullying (17%). In delivering actionable content to ECC managers, the toolkit shows promise in addressing and mitigating occupational stress in ECCs. Further research needs to determine the relationship of this strategy for reducing ECC stress.

Trading-off privacy and utility: the Washington State experience assessing the performance of a public health digital exposure notification system for coronavirus disease 2019.

OBJECTIVE: Digital exposure notifications (DEN) systems were an emergency response to the coronavirus disease 2019 (COVID-19) pandemic, harnessing smartphone-based technology to enhance conventional pandemic response strategies such as contact tracing. We identify and describe performance measurement constructs relevant to the implementation of DEN tools: (1) reach (number of users enrolled in the intervention); (2) engagement (utilization of the intervention); and (3) effectiveness in preventing transmissions of COVID-19 (impact of the intervention). We also describe WA State's experience utilizing these constructs to design data-driven evaluation approaches. METHODS: We conducted an environmental scan of DEN documentation and relevant publications. Participation in multidisciplinary collaborative environments facilitated shared learning. Compilation of available data sources and their relevance to implementation and operation workflows were synthesized to develop implementation evaluation constructs. RESULTS: We identified 8 useful performance indicators within reach, engagement, and effectiveness constructs. DISCUSSION: We use implementation science to frame the evaluation of DEN tools by linking the theoretical constructs with the metrics available in the underlying disparate, deidentified, and aggregate data infrastructure. Our challenges in developing meaningful metrics include limited data science competencies in public health, validation of analytic methodologies in the complex and evolving pandemic environment, and the lack of integration with the public health infrastructure. CONCLUSION: Continued collaboration and multidisciplinary consensus activities can improve the utility of DEN tools for future public health emergencies.

Engagement in Protective Behaviors by Digital Exposure Notification Users During the COVID-19 Pandemic, Washington State, January-June 2021.

OBJECTIVES: Smartphone-based digital exposure notification (EN) tools were introduced during the COVID-19 pandemic to supplement strained case investigation and contact tracing efforts. We examined the influence of an EN tool implemented in Washington State, WA Notify, on user engagement in behaviors that protect against COVID-19 transmission. METHODS: From January 25 through June 30, 2021, we administered 2 surveys to WA Notify users who received notification of a possible COVID-19 exposure. The initial survey, sent when users received a notification, focused on intent to engage in protective behaviors. The follow-up survey captured data on self-reported actual engagement in protective behaviors and contact by a public health contact tracer. RESULTS: Of 1507 WA Notify users who completed the initial survey, 40.1% (n = 604) reported intending to seek COVID-19 testing and 67.1% (n = 1011) intended to watch for COVID-19 symptoms. Of 407 respondents to the follow-up survey, 57.5% (n = 234) reported getting tested and 84.3% (n = 343) reported watching for COVID-19 symptoms. Approximately 84% (n = 1266) of respondents to the initial survey received a notification from WA Notify before being reached by public health contact tracers; on follow-up, 42.5% (n = 173) of respondents reported never being contacted by public health. CONCLUSIONS: Our findings suggest that WA Notify users may initiate protective behaviors earlier than nonusers who will not know of an exposure until notified by public health or by a known contact. Digital EN tools may be a valuable addition to existing public health outbreak investigation and response activities.

Equity and Accessibility of Washington State's COVID-19 Digital Exposure Notification Tool (WA Notify): Survey and Listening Sessions Among Community Leaders.

BACKGROUND: In November 2020, WA Notify, Washington State's COVID-19 digital exposure notification tool, was launched statewide to mitigate ongoing COVID-19 transmission. WA Notify uses the Bluetooth proximity-triggered, Google/Apple Exposure Notification Express framework to distribute notifications to users who have added or activated this tool on their smartphones. This smartphone-based tool relies on sufficient population-level activation to be effective; however, little is known about its adoption among communities disproportionately impacted by the COVID-19 pandemic or what barriers might limit its adoption and use among diverse populations. OBJECTIVE: We sought to (1) conduct a formative exploration of equity-related issues that may influence the access, adoption, and use of WA Notify, as perceived by community leaders of populations disproportionately impacted by the COVID-19 pandemic; and (2) generate recommendations for promoting the equitable access to and impact of this novel intervention for these communities. METHODS: We used a 2-step data collection process to gather the perspectives of community leaders across Washington regarding the launch and implementation of WA Notify in their communities. A web-based, brief, and informational survey measured the perceptions of the community-level familiarity and effectiveness of WA Notify at slowing the spread of COVID-19 and identified potential barriers and concerns to accessing and adopting WA Notify (n=17). Semistructured listening sessions were conducted to expand upon survey findings and explore the community-level awareness, barriers, facilitators, and concerns related to activating WA Notify in greater depth (n=13). RESULTS: Our findings overlap considerably with those from previous mobile health equity studies. Digital literacy, trust, information accessibility, and misinformation were highlighted as key determinants of the adoption and use of WA Notify. Although WA Notify does not track users or share data, community leaders expressed concerns about security, data sharing, and personal privacy, which were cited as outweighing the potential benefits to adoption. Both the survey and informational sessions indicated low community-level awareness of WA Notify. Community leaders recommended the following approaches to improve engagement: tailoring informational materials for low-literacy levels, providing technology navigation, describing more clearly that WA Notify can help the community, and using trusted messengers who are already engaged with the communities to communicate about WA Notify. CONCLUSIONS: As digital public health tools, such as WA Notify, emerge to address public health problems, understanding the key determinants of adoption and incorporating equity-focused recommendations into the development, implementation, and communication efforts around these tools will be instrumental to their adoption, use, and retention.

WA Notify: the planning and implementation of a Bluetooth exposure notification tool for COVID-19 pandemic response in Washington State.

Bluetooth exposure notification tools for mobile phones have emerged as one way to support public health contact tracing and mitigate the spread of COVID-19. Many states have launched their own versions of these tools. Washington State's exposure notification tool, WA Notify, became available on November 30, 2020, following a one-month Seattle campus pilot at the University of Washington. By the end of April 2021, 25% of the state's population had activated WA Notify, one of the highest adoption rates in the country. Washington State's formation of an Exposure Notification Advisory Committee, early pilot testing, and use of the EN Express system framework were all important factors in its adoption. Continuous monitoring and willingness to make early adjustments such as switching to automated texting of verification codes have also been important for improving the tool's value. Evaluation work is ongoing to determine and quantify WA Notify's effectiveness, timeliness, and accessibility.

Mixed-Methods Evaluation of the Washington State Practice Transformation Support Hub.

PURPOSE: Practice transformation initiatives have the potential to promote collaborations between public health, primary care, and behavioral health, but limited empirical evidence is available on how these programs affect participating clinical practices. OBJECTIVE: To report the findings from a mixed-methods program evaluation of the Washington Practice Transformation Support Hub (Hub), a publicly funded, multicomponent practice transformation initiative in Washington State. DESIGN: We used quantitative and qualitative methods to evaluate the impact of Hub activities on participating primary care and behavioral health practices. Pre- and posttest survey data were combined with administrative program data to understand the effect of program components. Qualitative interviews contextualized findings. SETTING: Urban and rural primary care and behavioral health practices in Washington State. PARTICIPANTS: One hundred seventy-five practices that were recruited to receive Hub coaching and facilitation from 8 coaches; of these, 13 practices and all coaches participated in key informant interviews. INTERVENTION: Practice coaching and facilitation supported by an online resource portal, from January 2017 through January 2019. MAIN OUTCOME MEASURES: Self-reported progress in specific activities in 3 practice-level domains: bidirectional integration of physical and behavioral health care (care integration); alignment with community-based services for whole-person care (clinical-community linkages); and value-based payment. RESULTS: Participation in Hub activities was associated with improvements in care integration and clinical-community linkages but not with progress toward value-based payment. Qualitative results indicated that practice progress was influenced by communication with practices, the culture of the practice, resource constraints (particularly in rural areas), and perceptions about sustainability. CONCLUSIONS: This statewide practice transformation initiative was successful in strengthening primary care and behavioral health integration and clinical-community linkages among participating practices but not value-based payment. Future practice transformation efforts may benefit from addressing barriers posed by communication, limited application of value-based payment, culture change, competing priorities, and resource limitations, particularly for rural communities.

A Revised Ecological Model of Occupational Stress: Applications to 9-1-1 Telecommunicators.

Background: A cohesive body of scientific evidence has documented the adverse impacts of occupational stress on worker health and safety and, to a lesser extent, on organizational outcomes. How such adverse impacts may be prevented and/or ameliorated are important to understand, but progress has been limited due to the lack of a robust and comprehensive theoretical model of occupational stress. Methods: Building on a review of existing theoretical models of occupational stress and an ecological framework, a multilevel conceptual model of occupational stress and strain is proposed that identifies various and potentially interacting sources of occupational stressors as well as potential protective factors. Results: The revised ecological model proposed herein embraces a broad conceptualization of outcomes and includes an individual worker, work unit (team) performance as well as organizational level outcomes; for example, resilience/dysfunction. Conclusion/Application to Practice: This model provides occupational health nurses with an improved understanding of occupational and worker health as well as guidance in developing targeted interventions and generating new lines of occupational stress research.

Improving Notifiable Disease Case Reporting Through Electronic Information Exchange-Facilitated Decision Support: A Controlled Before-and-After Trial.

OBJECTIVE: Outbreak detection and disease control may be improved by simplified, semi-automated reporting of notifiable diseases to public health authorities. The objective of this study was to determine the effect of an electronic, prepopulated notifiable disease report form on case reporting rates by ambulatory care clinics to public health authorities. METHODS: We conducted a 2-year (2012-2014) controlled before-and-after trial of a health information exchange (HIE) intervention in Indiana designed to prepopulate notifiable disease reporting forms to providers. We analyzed data collected from electronic prepopulated reports and "usual care" (paper, fax) reports submitted to a local health department for 7 conditions by using a difference-in-differences model. Primary outcomes were changes in reporting rates, completeness, and timeliness between intervention and control clinics. RESULTS: Provider reporting rates for chlamydia and gonorrhea in intervention clinics increased significantly from 56.9% and 55.6%, respectively, during the baseline period (2012) to 66.4% and 58.3%, respectively, during the intervention period (2013-2014); they decreased from 28.8% and 27.5%, respectively, to 21.7% and 20.6%, respectively, in control clinics (P < .001). Completeness improved from baseline to intervention for 4 of 15 fields in reports from intervention clinics (P < .001), although mean completeness improved for 11 fields in both intervention and control clinics. Timeliness improved for both intervention and control clinics; however, reports from control clinics were timelier (mean, 7.9 days) than reports from intervention clinics (mean, 9.7 days). CONCLUSIONS: Electronic, prepopulated case reporting forms integrated into providers' workflow, enabled by an HIE network, can be effective in increasing notifiable disease reporting rates and completeness of information. However, it was difficult to assess the effect of using the forms for diseases with low prevalence (eg, salmonellosis, histoplasmosis).

Unmet needs and opportunities for improving care for patients with advanced lung cancer on targeted therapies: a qualitative study.

OBJECTIVE: Lung cancer is increasingly recognised as a heterogeneous disease. Recent advances with targeted therapies for lung cancer with oncogenic mutations have greatly improved the prognosis for this subset of patients, yet little is known about their experiences. This study aimed to identify the needs and explore the healthcare experiences of these advanced patients with oncogenic mutation driven lung cancer. DESIGN: Qualitative interviews with patients with advanced or metastatic non-small cell lung cancer with oncogenic alterations in anaplastic lymphoma kinase, epidermal growth factor receptor or c-ros oncogene 1. SETTINGS: Patients were recruited from online lung cancer support groups within the USA. Interviews were conducted remotely or in person, transcribed verbatim and analysed using an iterative inductive and deductive process. PARTICIPANTS: We included 39 patients (11 males and 28 females) with a median age of 48. RESULTS: Two primary theme categories emerged: patients' unmet needs and improving healthcare experiences. Unmet needs are related to patients' desire to view their disease as a chronic illness, aspire to live a meaningful existence without financial devastation, desire for understanding along with emotional support and needing help with practical matters. Improving healthcare experiences involved patients' desire to trust the expertise of clinical providers, receive reliable care and be treated holistically and as informed partners. CONCLUSIONS: Patients with lung cancer with oncogenic mutations live uncharted experiences. Targeted therapy brings hope, but uncertainty is daunting. Patients grapple with the meaning and purpose of their lives while day-to-day obligations remain challenging. Healthcare teams are instrumental in their care experiences, and patients desire providers who are up-to-date on advances in the field and treat them as whole persons.

Prescription drug monitoring program use and utility by Washington State pharmacists: A mixed-methods study.

OBJECTIVES: To explore factors and situations that influence pharmacists to use the prescription drug monitoring program (PDMP) and to characterize actions taken by pharmacists after alarming scenarios from a PDMP query. DESIGN: Explanatory sequential 2-phase mixed-methods design: (1) cross-sectional Web-based survey of Washington State pharmacists followed by (2) interviews with purposefully selected respondents to explore statistically significant quantitative findings. SETTING AND PARTICIPANTS: The study was conducted in Washington State from September 2018 to February 2019. A total of 967 Washington State pharmacists from various practice settings, including inpatient and outpatient pharmacies, participated. Ten outpatient pharmacists were interviewed in the second phase. OUTCOME MEASURES: The pharmacists reported the frequency of PDMP use, opinion on the usefulness of PDMP, and action(s) taken after a concerning PDMP report. RESULTS: The usable response rate for pharmacists with a PDMP account was 17.6% (818/4659), and usable response rate for all pharmacists was 10.4% (967/9263). PDMP use varied by race, practice setting, and employer policy on PDMP use. Among the 818 PDMP users, 396 (48%) used the database at least once during a shift. Frequent PDMP users were more likely to recommend naloxone compared with less frequent users (adjusted odds ratio 1.70 [95% CI 1.09-2.65], P = 0.02). The following 3 interview themes were identified: time, company policy, and red flags. CONCLUSION: PDMP has value to pharmacists of all practice settings studied. Frequent PDMP use may facilitate more pharmacist interventions, such as a naloxone prescription.

Enhancing Access to Quality Online Training to Strengthen Public Health Preparedness and Response.

OBJECTIVES: To improve access to quality online training materials developed from 2010 to 2015 by 14 Preparedness and Emergency Response Learning Centers (PERLCs) by creating quality standards and enhancing searchability through a new Web-based public health training catalog. METHODS: The PERLC-developed training materials (n = 530) were evaluated for their capability to support development of preparedness competencies as established by 2 evidence-based competency frameworks. Inclusion/exclusion criteria and evaluation guidelines regarding training quality (design, technology, and instructional components) were systematically applied to PERLC products to create a training catalog. Twenty emergency preparedness professionals pilot tested content and provided feedback to improve catalog design and function. RESULTS: Seventy-eight percent of PERLC resources (n = 413) met our quality standards for inclusion in the catalog's searchable database: 358 self-paced courses, 55 informational briefs, and other materials. Twenty-one training bundles were curated. DISCUSSION: We established quality guidelines, identified strengths and weaknesses in PERLC resources, and improved accessibility to trainings. Guidelines established by this work can be generalized to trainings outside the preparedness domain. Enhancing access to quality training resources can serve as a valuable tool for increasing emergency preparedness competence.

Field-based evaluation of malaria outbreak detection and response in Mudzi and Goromonzi districts, Zimbabwe - 2017.

National-level evaluations may fail to identify capacity improvements for detecting and responding to outbreaks which begin and are first detected at the local level. In response to this issue, we conducted a field-based assessment of the malaria outbreak surveillance system in Mashonaland East, Zimbabwe. We visited eleven clinics in Mudzi and Goromonzi districts. Twenty-one interviews were conducted with key informants from the provincial (n = 2), district (n = 7), and clinic (n = 12) levels. Interviews focused on surveillance system activities, preparedness, data quality, timeliness, stability, and usefulness. Main themes were captured utilising standard qualitative data analysis techniques. While the surveillance system detects malaria outbreaks at all levels, we identified several gaps. Clinics experience barriers to timely and reliable reporting of outbreaks to the district level and staff cross-training. Stability of resources, including transportation (33% of informants, n = 7) and staff capacity (48% of informants, n = 10), presented barriers. Strengthening these surveillance barriers may improve staff readiness to detect malaria outbreaks, resulting in timelier outbreak response and a reduction in malaria outbreaks, cases, and deaths. By focusing at the local level, our assessment approach provides a framework for identifying and addressing gaps that may be overlooked when utilising tools that evaluate surveillance capacity at the national level.

Algorithmic Generation of Grammar Simplification Rules Using Large Corpora.

There is often a discontinuity between patients' literacy level and educational materials. In response, we are developing an online medical text simplification editor. In this paper, we describe generating grammar simplification rules from a large parallel corpus (N=141,500) containing original sentences and their simplified variants. We algorithmically identified grammatical transformations between sentences (N=26,600) and used distributional characteristics in two corpora to select transformations with the broadest application and the least ambiguity. This resulted in a top set of 146 rules. Two experts evaluated 20 representative rules reflecting 4 characteristics (long/short and weak/strong) each with 5 example sentences. Generally, we found that the rules are helpful for guiding simplification. Using a 5-point Likert scale (5=best), stronger rules scored higher for ease of applying (4.11), overall helpfulness (4.40) and usefulness of examples (4.05). Rule length did not affect the expert scores. The grammar simplification rules are being integrated in our text editor.

Destress 9-1-1-an online mindfulness-based intervention in reducing stress among emergency medical dispatchers: a randomised controlled trial.

OBJECTIVES: Emergency medical dispatchers (EMDs) experience significant stress in the workplace. Yet, interventions aimed at reducing work-related stress are difficult to implement due to the logistic challenges associated with the relatively unique EMD work environment. This investigation tested the efficacy of a 7-week online mindfulness-based intervention (MBI) tailored to the EMD workforce. METHODS: Active-duty EMDs from the USA and Canada (n=323) were randomly assigned to an intervention or wait list control condition. Participants completed surveys of stress and mindfulness at baseline, post intervention, and 3 months follow-up. Repeated measures mixed effects models were used to assess changes in stress and mindfulness. RESULTS: Differences between the intervention group and control group in pre-post changes in stress using the Calgary Symptoms of Stress Inventory were statistically significant, with a difference of -10.0 (95% CI: -14.9, -5.2, p<0.001) for change from baseline to post intervention, and a difference of -6.5 (95% CI: -11.9, -1.1, p=0.02) for change from baseline to 3 months follow-up. Change in mindfulness scores did not differ between groups. However, increases in mindfulness scores were correlated with greater reductions in stress for all participants, regardless of group (r=-0.53, p<0.001). CONCLUSIONS: Development of tailored online MBIs for employees working in challenging work environments offer a promising direction for prevention and intervention. This study found that a short, weekly online MBI for EMDs resulted in reductions in reports of stress. Implications of online MBIs in other emergency responding populations and directions for future research are discussed.

Improving Consumer Understanding of Medical Text: Development and Validation of a New SubSimplify Algorithm to Automatically Generate Term Explanations in English and Spanish.

BACKGROUND: While health literacy is important for people to maintain good health and manage diseases, medical educational texts are often written beyond the reading level of the average individual. To mitigate this disconnect, text simplification research provides methods to increase readability and, therefore, comprehension. One method of text simplification is to isolate particularly difficult terms within a document and replace them with easier synonyms (lexical simplification) or an explanation in plain language (semantic simplification). Unfortunately, existing dictionaries are seldom complete, and consequently, resources for many difficult terms are unavailable. This is the case for English and Spanish resources. OBJECTIVE: Our objective was to automatically generate explanations for difficult terms in both English and Spanish when they are not covered by existing resources. The system we present combines existing resources for explanation generation using a novel algorithm (SubSimplify) to create additional explanations. METHODS: SubSimplify uses word-level parsing techniques and specialized medical affix dictionaries to identify the morphological units of a term and then source their definitions. While the underlying resources are different, SubSimplify applies the same principles in both languages. To evaluate our approach, we used term familiarity to identify difficult terms in English and Spanish and then generated explanations for them. For each language, we extracted 400 difficult terms from two different article types (General and Medical topics) balanced for frequency. For English terms, we compared SubSimplify's explanation with the explanations from the Consumer Health Vocabulary, WordNet Synonyms and Summaries, as well as Word Embedding Vector (WEV) synonyms. For Spanish terms, we compared the explanation to WordNet Summaries and WEV Embedding synonyms. We evaluated quality, coverage, and usefulness for the simplification provided for each term. Quality is the average score from two subject experts on a 1-4 Likert scale (two per language) for the synonyms or explanations provided by the source. Coverage is the number of terms for which a source could provide an explanation. Usefulness is the same expert score, however, with a 0 assigned when no explanations or synonyms were available for a term. RESULTS: SubSimplify resulted in quality scores of 1.64 for English (P<.001) and 1.49 for Spanish (P<.001), which were lower than those of existing resources (Consumer Health Vocabulary [CHV]=2.81). However, in coverage, SubSimplify outperforms all existing written resources, increasing the coverage from 53.0% to 80.5% in English and from 20.8% to 90.8% in Spanish (P<.001). This result means that the usefulness score of SubSimplify (1.32; P<.001) is greater than that of most existing resources (eg, CHV=0.169). CONCLUSIONS: Our approach is intended as an additional resource to existing, manually created resources. It greatly increases the number of difficult terms for which an easier alternative can be made available, resulting in greater actual usefulness.

Protocol: a multi-level intervention program to reduce stress in 9-1-1 telecommunicators.

BACKGROUND: Nationwide, emergency response systems depend on 9-1-1 telecommunicators to prioritize, triage, and dispatch assistance to those in distress. 9-1-1 call center telecommunicators (TCs) are challenged by acute and chronic workplace stressors: tense interactions with citizen callers in crisis; overtime; shift-work; ever-changing technologies; and negative work culture, including co-worker conflict. This workforce is also subject to routine exposures to secondary traumatization while handling calls involving emergency situations and while making time urgent, high stake decisions over the phone. Our study aims to test the effectiveness of a multi-part intervention to reduce stress in 9-1-1 TCs through an online mindfulness training and a toolkit containing workplace stressor reduction resources. METHODS/DESIGN: The study employs a randomized controlled trial design with three data collection points. The multi-part intervention includes an individual-level online mindfulness training and a call center-level organizational stress reduction toolkit. 160 TCs will be recruited from 9-1-1 call centers, complete a baseline survey at enrollment, and are randomly assigned to an intervention or a control group. Intervention group participants will start a 7-week online mindfulness training developed in-house and tailored to 9-1-1 TCs and their call center environment; control participants will be "waitlisted" and start the training after the study period ends. Following the intervention group's completion of the mindfulness training, all participants complete a second survey. Next, the online toolkit with call-center wide stress reduction resources is made available to managers of all participating call centers. After 3 months, a third survey will be completed by all participants. The primary outcome is 9-1-1 TCs' self-reported symptoms of stress at three time points as measured by the C-SOSI (Calgary Symptoms of Stress Inventory). Secondary outcomes will include: perceptions of social work environment (measured by metrics of social support and network conflict); mindfulness; and perceptions of social work environment and mindfulness as mediators of stress reduction. DISCUSSION: This study will evaluate the effectiveness of an online mindfulness training and call center-wide stress reduction toolkit in reducing self-reported stress in 9-1-1 TCs. The results of this study will add to the growing body of research on worksite stress reduction programs. TRIAL REGISTRATION: ClinicalTrials.gov Registration Number: NCT02961621 Registered on November 7, 2016 (retrospectively registered).

Impact of new technologies on stress, attrition and well-being in emergency call centers: the NextGeneration 9-1-1 study protocol.

BACKGROUND: Our public health emergency response system relies on the "first of the first responders"-the emergency call center workforce that handles the emergency needs of a public in distress. Call centers across the United States have been preparing for the "Next Generation 9-1-1" initiative, which will allow citizens to place 9-1-1 calls using a variety of digital technologies. The impacts of this initiative on a workforce that is already highly stressed is unknown. There is concern that these technology changes will increase stress, reduce job performance, contribute to maladaptive coping strategies, lower employee retention, or change morale in the workplace. Understanding these impacts to inform approaches for mitigating the health and performance risks associated with new technologies is crucial for ensuring the 911 system fulfills its mission of providing optimal emergency response to the public. METHODS: Our project is an observational, prospective cohort study framed by the first new technology that will be implemented: text-to-911 calling. Emergency center call takers will be recruited nationwide. Data will be collected by online surveys distributed at each center before text-to-911 implementation; within the first month of implementation; and 6 months after implementation. Primary outcome measures are stress as measured by the Calgary Symptoms of Stress Index, use of sick leave, job performance, and job satisfaction. Primary analyses will use mixed effects regression models and mixed effects logistic regression models to estimate the change in outcome variables associated with text-to-911 implementation. Multiple secondary analyses will examine effects of stress on absenteeism; associations between technology attitudes and stress; effects of implementation on attitudes towards technology; and mitigating effects of job demands, job satisfaction, attitudes towards workplace technology and workplace support on change in stress. DISCUSSION: Our public health dependence on this workforce for our security and safety makes it imperative that the impact of technological changes such as text-to-911 are researched so appropriate intervention efforts to can be developed. Failing to protect our 9-1-1 call takers from predictable health risks would be similar to knowingly exposing field emergency responders to a toxic situation without following OSHA required training and practice standards assuring their protection.