AJPH RESEARCH

Public Health System Research in Public Health Emergency Preparedness in the United States (2009–2015): Actionable Knowledge Base Elena Savoia, MD, MPH, Leesa Lin, MSPH, Dottie Bernard, MPH, Noah Klein, BS, Lyndon P. James, MBBS, and Stefano Guicciardi, MD Background. In 2008, the Institute of Medicine released a letter report

supported the use of communication strategies that address differences

identifying 4 research priority areas for public health emergency pre-

in access to information, knowledge, attitudes, and practices across

paredness in public health system research: (1) enhancing the usefulness

segments of the population as well as evidence on specific communication

of training, (2) improving timely emergency communications, (3) creating

barriers experienced by public health and health care personnel.

and maintaining sustainable response systems, and (4) generating ef-

Forty-eight studies provided evidence on how to create and sustain

fectiveness criteria and metrics.

preparedness systems. Results included how to build social capital across organizations and citizens and how to develop sustainable and

Objectives. To (1) identify and characterize public health system research in public health emergency preparedness produced in the United States

useful planning efforts that maintain flexibility and rely on available medical data. Twenty-six studies provided evidence on the usefulness of

from 2009 to 2015, (2) synthesize research findings and assess the level

measurement efforts, such as community and organizational needs as-

of confidence in these findings, and (3) describe the evolution of knowledge

sessments, and new methods to learn from the response to critical

production in public health emergency preparedness system research.

incidents.

Search Methods and Selection Criteria. We reviewed and included the

Conclusions: In the United States, the field of public health emergency

titles and abstracts of 1584 articles derived from MEDLINE, EMBASE,

preparedness system research has been supported by the US Centers for

and gray literature databases that focused on the organizational or financial aspects of public health emergency preparedness activities and

Disease Control and Prevention since the release of the 2008 Institute of Medicine letter report. The first definition of public health emergency

were grounded on empirical studies.

preparedness appeared in 2007, and before 2008 there was a lack of research and empirical evidence across all 4 research areas identified by

Data Collection and Analysis. We included 156 articles. We appraised the

the Institute of Medicine. This field can be considered relatively new

quality of the studies according to the study design. We identified themes

compared with other research areas in public health; for example, to-

during article analysis and summarized overall findings by theme. We

bacco control research can rely on more than 70 years of knowledge

determined level of confidence in the findings with the GRADE-CERQual

production. However, this review demonstrates that, during the past 7

tool.

years, public health emergency preparedness system research has evolved from generic inquiry to the analysis of specific interventions with more

Main Results. Thirty-one studies provided evidence on how to enhance

empirical studies.

the usefulness of training. Results demonstrated the utility of drills and exercises to enhance decision-making capabilities and coordination across

Public Health Implications: The results of this review provide an evidence

organizations, the benefit of cross-sector partnerships for successfully

base for public health practitioners responsible for enhancing key com-

implementing training activities, and the value of integrating evaluation

ponents of preparedness and response such as communication, training,

methods to support training improvement efforts. Thirty-six studies

and planning efforts. (Am J Public Health. 2017;107: e1–e6. doi:10.2105/

provided evidence on how to improve timely communications. Results

AJPH.2017.304051)

PLAIN-LANGUAGE SUMMARY In this systematic literature review, we analyzed knowledge production in public health emergency preparedness system research in the timeframe 2009–2015. We included 56 studies in the synthesis of evidence and assessed them for

Supplement 2, 2017, Vol 107, No. S2

AJPH

their quality and aggregated findings. Results show that this field can still be considered relatively new compared with other research areas in public health. However, this review demonstrates that, during the past 7 years, public health emergency preparedness system research

has evolved from generic inquiry to the analysis of specific interventions, with more empirical studies. Research gaps remain, in particular in the area of information sharing, communication to the public, and the development of criteria and metrics.

Savoia et al.

Peer Reviewed

Research

e1

AJPH RESEARCH

N

ine years ago, by request of the Centers for Disease Control and Prevention (CDC), the Institute of Medicine (IOM) convened an ad hoc committee that issued a landmark report: Research Priorities in Emergency Preparedness and Response for Public Health Systems.1 This report defined 4 research priority areas for emergency preparedness and response in public health systems: (1) enhancing the usefulness of training, (2) improving timely emergency communications, (3) creating and maintaining sustainable response systems, and (4) generating effectiveness criteria and metrics. The 2008 IOM letter report was specifically created to guide the research agenda of the CDC’s Office of Public Health Preparedness and Response in establishing the preparedness and emergency response research centers.2 However, its accentuation of the need to further develop the public health emergency preparedness research field and integrate the use of a public health system research (PHSR) approach into public health emergency preparedness significantly broadened its impact to the whole field. We present the results of a systematic literature review conducted with the following 3 objectives: (1) identify and characterize PHSR in US public health emergency preparedness since the issuing of the IOM letter report (2009–2015), (2) synthesize research findings and assess the level of confidence in these findings, and (3) understand the evolution of knowledge production in public health emergency preparedness system research and generate the base synthesis to identify knowledge gaps. Our review is the first effort, to our knowledge, to characterize the knowledge growth and state of science in the field of public health emergency preparedness since the 2008 report was issued, and it lays the groundwork for an informed approach to future research.

within communities, and the impact of these services on public health”3(p180)—and the definition of public health emergency preparedness developed by Nelson et al.—“the capability of the public health and health care systems, communities, and individuals, to prevent, protect against, quickly respond to, and recover from health emergencies, particularly those whose scale, timing, or unpredictability threatens to overwhelm routine capabilities.”4(p.S9) We applied a previously published search strategy5 to MEDLINE, EMBASE, and gray literature sources for the years 2009 to 2015 (Table A, available as a supplement to the online version of this article at http://www. ajph.org). We reviewed the titles and abstracts of 1584 articles to determine eligibility for full-text review on the basis of the following 2 criteria: (1) the article had to focus on the organizational or financial aspects of public health emergency preparedness activities delivered by a key public health system sector cited in the IOM letter report, and (2) the findings had to be grounded on an empirical study. We considered any event that could or did overwhelm the routine capabilities of a specific public health system because of timing, scale, or unpredictability a public health emergency. Reviewers met several times to analyze a sample of articles before further classifying them into the 4 IOM priority areas. Two reviewers examined each article. We created an additional cross-cutting category to include articles that focused on protecting vulnerable populations in emergencies. The 5 categories are not intended to be mutually exclusive. We conducted the review in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement.6

Categorization of Articles and Evidence Synthesis We included only empirical research in the evidence synthesis and categorized studies

METHODS In this literature review, we focused on the scientific production of public health emergency preparedness system research in the United States, adopting the definition of PHSR developed by Mays et al.—“a field of study that examines the organization, financing, and delivery of public health services

e2

Research

Peer Reviewed

Savoia et al.

into 3 methodological streams: quantitative (randomized group comparison, nonrandomized group comparison, and descriptive surveys), qualitative (interviews, focus groups, textual analysis, and case studies), and mixed methods (those combining quantitative and qualitative methods). We examined the content of the articles to derive themes from a combination of findings across studies within each IOM area.

Quality Appraisal and Confidence in Findings We assessed individual study quality using 1 of a number of quality appraisal tools, depending on study design (Table B, available as a supplement to the online version of this article at http://www.ajph.org). We used the GRADE-CERQual7 approach to assess the limitations of the individual studies and confidence in aggregate findings for each theme. Consistent with this approach, we defined review findings as an analytic output from a qualitative evidence synthesis that, on the basis of data from primary studies using quantitative, qualitative, or mixed approaches, describes a phenomenon or an aspect of a phenomenon we denoted “theme.” GRADE-CERQual is a structured approach to appraisal requiring reviewer judgment and interpretation on the basis of 4 components (Table C, available as a supplement to the online version of this article at http://www. ajph.org).

RESULTS The search strategy retrieved 1584 articles; 526 met the inclusion criteria for full-text review, of which we included 156 in the synthesis. The distribution of articles by IOM area and study design is presented in Figure 1. We derived themes from the aggregation

ABOUT THE AUTHORS Elena Savoia, Leesa Lin, Dottie Bernard, Noah Klein, Lyndon P. James, and Stefano Guicciardi are with the Emergency Preparedness Research, Evaluation & Practice (EPREP) Program, Division of Policy Translation & Leadership Development, Harvard T. H. Chan School of Public Health, Boston, MA. Correspondence should be sent to Elena Savoia, MD, MPH, Senior Scientist, Department of Biostatistics, Deputy Director, Emergency Preparedness, Research, Evaluation & Practice (EPREP) Program, Division of Policy Translation & Leadership Development, Harvard T. H. Chan School of Public Health, Landmark building, 3rd Floor EAST, 401 Park Drive, Boston, MA 02115 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted June 25, 2017. doi: 10.2105/AJPH.2017.304051

AJPH

Supplement 2, 2017, Vol 107, No. S2

AJPH RESEARCH

Unique citations retrieved by search of electronic databases (n = 1584)

Excluded (n = 1058) Non-PHEP, nondomestic preparedness Full text review (n = 526) Excluded (n = 370) Not in priority areas or non-PHSR or nonempirical n = 156a

Enhancing the usefulness of trainings (included n = 31)

Improving timely emergency communication (included n = 36)

Creating and maintaining sustainable response systems (included n = 48)

Generating effectiveness criteria and metrics (included n = 26)

Protecting vulnerable populations (included n = 34)

Note. PHSR = public health system research. a

Articles included in the final 5 areas are not mutually exclusive.

FIGURE 1—Selection and Distribution of Articles in Systematic Review of Public Health Emergency Preparedness (PHEP): United States, 2009– 2015

of at least 10 studies, when available, for each area, with the exception of the “criteria and metrics” area for which we considered a cutoff of 5 studies sufficient because of the lack of literature in this field. References related to each theme are reported in Appendix A (available as a supplement to the online version of this article at http://www. ajph.org). In Table D (available as a supplement to the online version of this article at http://www.ajph.org), we provide the level of confidence in the findings within each theme, which is described with the GRADE-CERQual approach.

Enhance the Usefulness of Trainings We included 31 empirical studies in the evidence synthesis that describe research regarding the enhancement and usefulness of training in emergency preparedness. We identified 4 major themes in this area: (1) development of training programs, (2) evaluation of training, (3) use of drills and exercises, and (4) development of partnerships in support of training. On the basis of the literature, the inclusion of the use of a curriculum-planning process with integrated competency frameworks, the use of training needs assessments, and the

Supplement 2, 2017, Vol 107, No. S2

AJPH

integration of participant feedback into the training development process enhance the usefulness of training. The selection of appropriate training delivery methods and instructional activities is also important to accommodate differences in learning styles and overcome the challenge of engaging adult learners. For example, flexible training formats, such as online modules and blended e-learning models, have been studied as effective alternatives to traditional classroom learning. The literature reveals several useful methods for evaluating the effectiveness of training. Pre- and posttraining quizzes can measure changes in participants’ subject matter knowledge, observers can assess participant performance, and surveys and focus group discussions can capture participants’ reactions and level of satisfaction following training, measure changes in levels of confidence before and after training activities, and assess learners’ training needs. Specific evaluation tools can be used to assess training quality and the long-term impact of participation in training activities. Cost and costeffectiveness analysis are also useful approaches for guiding the development of training. Drills and exercises, as proxies for real emergencies, are well-accepted means of

increasing participant engagement in training and identifying gaps in participants’ knowledge and skills. A few studies examine the effectiveness of including embedded videos and using geographic mapping tools to enhance the effectiveness of simulations. Discussion-based tabletop exercises are recognized as methods to enhance decisionmaking capabilities and help clarify the roles and responsibilities of responders during a disaster. Full-scale exercises present valuable opportunities for testing coordination and command across organizations responding to an emergency and provide an operationsbased learning environment for participants. Full-scale exercises may be useful for administering just-in-time training to participants in narrowly focused, task-based learning environments. Just-in-time training has also been recognized as useful for volunteer groups, including dentists and public health nursing students. Several studies confirm the importance of providing training opportunities that include coordination between public health organizations, public safety agencies, and environmental and health care organizations to establish preincident relationships and exchange experience and knowledge before a crisis. Similarly, developing training in collaboration with community partners (e.g.,

Savoia et al.

Peer Reviewed

Research

e3

AJPH RESEARCH

the American Red Cross, faith-based organizations) is vital to ensure that training enhances participants’ skills and ultimately meets the unique needs of the communities being served during an emergency. The value of including a wide range of training partners, including tribal authorities, institutions of higher education, and private corporations, is well established in the literature. This includes expanding volunteer training to nonpublic health professionals such as medical and nursing students, dentists and dental hygienists, and people with specific functional needs who can be trained to serve their communities.

Improving Timely Emergency Communications Thirty-six peer-reviewed articles describe the current state of science in addressing strategies for improving communications in preparedness and response. We identified 4 major themes: (1) the improvement of knowledge, attitudes, and practice; (2) the use of information channels and access to information; (3) the role of communication in preparing the public health and health care workforce for threats; and (4) the influence of content, format, and delivery methods of messages regarding information sharing. During emergency situations, knowledge and attitudes regarding a specific threat differ across various segments of the population, characterized by age, gender, race, and social determinants, such as socioeconomic position and interpersonal networks—which potentially impact compliance with recommended behaviors. Those who do not feel personally at risk or do not trust the messenger are less likely to adopt recommended behaviors. Concern about oneself or family members being affected by a health threat is a better predictor of behavioral compliance than are individual perceptions of threat severity and susceptibility, especially regarding compliance with immunization practices. During the H1N1 pandemic, higher socioeconomic position individuals, those with higher news exposure, those with higher levels of pH1N1-related knowledge, and those possessing information-seeking behaviors were less likely to engage in incorrect preventive behaviors. Furthermore, the literature shows that communication effectiveness depends partly on an individual’s preexisting values,

e4

Research

Peer Reviewed

Savoia et al.

risk perceptions, previous trust in leaders and government, and community characteristics; these factors may change over the course of the emergency and are influenced by the severity of the situation. Individual access to information and information-seeking behaviors differ across population groups on the basis of sociodemographic characteristics. The literature describes the negative impact of online information seeking resulting from frustration in determining accurate information or oversaturation of messages, which may lead to increased fear and an attitude of information avoidance. The Internet and traditional media, such as radio, television news, and newspapers, are often reported as primary sources of information regarding risk, whereas family doctors, television news, and local public health officials are often considered the most trusted information sources. During the H1N1 pandemic, willingness to comply with preventive behaviors was positively correlated with the number of H1N1 influenza news articles individuals viewed and with information-seeking behaviors. Timely release of information was positively associated with the adoption of recommended behaviors. Data on the use of social media during an emergency situation are currently very limited, with Twitter being the only platform studied to date. Local health departments often experience difficulties in outreach and information dissemination efforts to health care professionals (including physicians and pharmacists) during an influenza outbreak; yet collaborative activities, such as managing and sharing information, were proven to strengthen partnerships. Redundancy in communication efforts directed at clinicians has proven ineffective, and relatively few clinicians visit state public health or institutional Web sites frequently enough to obtain up-to-date guidance. Gender, age, type of health care provider, and study site were associated with providers’ preferences regarding media of information delivery, with older providers preferring e-mail or fax and younger providers preferring short message service. The literature also suggests that enhancing selfefficacy in local health department workers is likely to enhance willingness to respond. The media play a significant role in framing the information environment people are exposed to and therefore shape the public’s

behaviors and attitudes to a threat. Web sites, commonly used by the CDC and health departments as a channel for information dissemination, might attract active information seekers but often bear several communication weaknesses: a lack of audience segmentation, limited content adequacy, and the need for too many resources to be kept up to date. During the H1N1 pandemic, local and state health departments had a limited ability to provide information online. Insufficient audience segmentation and inadequate content made communications unable to meet the needs of at-risk, low-literacy population groups. Frontline clinicians reported that the volume of information they received and the redundancy of messages from numerous communication channels was overwhelming, demonstrating a need for streamlining information through concise updates delivered in an effective message format.

Create and Maintain Sustainable Response Systems We included 48 empirical studies in the evidence synthesis to describe research informing the creation and maintenance of sustainable response systems. We identified 3 major themes: (1) building social capital, (2) guiding planning efforts, and (3) system’s organizational and financial characteristics. Social capital in public health emergency preparedness represents existing relationships and collaborations among organizations and individuals. At the organizational level, businesses, schools, faith- and communitybased organizations, and a host of government agencies (e.g., emergency management, health departments, law enforcement) can build social capital through collective preparedness efforts, including regionalization, coalition-building activities, mutual aid agreements, and initiatives that enhance collaboration among various response partners. At the individual level, social capital can be achieved by implementing community engagement activities focused on household preparedness education and by facilitating access to preparedness resources when needed. The literature underscores the need for flexible emergency plans that are tailorable to an emergency as needed. In consideration of such flexibility, the literature supports the use of data-driven approaches and planning tools

AJPH

Supplement 2, 2017, Vol 107, No. S2

AJPH RESEARCH

to guide plan development. Examples are scenario-based predictions to facilitate the decision-making process, decision-making techniques (e.g., analytical hierarchy process), Medicare data to identify population groups with special medical needs, and data from retrospective analyses of preparedness planning efforts (e.g., the Cities Readiness Initiative) as well as hospital and public health agency responses to specific incidents that identify gaps and strengths in preparedness functions and organizational models. During planning efforts, considering the potential links between public health systems’ organizational, financial, and legal infrastructures and preparedness is vital. Simulations have revealed that seemingly minor personnel or budget changes in health departments may mask considerable variations in response functions. During an emergency response, delays in the appropriation of designated funds may negatively affect the efficiency of response efforts. Legal aspects have been investigated for potential impacts on planning efforts, in particular laws and regulations related to specific emergencies (e.g., nuclear radiological emergencies), legal protections for public health and emergency medical services workers, and the legal implications of drugs and vaccines administered under emergency use authorizations. Factors related to willingness to respond have also been widely investigated across professional roles and types of emergencies.

Generating Effectiveness Criteria and Metrics In the evidence synthesis, we included 26 studies that describe research that informs the development of criteria and metrics for public health systems in public health emergency preparedness. We identified 3 major themes: (1) community assessments, (2) organizational assessments, and (3) learning from responses to disasters. The literature describes the use of community assessments (e.g., the Community Assessment for Public Health Emergency Response) as an efficient means for assessing populations’ needs in preparation for and response to emergencies. Such assessments can measure a community’s health status and specific population subgroups’ functional needs and can inform response efforts and priorities.

Supplement 2, 2017, Vol 107, No. S2

AJPH

Individual-level measures of self-sufficiency and social connectedness can also be integrated with data on household preparedness to describe population preparedness levels. Measurements regarding the structural and organizational aspects of preparedness are valued for their potential association with overall response performance. Measures have been developed to assess state and local preparedness levels for specific threats, for specific functions, and to assess partners’ engagement and the system’s adaptability to the response. Measures of the public health workforce and volunteers’ readiness and willingness to respond have also been developed. Organizational aspects of the response (e.g., implementation of flu clinics) were analyzed during the H1N1 pandemic to identify specific preparedness and response strengths and weaknesses. The literature emphasizes the importance of learning from responses to emergencies. Methods to enhance the after-action reporting process and derive lessons learned across multiple incidents have been developed and reported as valuable mechanisms to identify response gaps and areas for improvement.

Addressing the Needs of Vulnerable Populations In the evidence synthesis, we included 34 empirical studies that describe research regarding how to protect vulnerable populations during emergencies. We identified 3 themes: (1) personal preparedness, (2) trust and compliance, and (3) inequalities in access and use of information. Researchers have identified an association between socioeconomic position and personal preparedness, with higher income individuals being better prepared. Higher education, older age, being male, and higher English proficiency levels are also associated with better personal preparedness. The relationship between ethnicity and personal preparedness remains unclear, as does the influence of psychological aspects (e.g., mental distress) on the ability to prepare. Furthermore, the literature suggests the positive influence of social cohesion on personal preparedness. The literature shows differences in trust and compliance with recommended behaviors across segments of the population. For example, Blacks seem to be less likely to agree

that vaccines prevent disease and are safe and to trust doctors who recommend vaccines. During some emergencies (e.g., water contaminations), young individuals and Hispanics were less likely to comply with specific recommendations (e.g., a do not drink order) than were older individuals and non-Hispanics. Interestingly, during the H1N1 pandemic, Black non-Hispanics and Hispanics were more likely to be willing to take antiviral medication if hospitalized and if they trusted the government. Individuals affected by disabilities showed a lack of trust in their state government’s ability to support them during emergencies. Women are consistently reported as more compliant with quarantine orders than are men. Interestingly, higher education levels correlate to greater stated compliance with less restrictive quarantine measures, whereas lower education levels are associated with greater stated compliance with the most restrictive orders. The literature demonstrates clear inequalities among individuals and social groups in accessing and using information on health and specific threats. These inequalities affect knowledge, attitudes, and behaviors, contributing to the vulnerability of population subgroups (e.g., minorities, low socioeconomic position individuals, pregnant women) to public health emergencies. Social networks, small-group discussions led by a health promoter, and culturally tailored messages can be effective in improving disaster preparedness among vulnerable groups. Public health and emergency preparedness practitioners can mitigate the impact of stigmatization, often a consequence of a specific segment of the population being at higher risk for contracting a disease, by developing interventions addressing the social stressors exacerbated by emergencies.

DISCUSSION In the United States, since the release of the 2008 IOM letter report, the field of public health emergency preparedness system research has been supported in great part by the CDC. Public health emergency preparedness system research is a relatively new field compared with other research areas in public health; for example, tobacco control research can rely on more than 70 years of knowledge production. This review indicates that, in the

Savoia et al.

Peer Reviewed

Research

e5

AJPH RESEARCH

United States, empirical knowledge in this field has increased by roughly 50% since the 2008 IOM letter report was released. The fact that this review identified approximately the same number of articles that Savoia et al.6 identified in a larger timeframe (11 years vs 7 years covered by the current review) supports this conclusion. Most importantly, this review shows how knowledge production has evolved into actionable knowledge, with enhanced use of empirical studies across all areas. Furthermore, this review demonstrates that a large amount of knowledge in this field resulted from the CDC’s investment in the creation of the preparedness and emergency response research centers: more than 60% of the articles we identified were written by a researcher affiliated with 1 of the 9 preparedness and emergency response research centers. We generated the proposed synthesis to provide levels of confidence in the knowledge produced to date to facilitate the work of policymakers and practitioners in using research findings for practice purposes. The GRADE-CERQual methodology provided us the best appraisal tools available to extrapolate beyond insights from isolated studies and identify what is generalizable across multiple experiences. However, this approach poses some challenges when synthesizing the preparedness literature because preparedness studies currently have wide heterogeneity in the outcomes being investigated. Heterogeneity of outcomes resists formal mechanisms for pooling conclusions across studies.

Limitations We acknowledge that the literature search strategy, adopted from a previous study to allow comparisons over time, may lack specificity in this particular field. Public health emergency preparedness is a broad construct entailing a variety of subareas, and our adopted search strategy uses generic terms that may lack specificity in identifying articles in each IOM area. PHSR is a similarly broad field, and the categorization of an article as PHSR requires subjective judgment. Yet, this synthesis does not include articles related to research areas that were not considered a priority by the 2008 IOM letter report, limiting the findings to this niche of research. It is also possible that, in this evolving field,

e6

Research

Peer Reviewed

Savoia et al.

authors and database indexing strategies have become more specific in the use of the term “public health emergency preparedness” and that, for this reason, we are now able to identify more articles than we could in the past. Despite the growth in knowledge production over the past 7 years, large research gaps remain. Two areas emerge from the assessment of the level of confidence presented in Table D in the review findings as requiring a greater number of studies: communications and the development of criteria and metrics. More specifically, research is needed on the effectiveness of messages of varying contents and formats directed to the public and on the best way to disseminate these messages to the target audience. In relation to the area of criteria and metrics, new research has focused on the best ways to derive lessons learned from responses to specific emergencies, but because of the paucity of studies, the level of confidence in such methods is still low. Confidence can be assessed only on what has been produced; many public health emergency preparedness areas that are not included in this synthesis lack evidence. Among such areas, the effectiveness of information-sharing systems is certainly of major importance. We recognize that results from systematic reviews can direct and influence the development of future research agendas in a meaningful way only when well integrated with input from practitioners on what knowledge production is most needed to address practice questions, as well as on the best ways to disseminate existing knowledge that does not reach practitioners. This review should be considered only a first step in this direction. Future steps will consist in combining these results with feedback from practitioners engaged in preparedness efforts.

Conclusions Knowledge production in public health emergency preparedness system research in the United States has evolved across all priority research areas as identified by the IOM in 2008. Strategies to enhance the usefulness of training have been identified, such as effective approaches to engage adult learners. Research on communications has produced knowledge highlighting the importance of tailoring messages to the variety of audiences. The concept of social capital in preparedness

has evolved from a theoretical construct to the analysis of specific activities that foster relationship building across organizations and individuals. Data-driven planning activities have emerged as a new area of investigation, as have the use of evaluation activities to assess systems capacities, community needs, and lessons learned from responses to emergencies. Research gaps remain across all areas, especially in the area of communication in relation to information sharing across agencies. In addition, there is a lack of evidence across all areas on the transferability of specific interventions from system to system. CONTRIBUTORS E. Savoia conceptualized the review and drafted the article. L. Lin, D. Bernard, N. Klein, L. P. James, and S. Guicciardi conducted the review and interpreted the results. All authors worked on the final development of the article.

ACKNOWLEDGMENTS GRADE principles were adapted for application to descriptive quantitative studies and GRADE-CERQual principles were applied to mixed-method studies. Neither adaptation has been approved by the tool originators.

HUMAN PARTICIPANT PROTECTION No protocol approval was necessary because no human participants were involved in this study.

REFERENCES 1. Institute of Medicine. Research Priorities in Emergency Preparedness and Response for Public Health Systems: A Letter Report. Washington, DC: National Academies Press; 2008. 2. Leinhos M, Qari SH, Williams-Johnson M. Preparedness and emergency response research centers: using a public health systems approach to improve all-hazards preparedness and response. Public Health Rep. 2014;129 (suppl 4):8–18. 3. Mays GP, Halverson PK, Scutchfield FD. Behind the curve? What we know and need to learn from public health systems research. J Public Health Manag Pract. 2003; 9(3):179–182. 4. Nelson C, Lurie N, Wasserman J, Zakowski S. Conceptualizing and defining public health emergency preparedness. Am J Public Health. 2007;97(suppl 1): S9–S11. 5. Savoia E, Massin-Short SB, Rodday AM, Aaron LA, Higdon MA, Stoto MA. Public health systems research in emergency preparedness: a review of the literature. Am J Prev Med. 2009;37(2):150–156. 6. Moher D, Liberati A, Tetzlaff J, Altman DG; the PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. 7. Lewin S, Glenton C, Munthe-Kaas H, et al. Using qualitative evidence in decision making for health and social interventions: an approach to assess confidence in findings from qualitative evidence syntheses (GRADECERQual). PLoS Med. 2015;12(10):e1001895.

AJPH

Supplement 2, 2017, Vol 107, No. S2

Public Health System Research in Public Health Emergency Preparedness in the United States (2009-2015): Actionable Knowledge Base.

In 2008, the Institute of Medicine released a letter report identifying 4 research priority areas for public health emergency preparedness in public h...
547KB Sizes 0 Downloads 8 Views