Christine A. Bevc

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

BackgroundPublic 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.MethodsIn 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.ResultsThe 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.ConclusionsBecause 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.

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 NCs robust statewide preparedness program, as well as a likely exposure effect among non-accredited NC LHDs to the accreditation program.

Perceptions of Toxic Exposure: Considering “White Male” and “Black Female” Effects

Research on risk perception suggests that social position produces identifiable patterns in the way that people evaluate potential risks, particularly in locally polluted environments. The present study builds upon this literature by examining perceived risk of exposure to environmental toxins among residents located on the Gulf Coasts of Louisiana and Mississippi following Hurricane Katrina. Demographic information from a sample of residents was used to explore the concepts of the “white male effect” and the “black female effect,” discussed in recent research. In support of existing literature, we find that white males tend to be exceptionally risk accepting when asked about potential toxic exposure, whereas black females tend to be exceptionally risk averse compared to other groups. Our analysis suggests that awareness of differential vulnerability and long-standing conflicts over environmental contamination across the Gulf Coast region have left some residents with heightened sensitivity to the possibility of a locally polluted environment.

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 Preventions Public Health Preparedness Capabilities: National Standards for State and Local Planning.

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 Preventions (CDCs) 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 CDCs Office for State, Tribal, Local and Territorial Support and Office of Public Health Preparedness and Responses 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.

Measuring Changes in Local Surveillance and Investigation Capacity

Background: The outbreak of Ebola virus disease in West Africa and confirmation of the first cases in the United States highlight the need for robust and responsive public health surveillance system. With a 25% decline in funding since 2007, the impact on local surveillance capacities has not previously been described. Purpose: The Surveillance & Investigation domain of the Local Health Department Preparedness Capacities Survey (PCAS) was reweighted to reflect the national profile of LHDs. Changes in subdomain performance of capacities and the effect of population size on subdomain capacity performance were examined over time. Methods: Participating LHDs (n=208) from the PCAS sample were reweighted according to characteristics from the 2010 National Association of County and City Health Officials (NACCHO) Profile. Overall changes in preparedness capacity across four subdomains from 2010 to 2012 were tested for significant differences using a weighted t-test. A series of weighted least squares regression models were used to determine whether population size may have modified the temporal changes in preparedness capacity. Results: Significant declines were observed in the preparedness capacity in three of the four subdomains of Surveillance & Investigation. Results suggest that surveillance inputs from various sources, including hospitals, urgent care, poison control, pharmacies, and schools absentee reporting, especially for larger LHDs, may be more sensitive to changes or shifts over time versus others. Implications: Declines in preparedness capacity may have affected the ability of LHDs, particularly larger ones, to effectively respond to community preparedness needs and, specifically, the detection of highly communicable and novel disease events.

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.

Emotional Dimensions of Conducting Research in Disaster Settings: A Note on Social Psychological Considerations

In the wake of Hurricane Katrina, disaster research witnessed a convergence of researchers from the social sciences in disciplinary and multidisciplinary teams. National Science Foundation grants funded significant numbers of teams to address topics related to the event and the emotional responses of its impact. Research on disaster mental health is not a new field of study, and research has demonstrated the devastating psychological and mental health effects of disasters; however, the literature focuses predominantly on assisting victims and survivors, with substantially less literature related to the potential social psychological and emotional impacts related to research conducting intense field studies. This essay discusses the emotional dimensions of conducting disaster research by using classic and contemporary social psychological theories to explore how researchers deal with and/or negotiate the potential role conflict and the emotional dimensions of their fieldwork.

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.

Evaluating Use of Custom Survey Reports by Local Health Departments

This report demonstrates how providing survey feedback, like comparative reports, to survey respondents can result in improvement activities. For each of the past three years (2010-2013), the North Carolina Institute for Public Health (NCIPH) has invited local health departments (LHDs) from 40 states to participate in a preparedness capacities survey. In addition, NCIPH fielded a six-question evaluation survey to a subset of LHDs (n=70) to determine how LHDs use these reports. LHDs that reported using their custom reports compared their preparedness capacities to other LHDs, conducted strategic planning (e.g., benchmarking, setting preparedness goals), planned staff trainings, and disseminated the report both internally and to external preparedness partners. Through evaluation of custom report use, we have found that survey feedback is a valuable part of a participatory research approach that promotes and encourages discussion, motivates improvement, and provides opportunities to identify potential solutions relevant to both researchers and LHDs.