This Week's News 27-31 July 2009

6

Assessment of Local Public Health Workers' Willingness to Respond to Pandemic Influenza through Application of the Extended Parallel Process Model
PLoS ONE

26/07/2009

Daniel J. Barnett1,2,3*, Ran D. Balicer4, Carol B. Thompson5, J. Douglas Storey2,6,7, Saad B. Omer8, Natalie L. Semon1,2,3, Steve Bayer9†, Lorraine V. Cheek10, Kerry W. Gateley11, Kathryn M. Lanza12, Jane A. Norbin13, Catherine C. Slemp14, Jonathan M. Links1,2,3
1 Johns Hopkins Center for Public Health Preparedness, Baltimore, Maryland, United States of America, 2 Johns Hopkins Preparedness and Emergency Response Research Center, Baltimore, Maryland, United States of America, 3 Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America, 4 Department of Epidemiology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel, 5 Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America, 6 Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs, Baltimore, Maryland, United States of America, 7 Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America, 8 Hubert Department of Global Health, Emory University, Rollins School of Public Health, Atlanta, Georgia, United States of America, 9 Mid-Ohio Valley Region, Parkersburg, West Virginia, United States of America, 10 Preble County General Health District, Wright State University Masters of Public Health, Eaton, Ohio, United States of America, 11 Kanawha-Charleston Health Department, Charleston, West Virginia, United States of America, 12 Summit County Health District, Stow, Ohio, United States of America, 13 St. Paul-Ramsey County Department of Public Health, St. Paul, Minnesota, United States of America, 14 Bureau for Public Health, West Virginia Department of Health and Human Resources, Charleston, West Virginia, United States of America
Abstract

Background

Local public health agencies play a central role in response to an influenza pandemic, and understanding the willingness of their employees to report to work is therefore a critically relevant concern for pandemic influenza planning efforts. Witte's Extended Parallel Process Model (EPPM) has been found useful for understanding adaptive behavior in the face of unknown risk, and thus offers a framework for examining scenario-specific willingness to respond among local public health workers. We thus aim to use the EPPM as a lens for examining the influences of perceived threat and efficacy on local public health workers' response willingness to pandemic influenza.
Methodology/Principal Findings

We administered an online, EPPM-based survey about attitudes/beliefs toward emergency response (Johns Hopkins~Public Health Infrastructure Response Survey Tool), to local public health employees in three states between November 2006 – December 2007. A total of 1835 responses were collected for an overall response rate of 83%. With some regional variation, overall 16% of the workers in 2006-7 were not willing to “respond to a pandemic flu emergency regardless of its severity”. Local health department employees with a perception of high threat and high efficacy – i.e., those fitting a ‘concerned and confident’ profile in the EPPM analysis – had the highest declared rates of willingness to respond to an influenza pandemic if required by their agency, which was 31.7 times higher than those fitting a ‘low threat/low efficacy’ EPPM profile.

Conclusions/Significance

In the context of pandemic influenza planning, the EPPM provides a useful framework to inform nuanced understanding of baseline levels of – and gaps in – local public health workers' response willingness. Within local health departments, ‘concerned and confident’ employees are most likely to be willing to respond. This finding may allow public health agencies to design, implement, and evaluate training programs focused on emergency response attitudes in health departments.

Citation: Barnett DJ, Balicer RD, Thompson CB, Storey JD, Omer SB, et al. (2009) Assessment of Local Public Health Workers' Willingness to Respond to Pandemic Influenza through Application of the Extended Parallel Process Model. PLoS ONE 4(7): e6365. doi:10.1371/journal.pone.0006365
Editor: Yang Yang, Fred Hutchinson Cancer Research Center, United States of America

Received: February 27, 2009; Accepted: June 26, 2009; Published: July 24, 2009

Copyright: © 2009 Barnett et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: Center for Public Health Preparedness [CDC/Cooperative Agreement# U90TP324236; Grant# 906860]. Preparedness & Emergency Response Research Center (PERRC)[CDC/Cooperative Agreement# 1P01tP00288-01; Grant# 104264]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.

* E-mail: [e-mail]

† Deceased.
Introduction

The anticipated worldwide morbidity, mortality, and social disruption from an influenza pandemic [1] require detailed and tested approaches to staffing and resource allocation in public health systems [2]. The willingness of health responders to report to duty during an influenza pandemic is a highly salient concern given the “inevitable”nature of this threat [3] and its associated challenges. Scant margin exists in the nation's public health system for local health department workers – the backbone of public health system readiness – to “opt out” of response duties, given limitations of health system surge capacity [4], public health personnel shortages [5], and continued steep learning curves associated with relatively new 24/7 response expectations for health department employees.

The unwillingness of some health workers to place themselves at risk of exposure to emerging infectious diseases was observed during the 2003 SARS epidemic and the early years of the HIV/AIDS epidemic [6]. In the aftermath of the terror attacks of September 11, 2001 and the ensuing anthrax bioterrorism attacks, a growing body of research literature has examined willingness to respond to large-scale emergencies among a variety of health-related cohorts [7]–[14]. Despite the evidence for fundamental distinctions between ability and willingness to respond [7], [13], there remains a gap in the public health preparedness literature on training approaches that explicitly address response willingness (attitude) as a discrete outcome. Based on the principle that “all disasters begin locally”, these observations underscore a fundamental need to understand root causes of local public health workers' barriers to response willingness, as a basis for identifying and addressing public health response system gaps in this domain.
A variety of risk perception theories have been suggested and may help to identify barriers to health personnel adopting an emergency responder role. One prominent model conceptualizes risk perception as the sum of “hazard” and “outrage”, where hazard is a product of risk magnitude and probability, and outrage is a function of other peripheral influences independent of the actual risk, such as perceived authority, trust, and situational control [15].
Among the public health workforce, recent applications of this “Risk = Hazard+Outrage” model have uncovered a variety of potential peripheral risk perception influences on health department workers' response willingness apart from the actual hazard [16]. For example, in a 2005 pilot study conducted in three local health departments in Maryland, we found that a health department employee's individual perceived level of importance in their agency's response efforts was a particularly strong peripheral influence on response willingness toward an influenza pandemic [8].
The cumulative evidence from these studies suggests that willingness to respond is multidimensional. Specifically, its dimensions appear to include: 1) perceived threat, as evidenced by findings of scenario-specific response willingness rates; and 2) perceived efficacy, as highlighted by the powerful influences of response efficacy (“My response makes a difference”) and self-efficacy (“I can do what is expected of me as a responder”). Further, preparedness training for public health workers is a form of risk communication in itself, intended to build health department workers' efficacy in the face of a variety of hazards. To build a public health workforce that is not only able to respond, but also willing to do so, the above observations suggest the need for a unifying paradigm that can address both the threat and efficacy dimensions of willingness to respond. To date, the research literature on public health emergency response willingness has lacked such a paradigm.
The Extended Parallel Process Model (EPPM) [Figure 1] has been found to be useful for understanding adaptive behavior in the face of unknown risk [17]. First proposed by Witte in the early 1990s [18], the EPPM represents an integration and expansion of previous psychosocial models of “fear appeal.” The model focuses on messages that are received by both individuals and collectively by groups. Importantly, while the model was first developed to explain individual behavior [18], it has since been directly applied to the analysis of collective behavior [19]. Continued
Full-text: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0006365

7

Paging all doctors ... we need you too
Utica.OD.com, NY

27/07/2009

By AMY NEFF ROTH, Healthy Livin
The Mohawk Valley has fewer doctors per person than any region in the state, and the numbers aren’t likely to improve, according to health officials.
New York City has 387 doctors actively engaged in patient care for every 100,000 residents, according to the Center for Health Workforce Studies at SUNY Albany’s School of Public Health in Rensselaer. The Mohawk Valley has 165. The state average is 325.
Officials throughout the region agree that’s not enough doctors.
“I think we’re not at a crisis level yet. But when you look at the average age of our physicians, we’re within 10 years of crisis unless we bring in more doctors,” said Dr. Daniel Kopp, chief medical officer for Faxton-St. Luke’s Healthcare in Utica.
What does this mean for patients? Potentially longer waits for appointments, longer drives for care and “making do” with the care that’s available locally instead of traveling for specialist care or specialized tests, especially in rural areas where patients have fewer resources close to home.
Across the country, physicians are more scarce in rural than in non-rural areas, but in the Mohawk Valley, even more populated areas don’t necessarily have enough doctors, officials said.
Kopp said his hospital’s most urgent need is for hospitalists – doctors who manage care for patients while they’re in the hospital, leaving primary-care doctors free to concentrate on office care. Having enough hospitalists is key to recruiting young doctors, who don’t want to do hospital rounds or to be on call, Kopp said. Hospitalists are also important for patients from rural areas whose primary-care doctors simply don’t have the time to make the long drive to the hospital to check on patients regularly.
Other specialists in relatively short supply locally are orthopedic surgeons, neurosurgeons and urologists, Kopp said.
Phil Porter, CEO of Slocum-Dickson Medical Group in Utica, listed general surgery, orthopedics, ears-nose-and-throat, pulmonology and primary care as the fields with the greatest shortages in this area.
There are fledgling efforts under way to bring more doctors to the Mohawk Valley, in particular rural areas. Here are some:
• Columbia campus at Bassett Healthcare. Columbia University’s College of Physicians and Surgeons in New York City is establishing a small campus at Bassett Healthcare in Cooperstown, which officials say they hope will encourage more doctors to set up practices in rural areas. The program, which will accept 10-to-14 top students and give them considerable financial aid, will also change the way medical schools typically teach – giving them two and a half years, instead of two, in patient care and allowing them to work with the same patients throughout their medical school years.
Officials hope the program will have another benefit not found in its curriculum. “It’s an unusual physician who starts their practice somewhere they’ve never lived before,” acknowledged Dr. Lee Goldman, executive vice president for Health and Biomedical Sciences and dean of the faculties of Health Sciences and Medicine at Columbia.
• Doctors Across New York. In March, Gov. David Paterson announced the first awards under Doctors Across New York, a program to address underserved areas, mostly in rural areas or the inner city. The awards included $11 million over five years to help doctors pay off their student loans if they commit to practice in an underserved area for at least five years. Doctors in these areas typically earn less pay.
The program also allocated $11.1 million over two years to help expand or establish practice or health-care facilities in underserved areas.
Through the program, Bassett recently hired a general surgeon to practice at its affiliate, Delhi Hospital in Delaware County, where officials had feared there would be no general surgeon, said Dr. Steven Heneghan, chief of surgery and co-director of the Mithoefer Center for Rural Surgery at Bassett.
State Health Commissioner Richard Daines said that upstate is particularly short on pediatric psychiatrists, orthopedic surgeons, geriatricians and general surgeons.
• Local efforts. Local hospitals are also addressing the issue. For one thing, hospitals and area practices work hard to recruit doctors to this area.
And Faxton-St. Luke’s and St. Elizabeth Medical Center in Utica have been working together to find a way to make sure there are always specialists on call at one of the hospitals, Kopp said. For example, there may be enough orthopedic surgeons in Utica, but because of the call schedules, there are nights when neither hospital has one on call, meaning emergency patients have to go to Syracuse, he said.
Faxton-St. Luke’s is also looking into programs to bring more SUNY Upstate Medical University students and residents to Utica, Kopp said.
“We know that if we can get residents and medical students in our hospitals, there’s a better chance they’re going to like the area and come back to it after their training,” he said.
But it is not easy to recruit doctors to the Mohawk Valley.
A national shortage of doctors expected to get worse by 2020, Porter said, and recruiting foreign doctors has become more difficult since 9/11, when getting green cards became harder, he said.
Then there’s the area itself.
“Once you have somebody that would be interested in beautiful downtown Utica of the Mohawk Valley, three things come up,” Porter said. “One is concerns over the weather. Second thing is taxes. If not in reality, then certainly in perception, they view Upstate New York as being too heavily taxed ... and the third thing has to do with economic viability of the area, meaning will there be enough people; still here in five years.”
So who is most likely to come to this area?
People with ties to the area, people who like winter sports, people who have lived in cold climates before, families and people who visit the area before deciding, Porter said.
The recent building of big-box stores has helped, especially the Barnes & Noble, he said. In the months after the bookstore in the mall closed, Slocum-Dickson failed to recruit any doctors, he said.
The diversity of houses of worship, the Munson-Williams-Proctor Arts Institute, The Stanley Center for the Arts and the quality of some local school districts also help, he said.
Who’s least likely to come here?
People from warm climates and single doctors, Porter said.

8

In War and Isolation, a Fighter for Afghan Women
New York Times

27/07/2009

By DENISE GRADY
Everybody wants Pashtoon Azfar. Her government, American aid groups and her own colleagues, the midwives of Afghanistan, all want her to work for them, lead them, help them rebuild a health system from the rubble of war.
Ms. Azfar, 51, is trying to oblige. By day she directs Afghanistan’s Institute of Health Sciences, by night she works for a nonprofit group from Johns Hopkins University that focuses on women and children’s health, and somehow she also manages to serve as president of the Afghan Midwives Association.
Visiting from Kabul recently, she was the star at a Capitol Hill briefing titled “Maternal Health in Afghanistan: How Can We Save Women’s Lives?” Her audience included members of the Congressional caucus for women’s issues.
Afghanistan has the world’s second-highest death rate in women during pregnancy and childbirth (only Sierra Leone’s is worse). For every 100,000 births, 1,600 mothers die; in wealthy countries the rates range from 1 to 12. In one remote northeastern province, Badakhshan, 6,507 mothers die for every 100,000 births, according to a 2005 report in the medical journal Lancet. In all, 26,000 Afghan women a year die while pregnant or giving birth.
The main causes of these deaths are hemorrhage and obstructed labor, which can be fatal if a woman cannot obtain a Caesarean section. Even if the mother survives, obstructed labor without a Caesarean usually kills the baby. Most of the maternal deaths — 78 percent, according to the Lancet report — could be prevented. Against this bleak history, Ms. Azfar told her Washington audience, “I would like to share some successes with you.”
An intense woman with short, graying hair, Ms. Azfar rarely smiles. She ran through statistics showing notable increases recently in the country’s number of midwives, their education and the percentage of women who give birth with the help of a “skilled attendant,” usually a midwife. The United States, the World Bank, the European Commission, Unicef, the Hopkins group (known as Jhpiego) and other donors have all helped Afghanistan’s Ministry of Public Health to make improvements.
But there is a long way to go. Most women in Afghanistan, as many as 80 percent, still give birth without skilled help, and only a third receive any medical care at all during pregnancy.
Afghanistan’s problems mirror those of many other poor countries: shortages of personnel, supplies and transportation to clinics or hospitals, especially in remote regions and mountainous areas that are snowbound half the year. The deeper problems are cultural, rooted in the low status of women and the misperception that deaths in childbirth are inevitable — part of the natural order, women’s lot in life.
During her talk in Washington Ms. Azfar quoted Dr. Mahmoud Fathalla, an Egyptian physician and advocate for women’s health: “Women are not dying of diseases we can’t treat. ...They are dying because societies have yet to make the decision that their lives are worth saving.”
Ms. Azfar works 12 hours a day, seven days a week. She has irked relatives by missing weddings and other family events because of work.
“My children are not happy,” she said in an interview after her speech.
Ms. Azfar grew up in a village about an hour from Kabul.
“Everywhere then, girls went to school,” she said. “Women’s rights before the Taliban were the same as in Western countries. Women had the right to vote.”
Her mother had 10 children, 2 of whom died. She always gave birth alone, behind a closed door. When Ms. Azfar was 9, she began to help, by waiting outside the door to receive the newborn baby and wash and swaddle it, while her mother then delivered her own placenta.
Ms. Azfar never actually saw a birth until she began studying midwifery at age 16, and only then, she said, did she realize how brave her mother had been. She finished the rigorous three-year program at the top of her class in 1976.
“It was a very well-respected profession in my country,” she said.
But decades of war destroyed midwifery and much of health care, she said. Professionals fled the country, and many never went back.
“One day, 100 rockets came into Kabul,” she said. She and her husband, a physician, took their four children and moved to Pakistan, living there from 1992 to 2003. She had a fifth child there.
By the time she returned to Afghanistan, she said, midwifery was in a shambles. Spots in professional schools of all kinds were being filled by people with political connections instead of those with good grades. The midwives who had stayed behind had not received any continuing education. Their skills were outdated, and their attitudes were even worse.
“A culture of war was going on,” Ms. Azfar said. “If a mother came for delivery they didn’t treat her as she deserved or needed to be treated. There was no emotional support.”
Attitude counts in midwifery: if midwives and other health workers seem indifferent or disrespectful, women start to avoid the clinics, and they miss out on the help they urgently need.
Ms. Azfar acknowledged that it was hard to change attitudes, but she insisted that it could be done, by making “interpersonal skills” part of the training and the tests that students must pass to be allowed to practice. In Afghanistan, these things became part of the midwifery curriculum in 2004.
“Does she greet the mother properly?” she asked. “Offer her a chair? A drink of water? Introduce herself? Let the mother ask questions? They are trained. They have to do it.”
She has seen signs of progress, of hope.
“Just five years ago we started the reconstruction of this profession,” Ms. Azfar said. “These midwives, they are champions. Oh, I love them. They are my heart.”
A version of this article appeared in print on July 28, 2009, on page D5 of the New York edition.

9

Immigration: More Foreign Nurses Needed?
Business Week

21/07/2009

By Moira Herbst
Editor's note: This is the fourth article in an occasional series on immigration in a recession.
For more than a decade, the U.S. has faced a shortage of nurses to staff hospitals and nursing homes. While the current recession has encouraged some who had left the profession to return, about 100,000 positions remain unfilled. Experts say that if more is not done to entice people to enter the field—and to expand the U.S.'s nurse-training capacity—that number could triple or quadruple by 2025. President Barack Obama's goal of expanding health coverage to millions of the uninsured could also face additional hurdles if the supply of nurses can't meet the demand.
Some lawmakers are looking to the immigration pipeline as one means to raise staffing levels. In May, Representative Robert Wexler (D-Fla.) introduced a bill that would allow 20,000 additional nurses to enter the U.S. each year for the next three years as a temporary measure to fill the gap. If the bill doesn't pass on its own, lawmakers may include it in a comprehensive immigration reform package. Obama is slated to meet with congressional leaders on June 25 to discuss reforming U.S. immigration laws.
Hospital administrators such as William R. Moore in El Centro, Calif., a sparsely populated town 100 miles east of San Diego, see the Wexler bill as a potential life raft. Moore is chief human resources director at El Centro Regional Medical Center, a 135-bed public hospital that typically has 30 open positions for registered nurses (RNs). While it's hard to lure nurses from nearby big cities (San Diego is 100 miles west), Moore says he could quickly recruit dozens of eager, qualified nurses from the Philippines if the government allocated more visas. "All we want is temporary relief," says Moore. "Let us get a group of experienced RN hires from the Philippines, and we won't ask for more."
Obama begs to differ

Wexler's bill is opposed by labor unions, whose leaders say it would undermine efforts to produce a steady domestic workforce while sapping other nations' nurses. Obama has also expressed skepticism about the idea that the U.S. needs to import nurses, in particular because the U.S. unemployment rate continues to rise. "The notion that we would have to import nurses makes absolutely no sense," Obama said at a health-care forum in March. "There are a lot of people [in the U.S.] who would love to be in that helping profession, and yet we just aren't providing the resources to get them trained—that's something we've got to fix." The $787 billion economic stimulus bill included $500 million to address shortages of health workers in the U.S., with about $100 million to promote nursing and increase capacity at U.S. nurse-training schools.

The nursing shortage has a number of causes, including an aging workforce, difficult working conditions coupled with stagnating pay, and a lack of capacity at U.S. nursing schools. Peter I. Buerhaus, professor of nursing at Vanderbilt University Medical Center, says the recession has eased the nurse shortage in some areas of the U.S. as more Americans seek out the field's relative job security. Some hospitals also see less need for staff as more Americans lose health insurance and fewer people spend money on elective surgery and doctor visits. But Buerhaus estimates that by 2025 the nurse deficit will be twice as severe as the last major staffing shortage in the mid-1960s, after Congress passed the Medicare and Medicaid programs.
As openings have become more difficult to fill domestically, more foreign-born nurses have entered the workforce, most commonly through green cards that allow for permanent residency.
In 1994, 9% of the total registered nurse workforce was composed of foreign-born RNs; by 2008 that percentage had risen to 16.3%, or about 400,000 RNs, according to Buerhaus' research. Of those 400,000 nurses, about 10% had immigrated to the U.S. within the previous five years. About one-third of the increase in RNs from 2001 to 2008 was composed of foreign-born RNs.
Many U.S. nurses choosing not to work

The trend worries leaders of nurses' unions, who say importing workers can lower incentives to improve working conditions. Understaffing, mandatory overtime, and physically demanding work, such as lifting and bathing patients, take their toll. And while pay has risen in some regions to attract more nurses, in recent years it has flattened at the national level. That's why up to 500,000 registered nurses are choosing not to practice their profession—fully one-fifth of the current RN workforce of 2.5 million. Union leaders say the down economy is a chance to bring these nurses back into the field. "If unemployment is spiking, why do we need to bring in nurses from another country?" asks Ann Converso, president of United American Nurses, which represents 50,000 RNs. "We believe thousands and thousands of RNs would rejoin the profession if conditions improved." Converso says she doesn't oppose all overseas recruitment, but that lawmakers' focus should be on improving staffing ratios in hospitals to improve working conditions. "We have to again allow nurses to do what they do best: care for human beings," she says.

Mick Whitley, managing director of London-based global health-care staffing firm HCL International, says there's no need for alarm about foreign nurses. He points out that since 2006 it has become increasingly difficult for foreign-born nurses to obtain green cards to work in the U.S.; an applicant backlog has built up as annual quotas have been reached. "While patients in U.S. hospitals wait and suffer from a lack of sufficient care, experienced and caring internationally trained nurses who want to come here to help are also waiting [for a green card] for as long as seven years," says Whitley, a former nurse in the U.K. and Australia. "It's great that President Obama has committed more money to expanding health care, but the nurses that will be necessary to staff such expansions are nowhere to be found—at least not here, not yet."
Moore of El Centro Regional Medical Center says his hospital has been waiting for two years for 20 Philippine nurses he recruited to obtain visas. He says in the meantime he's unable to find talent in the area. "We're in the poorest and least literate county in California, right in the middle of the desert," says Moore. "We're not a destination for [American] nurses." Moore has had success hiring Philippine nurses, many of whom choose to stay and settle in El Centro. To them the U.S. "is the land of milk and honey, and the streets are paved in gold," says Moore. "They're not so particular."
Moore denies he wants to hire foreign-born talent to hold down wages. "We pay [a nurse] fresh out of school $28 an hour and $35-$40 with experience," he says.
One point everyone seems to agree on is that the U.S. needs more capacity to train nurses. Since 2002, enrollments at nursing schools have increased so much that up to 50,000 qualified applicants are turned away each year from training programs. The main problem is a lack of teaching staff at these schools. Dan Stultz, president of the Texas Hospital Assn., which represents more than 500 Texas hospitals, helped form the Texas Nursing Workforce Shortage Coalition to push for funding from the state legislature to boost capacity at Texas nursing schools. Stultz says the state has about 22,000 nurse vacancies now, and that the number could rise to 70,000 by 2020. Meanwhile, for the last five years, 8,000 to 12,000 nursing-student applicants have been denied places at training programs for lack of space. "We have qualified people that get accepted and can't attend," says Stultz. "We don't need more immigration; we need to increase capacity and grow our own workforce."
Herbst is a reporter for BusinessWeek in New York.