Public health intelligence challenges for local public health authorities responding to disease outbreaks: a mixed-methods systematic review protocol

Introduction

Worldwide, many types of hazardous events, including infectious disease outbreaks, are increasing in frequency (World Health Organization, 2019). Without effective risk management, these events may lead to emergencies and disasters which in turn may have devastating health, economic, political, and societal consequences. To help stakeholders address these risks the World Health Organization (WHO) has developed the Health Emergency and Disaster Risk Management Framework (Health EDRM) (World Health Organization, 2019). The Health EDRM is a conceptual framework intended to consolidate practice and assist all parties in adopting an approach which prioritises preparation. Information and knowledge management is a defined component of the Health EDRM. The WHO advocate planning for staffing and training at all levels of this function (World Health Organization, 2019).

In England, many public health services including some information and knowledge management functions are delivered by local governments (also known as local authorities). However, a report from the House of Commons Health and Social Care, and Science and Technology Committees on the United Kingdoms’ response to the coronavirus disease 2019 (COVID-19) pandemic describes a perceived failure to value public health at the local level (House of Commons, 2021). Indeed, The Local Government Association has stated that had the role of local public health been clearly recognised, measures such as contact tracing would have been rolled out quicker (Local Government Association, 2021). They have also highlighted poor understanding of roles and responsibilities, levers, and powers as key fault lines in the system (Cross Party Local Government Association, 2021). In England emergency preparedness, response and recovery is co-ordinated by multi-agency partnerships which incorporate local authorities. These partnerships are called Local Resilience Forums (LRFs). Importantly, LRFs are not separately resourced meaning they have no access to capacity beyond individual partners (Local Government Association, no date).

Even before the COVID-19 pandemic, there were documented concerns around the public health information and knowledge workforce. These included the effects of team reorganisations, funding reduction, lack of clear career pathways, workforce immobility and insufficient support from national bodies (Centre for Workforce Intelligence, 2015 and Shickle et al., 2018). Understanding levels of preparedness in advance of a health emergency, has been highlighted as an important knowledge gap by the WHO (World Health Organization, 2021). This research will explore the challenges sub-national Public Health Authorities have experienced in responding to the COVID-19 pandemic as part of a wider project to explore the English experience.

A preliminary literature search identified no existing or ongoing systematic reviews on sub-national information and knowledge management challenges during disease outbreaks. A recent narrative review, global in scope, describes the main health information management challenges during COVID-19 as:

(Massoudi and Sobolevskaia, 2021)

However, Massoudi and Sobolevskaia do not provide detail on the challenges sub-national Public Health Authorities have faced. And although the authors highlight workforce issues as important, the review does not directly address these. It is pertinent to examine workforce issues because the WHO have stated the public health workforce’s role is often overlooked during implementation of international regulations to improve health security (World Health Organization, 2022).

In the UK, information and knowledge management in public health is also called Public Health Intelligence. The concept of Public Health Intelligence, as a defined public health discipline, has gradually emerged and developed in complexity. Public Health Intelligence can be portrayed as spanning the full intelligence cycle (Regmi & Gee, 2016) which Bowsher et al., 2020 describe as encompassing direction, collection, processing and analysis and dissemination (Figure 1).

Figure 1. A conceptualisation of the Intelligence Cycle described by Bowsher et al., 2020.

The cycle can be understood as a process that transforms data into public health intelligence. Here, intelligence is distinct from data, because it enables evidence-based decisions which are actionable. In other words - intelligence becomes information that is useful. Assessing health needs is the starting point for public health activities and therefore, an information system is a core aspect of any public health activity (Regmi & Gee, 2016).

This paper is the protocol for a mixed-methods systematic review which will inform a larger mixed-methods research project. The larger project will explore the challenges that English local authorities have experienced in responding to the COVID-19 pandemic from a public health intelligence perspective. The review will fill knowledge gaps by synthesising literature on sub-national public health intelligence responses to infectious disease outbreaks. Facilitators and barriers to a response and how preparedness for disease outbreaks could be improved will be explored. Emphasis on workforce issues will allow the examination of the contribution of workforce planning and training as advocated by WHO (World Health Organization, 2019).

The review is not limited to the English public health system or to just COVID-19 outbreaks. This is so comparisons can be made across countries and types of outbreak. The results will elucidate the facilitators and barriers to sub-national public health intelligence responses.

Research questions

In relation to propagated disease outbreaks, key questions the review will address are:

Methods

A protocol has been registered with the PROSPERO International Prospective Register of Systematic Reviews on 8^th February 2022. The registration number is CRD42022308042.

To minimise bias, the review aims to identify, evaluate, summarise, and synthesise studies in a systematic way. Quantitative, qualitative and mixed-methods studies may all address the research questions therefore a mixed-methods convergent integrated approach is appropriate for synthesis and integration (Lizarondo et al., 2020).

Discussion

This research will systematically review recent studies that relate to sub-national public health authorities’ public health intelligence responses during disease outbreaks. The review will identify and synthesise the facilitators and barriers to an outbreak response identified in the primary literature. This will fill important knowledge gaps regarding sub-national responses and workforce-related issues. The findings will provide information to support the organisation of services, training development, preparedness assessment and/or implementation of directives.

Whilst this study is not specifically designed to compare how public health intelligence activities which emerged in 2020 (the pandemic period), differed to pre-pandemic activities or how the emergence of social media effected responses, these comparisons are inherently covered by the research questions.

The focus on sub-national public health entities is intended to allow exploration of facilitators and barriers to disease outbreak response at a local level. This enhanced focus will allow operational aspects, including workforce issues, to be explored in detail. Indeed, previous work has highlighted knowledge gaps around public health preparedness indicators at the local and regional level (Ontario Agency for Health Protection and Promotion/Public Health Ontario, 2020).

Lee et al. (2023) conducted a scoping review exploring priority areas and indicators for Public Health Emergency Preparedness (PHEP) with a focus on infectious disease emergencies. The review identified several ‘emerging’ themes. These included: planning to mitigate inequities, research and evidence-informed decision making, building vaccination capacity, building laboratory and diagnostic system capacity, building infection prevention and control capacity, financial investment in infrastructure, health system capacity, climate and environmental health, public health legislation and phases of preparedness.

This research will contribute to a better response to public health emergencies as the findings can be compared to existing work on local indicators of PHEP, including that undertaken by the Ontario Agency for Health Protection and Promotion (2020) and Lee et al., 2023. In relation to public health intelligence, the review will provide empirically derived support for previously identified indicators, explore ‘emerging’ themes, and identify potential new indicators of preparedness.

Other anticipated findings include: 1) a description of the evidence base, 2) reported response characteristics (what was done and how this was organised and resourced) and 3) a summary of recommendations. Findings will be presented by considering individual, team, organisational and system levels, where appropriate, as identified during analysis. Whilst the results will be written up as part of a PhD thesis and shared at relevant seminars and symposiums, a publication in an academic journal is also planned.

Strengths and limitations

The rigorous mixed-methods design will limit bias and ensure appropriate evidence is considered regardless of its research methodology i.e., whether it is from a quantitative, qualitative or mixed-methods study.

Amendments

The PROSPERO record was revised after piloting of the inclusion criteria revealed a very large number of studies would need to be full text screened. A decision was taken to limit the review to peer reviewed literature and to apply a date limit.