Planning for an Influenza Pandemic: Social Justice and Disadvantaged Groups

Social innovation in health and community-driven engagement as a key strategy for addressing COVID-19 crisis challenges: insights and reflections from the multicultural society of Iran

Background

Social innovation is one of the strategies for appealing to people and encouraging social cooperation and engagement in interventions during crisis periods. In this regard, community engagement is an operative and innovative community health approach for achieving successful health outcomes. There is limited information about the role and operational impact of social innovation on community engagement during the challenges posed by the COVID-19 crisis. In this study, we aim to contribute to the understanding of innovative social strategies to attract social participation in crises such as the COVID-19 pandemic by highlighting the experience of social innovative strategies based on community-driven engagement in Iran.

Methods

This qualitative study was conducted in seven provinces of Iran-Mazandaran, Zanjan, Golestan, Lorestan, Tehran, Kurdistan, and Khuzestan-from 4 September 2021 to 1 March 2022. A sample of Iranians (15-71 years) was selected by purposeful and snowball sampling methods to participate in the study, and 187 semi-structured telephone interviews were conducted. Participants were recruited from three levels of the community: community leaders, healthcare providers, and laypeople. The data collection tool was an interview guide, which was designed based on a review of the literature. The data were analyzed using conventional content analysis. Exploratory analyses were performed to identify social innovative strategies based on community engagement used during the COVID-19 crisis in Iran. The interviews continued until data saturation was reached.

Results

Based on our findings, we distilled innovative strategies into 6 main themes and 37 categories: (1) information giving/sharing, (2) consultation, (3) involvement/collaboration, (4) health education and prevention, (5) empowering, and (6) advocacy. The results revealed that the participants were very driven to engage in the management and control of the COVID-19 crisis, even though they faced significant challenges.

Conclusion

The spread of the COVID-19 pandemic required social- and community-based responses. These reactions increased the possibility of fair access to health services, especially for vulnerable groups and minorities. As with other epidemics, applying the experience of the comprehensive participation of communities played an important and active role in the prevention and control of COVID-19. In this regard, giving and sharing information, consultation, involvement/collaboration, health education/prevention, empowerment, and advocacy are the most important innovative strategies that might encourage the community to perform COVID-19 crisis management and control.

How prepared is the world? Identifying weaknesses in existing assessment frameworks for global health security through a One Health approach

The COVID-19 pandemic has exposed faults in the way we assess preparedness and response capacities for public health emergencies. Existing frameworks are limited in scope, and do not sufficiently consider complex social, economic, political, regulatory, and ecological factors. One Health, through its focus on the links among humans, animals, and ecosystems, is a valuable approach through which existing assessment frameworks can be analysed and new ways forward proposed. Although in the past few years advances have been made in assessment tools such as the International Health Regulations Joint External Evaluation, a rapid and radical increase in ambition is required. To sufficiently account for the range of complex systems in which health emergencies occur, assessments should consider how problems are defined across stakeholders and the wider sociopolitical environments in which structures and institutions operate. Current frameworks do little to consider anthropogenic factors in disease emergence or address the full array of health security hazards across the social-ecological system. A complex and interdependent set of challenges threaten human, animal, and ecosystem health, and we cannot afford to overlook important contextual factors, or the determinants of these shared threats. Health security assessment frameworks should therefore ensure that the process undertaken to prioritise and build capacity adheres to core One Health principles and that interventions and outcomes are assessed in terms of added value, trade-offs, and cobenefits across human, animal, and environmental health systems.

Socio-demographic disparities in receipt of clinical health care services during the COVID-19 pandemic for Canadian children with disability

BACKGROUND

Little is known about the experience of receiving in-person and virtual clinical health care services during the COVID-19 pandemic for Canadian children with developmental disabilities and delays facing multiple layers of vulnerability (e.g., low income, low educational attainment families). We examined the relationship between socio-demographic factors and the receipt of these services (physical and mental health services) during COVID-19 for Canadian children with these conditions.

METHODS

Data collected in Canada for the Global Report on Developmental Delays, Disorders and Disabilities were used. The survey: (1) was developed and disseminated in collaboration with caregivers of children with disabilities, (2) included topics such as response to the pandemic and receipt of services and supports, and (3) documented the experiences of a non-random convenience sample of caregivers of children (any age) with these conditions during and prior to the pandemic. We used four logistic regression models to assess the association between socio-demographic factors and receipt of services.

RESULTS

Being a single parent, having low educational attainment (high school or less), having low income (making less than $40,000 per year), working less than full time (working part-time, working reduced hours due to COVID, retired, stay home parent or student), as well as male gender and older age of the child with disability were factors associated with decreased likelihood of receiving services.

CONCLUSION

Our findings point to the need for tailoring services for families of children with disabilities, particularly low socioeconomic status families, to ensure continuity of care during public health emergencies.

Demographics, Socioeconomic Context, and the Spread of Infectious Disease: The Case of COVID-19

Importance: Due to the evolving variants of coronavirus disease 2019 (COVID-19), it is important to understand the relationship between the disease condition and socioeconomic, demographic, and health indicators across regions. Background: Studies examining the relationships between infectious disease and socioeconomic variables are not yet well established. Design: A total of 3042 counties in the United States are included as the observation unit in the study. Two outcome variables employed in the study are the control of disease spread and infection prevalence rates in each county. Method: Data are submitted to quantile regression, hierarchical regression, and random forest analyses to understand the extent to which health outcomes are affected by demographics, socioeconomics, and health indicators. Results: Counties with better control of the disease spread tend to have lower infection rates, and vice versa. When measuring different outcome variables, the common risk factors for COVID-19 with a 5% level of statistical significance include employment ratio, female labor ratio, young population ratio, and residents’ average health risk factors, while protective factors include land size, housing value, travel time to work, female population ratio, and ratio of residents who identify themselves as mixed race. Conclusions: The implications of the findings are that the ability to maintain social distancing and personal hygiene habits are crucial in deterring disease transmission and lowering incidence rates, especially in the early stage of disease formation. Relevant authorities should identify preventive factors and take early actions to fight infectious diseases in the future.

Not the great equalizers: Covid-19, 1918-20 influenza, and the need for a paradigm shift in pandemic preparedness

Despite common perceptions to the contrary, pandemic diseases do not affect populations indiscriminately. In this paper, we review literature produced by demographers, historians, epidemiologists, and other researchers on disparities during the 1918-20 influenza pandemic and the Covid-19 pandemic. Evidence from these studies demonstrates that lower socio-economic status and minority/stigmatized race or ethnicity are associated with higher morbidity and mortality. However, such research often lacks theoretical frameworks or appropriate data to explain the mechanisms underlying these disparities fully. We suggest using a framework that considers proximal and distal factors contributing to differential exposure, susceptibility, and consequences as one way to move this research forward. Further, current pandemic preparedness plans emphasize medically defined risk groups and epidemiological approaches. Therefore, we conclude by arguing in favour of a transdisciplinary paradigm that recognizes socially defined risk groups, includes input from the social sciences and humanities and other diverse perspectives, and contributes to the reduction of health disparities before a pandemic hits.

Cohort profile: The UK COVID-19 Public Experiences (COPE) prospective longitudinal mixed-methods study of health and well-being during the SARSCoV2 coronavirus pandemic

Public perceptions of pandemic viral threats and government policies can influence adherence to containment, delay, and mitigation policies such as physical distancing, hygienic practices, use of physical barriers, uptake of testing, contact tracing, and vaccination programs. The UK COVID-19 Public Experiences (COPE) study aims to identify determinants of health behaviour using the Capability, Opportunity, Motivation (COM-B) model using a longitudinal mixed-methods approach. Here, we provide a detailed description of the demographic and self-reported health characteristics of the COPE cohort at baseline assessment, an overview of data collected, and plans for follow-up of the cohort. The COPE baseline survey was completed by 11,113 UK adult residents (18+ years of age). Baseline data collection started on the 13th of March 2020 (10-days before the introduction of the first national COVID-19 lockdown in the UK) and finished on the 13th of April 2020. Participants were recruited via the HealthWise Wales (HWW) research registry and through social media snowballing and advertising (Facebook®, Twitter®, Instagram®). Participants were predominantly female (69%), over 50 years of age (68%), identified as white (98%), and were living with their partner (68%). A large proportion (67%) had a college/university level education, and half reported a pre-existing health condition (50%). Initial follow-up plans for the cohort included in-depth surveys at 3-months and 12-months after the first UK national lockdown to assess short and medium-term effects of the pandemic on health behaviour and subjective health and well-being. Additional consent will be sought from participants at follow-up for data linkage and surveys at 18 and 24-months after the initial UK national lockdown. A large non-random sample was recruited to the COPE cohort during the early stages of the COVID-19 pandemic, which will enable longitudinal analysis of the determinants of health behaviour and changes in subjective health and well-being over the course of the pandemic.

Travail de care des travailleuses de la santé en situation de pandémie de COVID-19 : quel engagement de la part des autorités gouvernementales?

La COVID-19 a pressé les gouvernements à intervenir à l'aide de données partielles sur l'efficacité des moyens. Les femmes sont particulièrement touchées car elles sont plus nombreuses à s'occuper des autres. Cette étude a pour but de comprendre l'influence des décisions politiques sur les conditions de vie et de travail des travailleuses de la santé. Une analyse des interventions gouvernementales de santé publique du Québec et des revendications des travailleuses de la santé retrouvées dans les documents journalistiques et les communiqués de presse officiels du gouvernement (13 avril au 1er juillet 2020) a été effectuée. Les résultats démontrent le manque de reconnaissance des autorités face à certains types de care, ainsi qu'une inadéquation dans les moyens de prise en charge pour prendre soin de la population. Le peu de reconnaissance des conditions de vie et de travail lors de décisions politiques engendre une répartition inéquitable des fardeaux associés à la pandémie.

Community engagement for outbreak preparedness and response in high-income settings: A systematic review

BACKGROUND

This review aims to (i) identify and critique existing methods of community engagement for outbreak preparedness and response in high-income settings, and (ii) understand community members' experiences of community engagement, and their views and concerns towards pandemic planning/response.

METHODS

Following the PRISMA guidelines, a systematic review was conducted by searching Medline, Embase, PubMed, Global Health, CINAHL Plus and Scopus for publications from 2004 to June 2019. Potential literature was screened using explicit inclusion and exclusion criteria. Included studies were appraised using the Critical Appraisal Skills Programme Qualitative Research checklist. Those using deliberative approaches were appraised using additional criteria for judging deliberation quality. Thematic synthesis was then conducted.

RESULTS

Primary studies employed participatory research approaches, deliberative forums, interviews/focus groups to engage community members on pandemic planning/response with varying degrees of involvement and methodological rigour. This review indicates such endeavours must take into account instrumental and relational considerations: socioeconomic pressures; agency and capacity; diversity and divergent views; educate, communicate and engage; trust and transparency.

CONCLUSION

Community engagement for pandemic planning/response requires clear methods, processes and who 'community' constitutes. Instrumental and relational considerations must be addressed concurrently in pandemic planning/response to enhance preparedness for public health emergencies.

Accelerating the De-Personalization of Medicine: The Ethical Toxicities of COVID-19

The COVID-19 pandemic has, of necessity, demanded the rapid incorporation of virtual technologies which, suddenly, have superseded the physical medical encounter. These imperatives have been implemented in advance of evaluation, with unclear risks to patient care and the nature of medical practice that might be justifiable in the context of a pandemic but cannot be extrapolated as a new standard of care. Models of care fit for purpose in a pandemic should not be generalized to reconfigure medical care as virtual by default, and personal by exception at the conclusion of the emergency.

A framework for identifying and mitigating the equity harms of COVID-19 policy interventions

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a global pandemic. Governments have implemented combinations of "lockdown" measures of various stringencies, including school and workplace closures, cancellations of public events, and restrictions on internal and external movements. These policy interventions are an attempt to shield high-risk individuals and to prevent overwhelming countries' healthcare systems, or, colloquially, "flatten the curve." However, these policy interventions may come with physical and psychological health harms, group and social harms, and opportunity costs. These policies may particularly affect vulnerable populations and not only exacerbate pre-existing inequities but also generate new ones.

METHODS

We developed a conceptual framework to identify and categorize adverse effects of COVID-19 lockdown measures. We based our framework on Lorenc and Oliver's framework for the adverse effects of public health interventions and the PROGRESS-Plus equity framework. To test its application, we purposively sampled COVID-19 policy examples from around the world and evaluated them for the potential physical, psychological, and social harms, as well as opportunity costs, in each of the PROGRESS-Plus equity domains: Place of residence, Race/ethnicity, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital, Plus (age, and disability).

RESULTS

We found examples of inequitably distributed adverse effects for each COVID-19 lockdown policy example, stratified by a low- or middle-income country and high-income country, in every PROGRESS-Plus equity domain. We identified the known policy interventions intended to mitigate some of these adverse effects. The same harms (anxiety, depression, food insecurity, loneliness, stigma, violence) appear to be repeated across many groups and are exacerbated by several COVID-19 policy interventions.

CONCLUSION

Our conceptual framework highlights the fact that COVID-19 policy interventions can generate or exacerbate interactive and multiplicative equity harms. Applying this framework can help in three ways: (1) identifying the areas where a policy intervention may generate inequitable adverse effects; (2) mitigating the policy and practice interventions by facilitating the systematic examination of relevant evidence; and (3) planning for lifting COVID-19 lockdowns and policy interventions around the world.

Screening for economic hardship for child welfare-involved families during the COVID-19 pandemic: A rapid partnership response

BACKGROUND

Pandemics have a wide range of economic, health and social consequences related to both the spread of a disease and efforts made by government leaders to contain it which may be particularly detrimental for the child welfare-involved population. This is because child welfare agencies serve some of the highest needs children and families. A significant proportion of these families face economic hardship, and as a result of containment measures for COVID-19, more families inevitably will.

OBJECTIVE

Given the range of negative consequences related to the pandemic and the evolving supports available to families, child protection workers needed a clinical tool to guide and support work with families informed by an understanding of economic hardship. The objective of this paper is to report on the development and implementation strategy of a tool to be used for practice intervention during the pandemic.

METHODS

Action research methodology was utilized in the creation of the clinical tool. The tool's development and implementation occurred through an academic/child welfare sector partnership involving child welfare agencies representing diverse regions and populations in Ontario, Canada. Factor analysis of representative child welfare data from the Ontario Incidence Study of Reported Child Abuse and Neglect 2018 (OIS-2018) on economic hardship was used to inform the development of questions on the clinical tool.

RESULTS

The development and implementation strategy of the clinical tool are described, including the results from analyses of the OIS-2018.

CONCLUSIONS

Future directions for the project are discussed, including considerations for using this tool beyond the pandemic.

Pandemic Surveillance and Racialized Subpopulations: Mitigating Vulnerabilities in COVID-19 Apps

Debates about effective responses to the COVID-19 pandemic have emphasized the paramount importance of digital tracing technology in suppressing the disease. So far, discussions about the ethics of this technology have focused on privacy concerns, efficacy, and uptake. However, important issues regarding power imbalances and vulnerability also warrant attention. As demonstrated in other forms of digital surveillance, vulnerable subpopulations pay a higher price for surveillance measures. There is reason to worry that some types of COVID-19 technology might lead to the employment of disproportionate profiling, policing, and criminalization of marginalized groups. It is, thus, of crucial importance to interrogate vulnerability in COVID-19 apps and ensure that the development, implementation, and data use of this surveillance technology avoids exacerbating vulnerability and the risk of harm to surveilled subpopulations, while maintaining the benefits of data collection across the whole population. This paper outlines the major challenges and a set of values that should be taken into account when implementing disease surveillance technology in the pandemic response.

Immediate and Long-Term Implications of the COVID-19 Pandemic for People With Disabilities

Some people with disabilities may have greater risk of contracting COVID-19 or experiencing worse outcomes if infected. Although COVID-19 is a genuine threat for people with disabilities, they also fear decisions that might limit lifesaving treatment should they contract the virus.During a pandemic, health systems must manage excess demand for treatment, and governments must enact heavy restrictions on their citizens to prevent transmission. Both actions can have a negative impact on people with disabilities.Ironically, the sociotechnical advances prompted by this pandemic could also revolutionize quality of life and participation for people with disabilities. Preparation for future disasters requires careful consideration.

Prioritising access to pandemic influenza vaccine: a review of the ethics literature

Background

The world is threatened by future pandemics. Vaccines can play a key role in preventing harm, but there will inevitably be shortages because there is no possibility of advance stockpiling. We therefore need some method of prioritising access.

Main text

This paper reports a critical interpretative review of the published literature that discusses ethical arguments used to justify how we could prioritise vaccine during an influenza pandemic. We found that the focus of the literature was often on proposing different groups as priorities (e.g. those with pre-existing health conditions, the young, the old, health care workers etc.). Different reasons were often suggested as a means of justifying such priority groupings (e.g. appeal to best overall outcomes, fairness, belonging to a vulnerable or ‘at risk’ group etc.). We suggest that much of the literature, wrongly, assumes that we are able to plan priority groups prior to the time of a particular pandemic and development of a particular vaccine. We also point out the surprising absence of various issues from the literature (e.g. how vaccines fit within overall pandemic planning, a lack of specificity about place, issues of global justice etc.).

Conclusions

The literature proposes a wide range of ways to prioritise vaccines, focusing on different groups and ‘principles’. Any plan to use pandemic vaccine must provide justifications for its prioritisation. The focus of this review was influenza pandemic vaccines, but lessons can be learnt for future allocations of coronavirus vaccine, if one becomes available.

Planning for Pandemics: Lessons From the Past Decade

It is now 10 years since the disease we now know as SARS--severe acute respiratory syndrome--caused more than 700 deaths around the world and made more than 8,000 people ill. More recently, in 2009 the global community experienced the first influenza pandemic of the 21st century--the 2009 H1N1 influenza pandemic. This paper analyses the major developments in international public health law relating to infectious diseases in the period since SARS and considers their implications for pandemic planning.

Health inequalities and infectious disease epidemics: a challenge for global health security

In today's global society, infectious disease outbreaks can spread quickly across the world, fueled by the rapidity with which we travel across borders and continents. Historical accounts of influenza pandemics and contemporary reports on infectious diseases clearly demonstrate that poverty, inequality, and social determinants of health create conditions for the transmission of infectious diseases, and existing health disparities or inequalities can further contribute to unequal burdens of morbidity and mortality. Yet, to date, studies of influenza pandemic plans across multiple countries find little to no recognition of health inequalities or attempts to engage disadvantaged populations to explicitly address the differential impact of a pandemic on them. To meet the goals and objectives of the Global Health Security Agenda, we argue that international partners, from WHO to individual countries, must grapple with the social determinants of health and existing health inequalities and extend their vision to include these factors so that disease that may start among socially disadvantaged subpopulations does not go unnoticed and spread across borders. These efforts will require rethinking surveillance systems to include sociodemographic data; training local teams of researchers and community health workers who are able to not only analyze data to recognize risk factors for disease, but also use simulation methods to assess the impact of alternative policies on reducing disease; integrating social science disciplines to understand local context; and proactively anticipating shortfalls in availability of adequate healthcare resources, including vaccines. Without explicit attention to existing health inequalities and underlying social determinants of health, the Global Health Security Agenda is unlikely to succeed in its goals and objectives.

Tsunami-tendenko and morality in disasters

Disaster planning challenges our morality. Everyday rules of action may need to be suspended during large-scale disasters in favour of maxims that that may make prudential or practical sense and may even be morally preferable but emotionally hard to accept, such as tsunami-tendenko. This maxim dictates that the individual not stay and help others but run and preserve his or her life instead. Tsunami-tendenko became well known after the great East Japan earthquake on 11 March 2011, when almost all the elementary and junior high school students in one city survived the tsunami because they acted on this maxim that had been taught for several years. While tsunami-tendenko has been praised, two criticisms of it merit careful consideration: one, that the maxim is selfish and immoral; and two, that it goes against the natural tendency to try to save others in dire need. In this paper, I will explain the concept of tsunami-tendenko and then respond to these criticisms. Such ethical analysis is essential for dispelling confusion and doubts about evacuation policies in a disaster.

Factors influencing H1N1 vaccine behavior among Manitoba Metis in Canada: a qualitative study

Background

During the first wave of the H1N1 influenza pandemic in 2009, Aboriginal populations in Canada experienced disproportionate rates of infection, particularly in the province of Manitoba. To protect those thought to be most at-risk, health authorities in Manitoba listed all Aboriginal people, including Metis, among those able to receive priority access to the novel vaccine when it first became available. Currently, no studies exist that have investigated the attitudes, influences, and vaccine behaviors among Aboriginal communities in Canada. This paper is the first to systematically connect vaccine behavior with the attitudes and beliefs that influenced Metis study participants’ H1N1 vaccine decision-making.

Methods

Researchers held focus groups (n = 17) with Metis participants in urban, rural, and remote locations of Manitoba following the conclusion of the H1N1 pandemic. Participants were asked about their vaccination decisions and about the factors that influenced their decisions. Following data collection, responses were coded into the broad categories of a social-ecological model, nuanced by categories stemming from earlier research. Responses were then quantified to show the most influential factors in positively or negatively affecting the vaccine decision.

Results

Media reporting, the influence of peer groups, and prioritization all had positive and negative influential effects on decision making. Whether vaccinated or not, the most negatively influential factors cited by participants were a lack of knowledge about the vaccine and the pandemic as well as concerns about vaccine safety. Risk of contracting H1N1 influenza was the biggest factor in positively influencing a vaccine decision, which in many cases trumped any co-existing negative influencers.

Conclusions

Metis experiences of colonialism in Canada deeply affected their perceptions of the vaccine and pandemic, a context that health systems need to take into account when planning response activities in the future. Participants felt under-informed about most aspects of the vaccine and the pandemic, and many vaccine related misconceptions and fears existed. Recommendations include leveraging doctor-patient interactions as a site for sharing vaccine-related knowledge, as well as targeted, culturally-appropriate, and empowering public information strategies to supply reliable vaccine and pandemic information to potentially at-risk Aboriginal populations.

Equity in the receipt of oseltamivir in the United States during the H1N1 pandemic

OBJECTIVES

We assessed the relationship between individual characteristics and receipt of oseltamivir (Tamiflu) in the United States during the H1N1 pandemic and other flu seasons.

METHODS

In a cohort of individuals enrolled in pharmacy benefit plans, we used a multivariate logistic regression model to measure associations between subscriber characteristics and filling a prescription for oseltamivir during 3 flu seasons (October 2006-May 2007, October 2007-May 2008, and October 2008-May 2010). In 19 states with county-level influenza rates reported, we controlled for disease burden.

RESULTS

Approximately 56 million subscribers throughout the United States were included in 1 or more study periods. During pandemic flu, beneficiaries in the highest income category had 97% greater odds of receiving oseltamivir than those in the lowest category (P < .001). After we controlled for disease burden, subscribers in the 2 highest income categories had 2.18 and 1.72 times the odds of receiving oseltamivir compared with those in the lowest category (P < .001 for both).

CONCLUSIONS

Income was a stronger predictor of oseltamivir receipt than prevalence of influenza. These findings corroborate concerns about equity of treatment in pandemics, and they call for improved approaches to distributing potentially life-saving treatments.

A community-based participatory approach and engagement process creates culturally appropriate and community informed pandemic plans after the 2009 H1N1 influenza pandemic: remote and isolated First Nations communities of sub-arctic Ontario, Canada

BACKGROUND

Public health emergencies have the potential to disproportionately impact disadvantaged populations due to pre-established social and economic inequalities. Internationally, prior to the 2009 H1N1 influenza pandemic, existing pandemic plans were created with limited public consultation; therefore, the unique needs and characteristics of some First Nations communities may not be ethically and adequately addressed. Engaging the public in pandemic planning can provide vital information regarding local values and beliefs that may ultimately lead to increased acceptability, feasibility, and implementation of pandemic plans. Thus, the objective of the present study was to elicit and address First Nations community members' suggested modifications to their community-level pandemic plans after the 2009 H1N1 influenza pandemic.

METHODS

The study area included three remote and isolated First Nations communities located in sub-arctic Ontario, Canada. A community-based participatory approach and community engagement process (i.e., semi-directed interviews (n = 13), unstructured interviews (n = 4), and meetings (n = 27)) were employed. Participants were purposively sampled and represented various community stakeholders (e.g., local government, health care, clergy, education, etc.) involved in the community's pandemic response. Collected data were manually transcribed and coded using deductive and inductive thematic analysis. The data subsequently informed the modification of the community-level pandemic plans.

RESULTS

The primary modifications incorporated in the community-level pandemic plans involved adding community-specific detail. For example, 'supplies' emerged as an additional category of pandemic preparedness and response, since including details about supplies and resources was important due to the geographical remoteness of the study communities. Furthermore, it was important to add details of how, when, where, and who was responsible for implementing recommendations outlined in the pandemic plans. Additionally, the roles and responsibilities of the involved organizations were further clarified.

CONCLUSIONS

Our results illustrate the importance of engaging the public, especially First Nations, in pandemic planning to address local perspectives. The community engagement process used was successful in incorporating community-based input to create up-to-date and culturally-appropriate community-level pandemic plans. Since these pandemic plans are dynamic in nature, we recommend that the plans are continuously updated to address the communities' evolving needs. It is hoped that these modified plans will lead to an improved pandemic response capacity and health outcomes, during the next public health emergency, for these remote and isolated First Nations communities. Furthermore, the suggested modifications presented in this paper may help inform updates to the community-level pandemic plans of other similar communities.

Social justice in pandemic preparedness

Pandemic influenza planning in the United States violates the demands of social justice in 2 fundamental respects: it embraces the neutrality of procedural justice at the expense of more substantive concern with health disparities, thus perpetuating a predictable and preventable social injustice, and it fails to move beyond lament to practical planning for alleviating barriers to accessing care. A pragmatic social justice approach, addressing both health disparities and access barriers, should inform pandemic preparedness. Achieving social justice goals in pandemic response is challenging, but strategies are available to overcome the obstacles. The public engagement process of one state's pandemic ethics project influenced the development of these strategies.

The 2009 H1N1 pandemic response in remote First Nation communities of Subarctic Ontario: barriers and improvements from a health care services perspective

OBJECTIVES

To retrospectively examine the barriers faced and opportunities for improvement during the 2009 H1N1 pandemic response experienced by participants responsible for the delivery of health care services in 3 remote and isolated Subarctic First Nation communities of northern Ontario, Canada.

STUDY DESIGN

A qualitative community-based participatory approach.

METHODS

Semi-directed interviews were conducted with adult key informants (n=13) using purposive sampling of participants representing the 3 main sectors responsible for health care services (i.e., federal health centres, provincial hospitals and Band Councils). Data were manually transcribed and coded using deductive and inductive thematic analysis.

RESULTS

Primary barriers reported were issues with overcrowding in houses, insufficient human resources and inadequate community awareness. Main areas for improvement included increasing human resources (i.e., nurses and trained health care professionals), funding for supplies and general community awareness regarding disease processes and prevention.

CONCLUSIONS

Government bodies should consider focusing efforts to provide more support in terms of human resources, monies and education. In addition, various government organizations should collaborate to improve housing conditions and timely access to resources. These recommendations should be addressed in future pandemic plans, so that remote western James Bay First Nation communities of Subarctic Ontario and other similar communities can be better prepared for the next public health emergency.

Racial and ethnic disparities in uptake and location of vaccination for 2009-H1N1 and seasonal influenza

To learn more about racial and ethnic disparities in influenza vaccination during the 2009-H1N1 pandemic, we examined nationally representative survey data of US adults. We found disparities in 2009-H1N1 vaccine uptake between Blacks and Whites (13.8% vs 20.4%); Whites and Hispanics had similar 2009-H1N1 vaccination rates. Physician offices were the dominant location for 2009-H1N1 and seasonal influenza vaccinations, especially among minorities. Our results highlight the need for a better understanding of how communication methods and vaccine distribution strategies affect vaccine uptake within minority communities.

Preparing for an influenza pandemic: mental health considerations

There is a common belief that an influenza pandemic not only is inevitable, but that it is imminent. It is further believed by some, and dramatized by a 2006 made-for-television-movie, that such a pandemic will herald an end to life as we know it. Are such claims hyperboles, or does a pandemic represent the most significant threat to public health in the new millennium? Any potential effects of a disease on a population are mediated not only through the pathophysiological mechanisms of the disease itself, but through the psychological and behavioral reactions that such a disease might engender. It is the purpose of this paper to explore the potential psychological and behavioral reactions that may accompany an influenza pandemic.

Using patient evaluations to empirically assess medicaid programs for social justice

The Medicaid program serves a social justice function in the United States. The program's effectiveness in achieving this aim is traditionally evaluated in terms of resource allocation and distribution using measures and concepts such as financing, access, and enrollment. The patient's perspective in ascertaining the quality of actual care delivery has not been utilized to ascertain social justice. This paper uses the confidential evaluations of 40% of the hospitals in Rhode Island, New Jersey, and Connecticut to compare the experiences of Medicaid patients versus privately insured patients hospitalized in 2002 and cross-validates results in independent samples collected in 2003 and 2004. The results found that Medicaid patients experienced interactions with physicians that resulted in lower ratings of statistical and practical significance than privately insured patients. Admissions and discharge processes were also rated lower by Medicaid patients. The "hotel" amenities provided by hospitals-room and meals-were rated more favorably by Medicaid patients. Yet there were no significant differences in Medicaid and private insurance patients' overall satisfaction with their acute care experience. Medicaid patients' evaluations should be considered a key component of evaluating whether a state's Medicaid program has achieved patients' and society's need for social justice.

Canadian survey on pandemic flu preparations

Background

The management of pandemic influenza creates public health challenges.

An ethical framework, 'Stand on Guard for Thee: ethical considerations in pandemic influenza preparedness' that served as a template for the World Health Organization's global consultation on pandemic planning, was transformed into a survey administered to a random sample of 500 Canadians to obtain opinions on key ethical issues in pandemic preparedness planning.

Methods

All framework authors and additional investigators created items that were pilot-tested with volunteers of both sexes and all socioeconomic strata. Surveys were telephone administered with random sampling achieved via random digit dialing (RDD). Eligible participants were adults, 18 years or older, with per province stratification equaling provincial percent of national population. Descriptive results were tabulated and logistic regression analyses were used to assess whether demographic factors were significantly associated with outcomes.

Results

5464 calls identified 559 eligible participants of whom 88.5% completed surveys. Over 90% of subjects agreed the most important goal of pandemic influenza preparations was saving lives, with 41% endorsing saving lives solely in Canada and 50% endorsing saving lives globally as the highest priority. Older age (OR = 8.51, p < 0.05) and current employment (OR = 9.48, p < 0.05) were associated with an endorsement of saving lives globally as highest priority. About 90% of respondents supported the obligation of health care workers to report to work and face influenza pandemic risks excepting those with a serious health condition that increased risks. Over 84% supported the government's provision of disability insurance and death benefits for health care workers facing elevated risk. Strong majorities favored stocking adequate protective antiviral dosages for all Canadians (92%) and, if effective, influenza vaccinations (95%). Over 70% agreed Canada should provide international assistance to poorer countries for pandemic preparation, even if resources for Canadians were reduced. While 92% of this group, believed provision should be 7 to 10% of all resources generated, 43% believed the provision should be greater than 10%.

Conclusions

Results suggest trust in public health officials to make difficult decisions, providing emphasis on reciprocity and respect for individual rights.

Effective health risk communication about pandemic influenza for vulnerable populations

The consequences of pandemic influenza for vulnerable populations will depend partly on the effectiveness of health risk communications. Strategic planning should fully consider how life circumstances, cultural values, and perspectives on risk influence behavior during a pandemic. We summarize recent scientific evidence on communication challenges and examine how sociocultural, economic, psychological, and health factors can jeopardize or facilitate public health interventions that require a cooperative public. If ignored, current communication gaps for vulnerable populations could result in unequal protection across society during an influenza pandemic. We offer insights on communication preparedness gleaned from scientific studies and the deliberations of public health experts at a meeting convened by the Centers for Disease Control and Prevention, May 1 and 2, 2008.