Introduction
H1N1 Pandemic Funding to States, Territories, and Localities
The US Congress appropriated funding to support state, local, tribal, and territorial health department H1N1 planning and response activities following the detection and spread of novel influenza A (H1N1) virus in April 2009.1 Congress initially appropriated funds to the Centers for Disease Control and Prevention (CDC). The CDC then administered funds through the Public Health Emergency Response (PHER) grant to health departments in all 50 states, eight territories and freely associated states, and four localities (Chicago, Illinois, Los Angeles County, California, New York, New York, and Washington, DC). PHER grant funds were intended for surveillance, control, and prevention of H1N1-associated illness and death through mass vaccination and other response-related activities.2 The CDC disseminated guidance and funding to PHER grantees across four phases, detailed in Table 1.3-6 Inherent within the four phases of guidance was the CDC's recognition of the need for PHER grantees to engage partners in their H1N1 planning and response activities.
Table 1 Four Phases of CDC's PHER Guidance and Funding
Abbreviations: ACIP, Advisory Committee on Immunization Practices; CDC PHER, Public Health Emergency Response
aGrantees selected one of two application deadlines under PHER Phase IV.
PHER Phase IV stipulated that “Applicants must only apply for funds that can be justified as necessary for supporting the vaccination campaign.”
Literature on Partnerships
There is a significant body of literature suggesting that partnerships between agencies, service providers, and other key stakeholders can expand resources and facilitate focus on community health issues more effectively than agencies or organizations acting alone.Reference Butterfoss7-Reference Elrod, Hamblen and Norris12 Scholarship in the field of preparedness and response highlights similar themes, namely that effective response to public health emergencies requires active collaboration and shared responsibility between organizations, and that a community's recovery from disaster depends partly on the strength of its partnerships.Reference Butterfoss7, 8 Partnerships can assist communities in preparing, responding, and recovering from a public health emergency; minimizing and mitigating risk; and providing valuable resources and services.8-Reference Elrod, Hamblen and Norris12 Partners can provide tangible benefits and resources to aid their communities in the preparedness, response, and recovery phases. For example, businesses can provide physical, economic and human resources such as office space, transportation, and volunteers, while faith-based groups, educational institutions, and the media can disseminate critical information.8, Reference Gurwitch, Pfefferbaum and Montgomery10 The literature also suggests that developing partnerships and jointly-formulated plans before an actual public health emergency occurs is essential.Reference Norris, Stevens and Pfefferbaum9-Reference Norris, Hamblen and Watson14 This is because organizations need established methods of communication, mutual understanding, and trust to collaborate effectively during a response.8, Reference Norris, Stevens and Pfefferbaum9 It may prove challenging to actively and effectively work together to respond to an emergency when organizations have not collaborated previously.Reference Norris, Stevens and Pfefferbaum9
Purpose of this Inquiry
While prior work in public health preparedness, response, and recovery describes the value of partnerships, few studies approach the topic empirically.Reference Butterfoss7-Reference Rosenfeld, Etkind and Grasso15 Moreover, gaps exist in examining which specific partnerships need to be in place prior to an effective response, if partnerships are strengthened through engaging in a response, and how strong partnerships are sustained afterwards. This inquiry explores if PHER grantee health department partnerships with key sectors, agencies, and programs were strengthened through engaging in a public health emergency response (eg H1N1).
Methods
Participants and Assessment Instrument
The CDC administered an assessment instrument to PHER grantees (n = 62) in May 2011 to investigate H1N1-related response outcomes, including the strength of partnerships between the grantee health department and key sectors, agencies, and programs. The PHER grant award stipulations required state, local, and territorial health departments to complete this assessment instrument and report these (and other) data to the CDC. Inclusion criteria for the inquiry included all PHER grantees. There were no exclusion criteria. The CDC subject matter experts in public health preparedness and response reviewed the instrument, and their recommended revisions were incorporated to strengthen the assessment instrument's face validity prior to its administration to PHER grantees. The CDC addressed confidentiality through an existing arrangement in which it would not disseminate PHER grantee-level data through peer-reviewed publications without permission of the grantee(s). This contributed to an environment in which PHER grantees could submit candid responses since only aggregate level data (and not individual grantee responses) were publishable.
Partner types included state immunization programs, private medical providers, schools (K-12), main education authorities (eg Departments of Education), businesses (non-pharmacy), and retail pharmacies. The CDC identified these partner types as being critical to the H1N1 response in its four phases of guidance to PHER grantees. The CDC's guidance also bound the H1N1 response period between April 2009 and July 2010, although PHER grantees had latitude in determining when the H1N1 response officially ended within their jurisdictions.
Within the assessment instrument, PHER grantees rated the strength of their partnerships with each partner type (before and after the H1N1 response) using a four-point ordinal scale of minimal, average, good, and excellent (or not applicable, N/A). Grantees also provided a narrative response describing if, and how, PHER funding contributed to strengthening partnerships with each partner type during the H1N1 response.
Analysis
PHER grantee responses were de-identified and data were reviewed in aggregate. Numeric values were assigned to grantees’ self-reported responses regarding partner strength (before and after the H1N1 response): 1 for minimal; 2 for average; 3 for good; and 4 for excellent. Descriptive statistics were generated, and partner strength ratings compared (for all PHER grantees and for each partner type) using paired t tests in SPSS (PASW Statistics 18, Release Version 18.0.1. IBM, Armonk, New York USA). Paired t tests were employed because they are an accepted way of testing before and after differences in data from the same sample. This method was utilized under the assumption that partner strength ratings are equidistant from one another. Data were excluded from the t-test for a particular partner type when a PHER grantee reported N/A for that particular partner type. The rationale for this is that it was unclear how to interpret an N/A response accurately (eg none, not important in the jurisdiction, not present in the jurisdiction). Coding entailed reading line-by-line through the qualitative responses for each partner type, and attributing codes to segments of PHER grantees’ responses in an initial effort to organize the data by inductive themes.Reference Patton16 Codes were then collapsed into thematic categories based on topics that were repeated across different partner types, and additionally documented the number of grantees whose comments contributed to each category.
Results
Sixty-one PHER grantees (61/62, 98%) completed the assessment instrument's section on partnerships.
Partnership Strength Differences Before and After the H1N1 Response
Figure 1 shows the mean partnership strength, before and after the H1N1 response, for each partner type. The PHER grantees reported that their partnerships with retail pharmacies were most strengthened (mean increase = 1.11, SD = .82). This was followed by schools (K-12) (mean increase = .90, SD = .58); private medical providers (mean increase = .81, SD = .68); immunization programs (mean increase = .80, SD = .61); main education authorities (mean increase = .75, SD = .68); and businesses (mean increase = .74, SD = .61). Mean PHER grantee increases in the strength of each partner type were statistically significant for all partner types (P < .01).
Figure 1 Mean Partnership Strength by Partner Type, Before and After H1N1
Of all partner types, PHER grantees reported the strongest partnerships with immunization programs, both before (mean = 2.87, SD = .83) and after (mean = 3.67, SD = .51) the H1N1 response. The PHER grantees reported the least strong partnerships (of all partner types) before (mean = 1.98, SD = .77) and after (mean = 2.72, SD = .67) the H1N1 response with businesses and retail pharmacies before (mean = 1.91, SD = .02) and after (mean = 3.02, SD = .82).
PHER-Supported Increases in Partnership Strength
Figure 2 shows the number and percentage of grantees attributing increases in the strength of their partnerships to PHER funding. Grantees reported that PHER funding contributed to increasing the strength of their partnerships with schools most frequently (K-12) (46/46, 100%), and businesses least frequently (31/37, 83.8%).
Figure 2 Percent of Grantees Attributing Increased Partner Strength to PHER Funding, by Partner Type
How PHER Funding Contributed To Increased Partnership Strength
Three themes emerged from the qualitative data. Grantees reported that PHER funding contributed to increased partnership strength by supporting collaborative activities in: (1) coordinating vaccination efforts and medical countermeasure dispensing; (2) managing and sharing information; and (3) developing risk communication and community mitigation strategies.
Qualitative data analysis revealed that coordinating vaccination and medical countermeasure dispensing activities helped PHER grantees strengthen their partnerships with private medical providers, immunization programs, private business, schools (K-12), and retail chain pharmacies. Collaborating with immunization programs in planning and implementing vaccine dispensing programs, and working with businesses, retail pharmacies and schools in implementing points of dispensing in their facilities contributed to the increased partnership strength.
Managing and sharing information also contributed to PHER grantees’ strengthened partnerships with immunization programs, private medical providers, and retail pharmacies. Grantees engaged in information sharing with immunization programs through modifying and developing immunization tracking and vaccine management systems. The PHER grantees engaged in information sharing with private medical providers through the Health Alert Network, professional medical organizations, and web-based platforms, and by providing retail pharmacies with information on anti-viral medicine and H1N1 vaccination.
Additionally, collaboratively developing risk communication and community mitigation strategies helped PHER grantees strengthen their partnerships with education agencies, schools (K-12), and businesses. This occurred when grantees collaborated in developing communication campaigns and mitigation practices for a particular partner's setting (eg, a school, business, etc.).
Discussion
The PHER grantees reported strengthened partnerships after the H1N1 response across all six partner types. Mean partnership strength between PHER grantees and retail pharmacies was lower before and after the H1N1 response than for the other five partner types, yet reflected the largest mean increase in strength in comparison to other partner types. The results therefore demonstrate that partnerships can and do strengthen through engaging in a response itself, even for less typical collaborators in public health initiatives (eg, retail pharmacies). This is an important point not generally highlighted in the literature.
The findings also suggest that collaboratively engaging partners in a response can render strong partnerships stronger, and can also strengthen relatively less robust ones. While additional inquiry is warranted, these results suggest that health departments consider conducting more intensive outreach to their current and potential partners to facilitate greater integration of public health preparedness, response, and recovery activities. This may hold true for typical public health collaborators such as immunization programs, as well as for less typical ones such as businesses and retail pharmacies.
Of note is that the provision of PHER dollars, and the activities it supported, led to very little change in the relative rankings of partnership strength. The PHER grantees’ mean partnership strength with immunization programs still ranked at the top after the H1N1 response, schools and private medical providers remained in the middle third, and businesses and retail pharmacies continued to rank in the lowest third. The PHER funding thus contributed to increases in partnership strength across all partner types somewhat uniformly. This differential partnership strength may reflect issues of synergy, reciprocity, and mutual benefit among partners. For example, immunization programs (given their public health focus) may naturally demonstrate greater synergy with a health department's preparedness and response program than would businesses or retail pharmacies, especially if the latter do not perceive the benefit of sustaining their role as a public health partner over time. Consequently, it may not be feasible to expect that the relative strength of a health department's partnership with the business sector would exceed that of the immunization sector, regardless of a public health emergency response's type, duration, or intensity. Conversely, if health departments desire significant gains in partnership strength with a particular partner type, they may need to consider more intensive and targeted interventions.
This inquiry also demonstrates that CDC's PHER funding contributed to increasing the strength of grantees’ partnerships. These findings support the notion that partnerships can be strengthened when federal guidance and funding are provided to state, territorial, and local health departments. This is a positive outcome to note for both public health emergency response and community resilience efforts. These findings, though, simultaneously raise the issue of partnership sustainability; whether state, territorial, and local health departments can sustain their partnerships in an era in which federal funding for public health preparedness and response programs is declining. The issue of partnership sustainability has implications for future responses, as well as for efforts to build community resilience to mitigate the impact of public health emergencies.
The H1N1 response was also relatively more intense, and was spread out over a longer period of time, than is typical for public health emergency responses. Consequently, health departments and their partners collaborated in very tangible ways, and for longer periods of time, than would typically be the case. This may therefore have contributed to relationship building and increased partnership strength. The exigencies of the outbreak itself may have also prompted certain partnerships to strengthen (potentially regardless of PHER funding and guidance). Other factors such as the availability of funding (other than PHER) and the particular context and characteristics of the response itself may also have contributed to relationship building and increased partnership strength.
Preliminary data reported here thus shed light on the need for better conceptualization and measurement of how strong partnerships contribute to a strong public health response; how participating in a public health response can strengthen partnerships; and how other factors (eg, public and private funding, duration of the response) impact partnerships. This work suggests that partnerships can and do strengthen through engagement in a real public health response, but does not necessarily support (or disprove) the position that strong partnerships should be in place prior to mounting an effective response. This is not to negate the claim that the existence of strong partnerships prior to a response may improve response effectiveness and efficiency, as response effectiveness or efficiency within this inquiry was not specifically examined, nor was response effectiveness or efficiency linked to partnership strength. Rather, this inquiry suggests the need for better conceptualization and research regarding the role of partnerships in public health emergency response, including what elements of preparedness and response partnerships can and should be fostered in advance of a response (eg, memoranda of understanding, contracts) and what elements may be less critical to have in place.
More data are also needed on how preparedness and response partnerships are sustained over time in the presence of real incidents and in their absence (eg, through ongoing planning, training, exercising), as well as how decreased federal funding impacts partnership strength and sustainability. There is also a need to gain a better understanding of reciprocity and mutual benefit within public health preparedness and response by learning more about what different partner types (eg, schools, businesses, retail pharmacies) value and want from their partnerships with state, territorial, and local public health departments. The need to link future findings in these areas with response outcomes such as vaccination rates in key populations and at-risk groups, illness prevented or mitigated, and the economic benefits of strengthened partnerships should also be explored.
Limitations
This inquiry was designed and operationalized within the confines of an established governmental grant reporting system. The inquiry's approach would therefore likely have varied had it been operationalized within a research (rather than an applied or programmatic) setting. Hypotheses could have been more fully tested and findings more robustly validated (eg, through a more detailed assessment instrument, or by delving more deeply using measures of effective partnerships such as shared mission, trust, and open communication).Reference Foster-Fishman, Berkowitz and Lounsbury17-23
The possibility also exists that confounding factors contributed to increased partnership strength during the H1N1 response. This inquiry does not capture the extent to which factors such as the availability of funding (other than PHER) and the particular context and characteristics of the response itself may have contributed to relationship building and increased partnership strength.
The inquiry's findings are also based on grantee self-reported data. The possibility therefore exists that state, territorial, and local health departments may have biased their reporting to ensure continuing federal support for public health emergency response efforts. Such concerns, however, may be unwarranted. No phase of PHER funding required engagement with partners, nor was funding in a later phase dependent upon partnership engagement in a previous phase. Similarly, the PHER grant was a one-time supplemental appropriation with a defined end point. Because grantees were in the final phase of PHER funding at the time of this inquiry, it was clear that no further funding would ensue regardless of how positively or negatively grantees ranked any increases in partnership strength.
The PHER grantees also assessed the before and after strength of their partnerships retrospectively, at the same point in time. Their assessments may have differed had they been queried pre- and post-H1N1 pandemic, rather than solely after the pandemic's end. Although simultaneous pre- and post-assessments are certainly not ideal, the literature does support the use of a retrospective pre-test design under certain real-world circumstances. Examples include cases in which it would be essentially impossible to gather data in advance of an intervention or, similarly, when the intervention being assessed requires immediate action with little or no time to gather baseline information (eg, due to an unforeseen event or disaster).Reference Pratt, McGuigan and Katzev24, Reference Griner Hill and Betz25 The retrospective pre-test design can therefore defensibly be applied to the H1N1 pandemic response. It was simply not possible, in April 2009, or prior, to know all the types of partners that would ultimately be deemed most salient for this particular type of response. In addition, the virulence of the virus was unknown, as was the availability of vaccine. Taken together, these factors led to a response requiring the catalyzing of partnerships with entities such as pharmacies, retail chains and private providers, who in many instances had previously been on the relative backburner of pandemic planning, especially in terms of vaccine dispensing. The retrospective pre-test design thus provided flexibility to develop questions that reflected actual program content as it evolved.Reference Pratt, McGuigan and Katzev24
Another limitation is that the point of reference for each partner type is unknown. For example, when PHER grantees responded to questions about each partner type (eg, businesses), the number, types, and sizes of businesses to which grantees were referring was not captured. Also not captured was whether grantees considered these partnerships to be between their health department and the partner organization (eg, an organizational partnership), between individuals employed by their health department and the partner organization (eg, a personal relationship/partnership), or a combination thereof.
Lastly, the assessment instrument scale did not include “none” as an option. Consequently, when grantees answered “minimal” to a question about partnership strength, this may have also included what would have been a “none” response, had this been an option. This may have led to an overestimated baseline of partnership strength and an underestimate of mean increases in partnership strength.
Conclusions
State, territorial, and local health departments reported that their partnerships were strengthened after the H1N1 response, and that CDC's PHER funding played a contributory role in strengthening these partnerships. Despite limitations resulting from data collection efforts in the context of an actual emergency response, the findings shed light on the role of partnerships in public health emergency responses, the subsequent strengthening of partnerships that can occur as a result of collaborative responses; and the need to consider optimizing efforts to establish or formalize partnerships as a key component of preparedness activity.
Disclaimer
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
