Emergency response and the need for collective competence in epidemiological teams

Abstract Objective To determine the challenges met by, and needs of, the epidemiology emergency response workforce, with the aim of informing the development of a larger survey, by conducting key informant interviews of public health experts. Methods We defined our study population as public health experts with experience of epidemiology deployment. Using purposive sampling techniques, we applied random number sampling to shortlists of potential interviewees provided by key organizations to obtain 10 study participants; we identified three additional interviewees through snowballing. The same interviewer conducted all key informant interviews during May–August 2019. We thematically analysed de-identified transcripts using a qualitative data analysis computer software package. Findings Despite our interviewees having a wide range of organizational and field experience, common themes emerged. Interviewees reported a lack of clarity in the definition of an emergency response epidemiologist; the need for a broader range of skills; and inadequate leadership and mentoring in the field. Interviewees identified the lack of interpersonal skills (e.g. communication) and a lack of career progression options as limitations to the effectiveness of emergency response. Conclusion The epidemiology emergency response workforce is currently not achieving collective competence. The lack of a clear definition of the role must be addressed, and leadership is required to develop teams in which complementary skills are harmonized and those less experienced can be mentored. Epidemiology bodies must consider individual professional accreditation to ensure that the required skills are being achieved, as well as enabling continual professional development.


Introduction
Global public health emergencies are becoming increasingly frequent and complex, partly driven by fragile and underresourced health-care systems. For an effective response to such emergencies, investment in a strong and equitable health-care system and workforce, to ensure the necessary combination of competencies, knowledge and skills, is essential. [1][2][3] Signatory States to the International Health Regulations (IHR) 2005 are required to have an agreed minimum capacity for infectious disease surveillance, alert and response. 4 However, IHR evaluations have shown that these minimum standards are rarely met; 2 the ongoing response to the coronavirus disease 2019 (COVID-19) pandemic provides further confirmation of the discordance between reported capacity and response. 5 Applied epidemiologists work to prevent excess mortality and morbidity by ensuring that appropriate investigation and control activities are implemented in an effective and timely manner, and provide information for evidence-based decisionmaking. [6][7][8][9] A commonly agreed core competency of an applied epidemiologist is an understanding of epidemiological methods for outbreak response and public health surveillance. 10 However, despite being key members of the health emergency workforce, the definition of epidemiology training can vary widely to include: an epidemiology course-work unit as part of a Master of Public Health degree; a doctorate degree on a specific epidemiology research topic; or even specialized training in field epidemiology such as the internationally recognized field epidemiology training programmes. Participation in such a programme does not confer a certain range of knowledge either, as there are three levels: frontline (≤ 6 months), intermediate (9 months-1 year) and advanced (2 years). 9,11 There is no professional accreditation for epidemiologists, and no recognition of sub-specializations such as emergency response.
To inform the development of an epidemiology emergency responder survey, 12,13 alongside stakeholder analysis and an unpublished literature review, we conducted key informant interviews ( Fig. 1) to investigate the challenges met by, and the needs of, the epidemiology emergency response workforce. We describe and discuss the major themes important to the interviewed public health experts, as revealed during these key informant interviews.

Study population
We defined our study population as individuals with experience of public health emergencies. Specifically, we wanted to interview people with direct experience of epidemiology deployment and of supervising epidemiologists in the field, or who had supported the deployment of epidemiologists. Interviewees were limited to those who could communicate in English for the interview.
We used a combination of purposive sampling techniques to identify key informant interviewees. 14, 15 We asked key organizations who deploy epidemiologists to emergencies to identify a shortlist of people for interview based on the above criteria. To ensure proportional representation Objective To determine the challenges met by, and needs of, the epidemiology emergency response workforce, with the aim of informing the development of a larger survey, by conducting key informant interviews of public health experts. Methods We defined our study population as public health experts with experience of epidemiology deployment. Using purposive sampling techniques, we applied random number sampling to shortlists of potential interviewees provided by key organizations to obtain 10 study participants; we identified three additional interviewees through snowballing. The same interviewer conducted all key informant interviews during May-August 2019. We thematically analysed de-identified transcripts using a qualitative data analysis computer software package. Findings Despite our interviewees having a wide range of organizational and field experience, common themes emerged. Interviewees reported a lack of clarity in the definition of an emergency response epidemiologist; the need for a broader range of skills; and inadequate leadership and mentoring in the field. Interviewees identified the lack of interpersonal skills (e.g. communication) and a lack of career progression options as limitations to the effectiveness of emergency response. Conclusion The epidemiology emergency response workforce is currently not achieving collective competence. The lack of a clear definition of the role must be addressed, and leadership is required to develop teams in which complementary skills are harmonized and those less experienced can be mentored. Epidemiology bodies must consider individual professional accreditation to ensure that the required skills are being achieved, as well as enabling continual professional development.
from a range of global agencies, we set minimum quotas for each organization based on their frequency of deployment of epidemiologists. Of an anticipated sample of 10 interviews, we aimed to interview four individuals employed by the World Health Organization (WHO), and two individuals employed by each of the Global Outbreak Alert and Response Network, Médecins Sans Frontières and the United States Centers for Disease Control and Prevention. From the shortlists provided by these four organizations, we selected interviewees by random number sampling using Stata version 15 (StataCorp, College Station, United States of America, USA).
We identified the remaining interviewees via a snowballing approach, where we asked each of the 10 interviewees obtained as above to name potential additional participants. To reduce the clustering of networks, we invited a maximum of two candidates to participate in our study per interviewee from the list compiled through snowballing.

Data collection
We selected our interview questions according to issues raised in our literature review and in open interviews conducted during an initial scoping exercise in 2018. For the latter, we used a convenience sample of three epidemiologists who had worked during emergencies in resource-constrained settings. We aimed to acquire practical details on epidemiologist deployment, as well as all interviewees' opinions on roles and required skills for applied epidemiology fieldwork, performance management in the field and workforce upskilling during deployments.
We conducted our key informant interviews during May-August 2019. We provided all participants with a study information sheet that outlined the project and expectations in plain language. Participation was voluntary, and each interviewee provided written consent. The same interviewer conducted all semi-structured key informant interviews either by telephone or internet communications, and continued the interviews until saturation (the point at which no new information, themes or issues were being discussed). 16,17 The interviewer asked questions in both an iterative style to ensure flow and a probing style to obtain clear answers. 18 We recorded all interviews in full and then used auto-transcription software Sonix (sonix.ai, San Francisco, USA) to transcribe these verbatim. The principal investigator then verified the accuracy of the interview transcriptions with the actual recordings. We provided participants with the opportunity to request a copy of their transcripted interview, and to comment if it was felt necessary (e.g. if they felt their anonymity was compromised).

Analysis
We redacted identifying information from the transcripts, then conducted data familiarization through listening to the recordings and reading the interview transcripts. 19 The transcripts were coded and then thematically analysed using the qualitative data analysis software NVivo 11 (QSR International Pty Ltd, Melbourne, Australia). We defined a theme as a recognized pattern within the data. 20,21 We conducted thematic analysis iteratively, and used inductive coding to identify relationships within the data without using a pre-existing frame. 16,20 We then reviewed and summarized codes before interpreting them for meaning. 20 To ensure that we considered the direct as well as underlying ideas that were discussed, we conducted both semantic and latent analysis of the interviews. 20 We adopted a pragmatic interpretivist approach [22][23][24] and aimed to understand the interview findings through a process of interpretation, as viewed through our personal culture and experience. 23 Our findings are an interpretation of the lived experiences of the participants, bound by both time and context. 23 Because the principal investigator of this study has worked in both acute and protracted emergencies as an epidemiologist, findings are also interpreted through her lived experience.

Ethics
The Australian National University Human Research Ethics Committee provided approval (identification no. 2019-521) of our study.

Interviewee demographics
We had to invite a total of 36 senior public health experts to participate in our study, identified via repeated random number sampling, before obtaining the agreement of 10 to be interviewed. The other three participants were obtained via snowballing. Study participants reported deployment to the largest health emergencies of the past decade, including: outbreaks of avian influenza, cholera, Ebola virus disease, Lassa fever, measles and severe acute respiratory syndrome; the aftermaths of natural disasters (e.g. Cyclone Winston in Fiji in 2016 and Cyclone Idai in Mozambique in 2019); and the refugee crises at Cox's Bazar (Bangladesh) and Kharaz (Yemen). Interviewees were mostly male (61.5%; 8/13) and most were employed by WHO at the time of interview (46.2%, 6/13). Other interviewees worked at Médecins Sans Frontières (3/13, 23.1%), the Global Outbreak Alert and Response Network (3/13, 23.1%) or an Australian health department (1/13, 7.7%) at the time of interview. We encouraged all interviewees to discuss previous experience in other public health agencies before their current employment, including the International Federation of Red Cross and Red Crescent Societies, Epidemiology emergency response workforce Amy Elizabeth Parry et al.
Public Health England, the Robert Koch Institute, the United States Centers for Disease Control and Prevention, the United Nations Food and Agriculture Organization and WHO (including headquarters and both regional and country offices).

Interview themes
Although the interviewees reported a diverse range of organizational and field experience, three common themes emerged. Interviewees reported (i) a lack of clarity in defining the role of an epidemiologist during emergency responses; (ii) the need for a broader range of skills over and above traditional epidemiology skills; and (iii) inadequate leadership and mentoring in the field.

(i) Role
In commencing with the simple question: "Who are emergency response epidemiologists and what do they do?", we uncovered a key issue of role classification (Box 1). Interviewees stated that the title epidemiologist was largely self-nominated, and reported that the emergency response workforce was largely individualistic with a high turnover and a widely varying combination of skills and experience.
We also learnt that epidemiology responders are often invited to join teams based on their availability, rather than their specialist role or any particular expertise required within the team. Interviewees reported how, when deployed to an emergency, they often had no or nonspecific terms of reference and had to begin by determining how their expertise could support the response (Box 1). With experience, epidemiology responders could understand their role and how they contributed to the response, and were able to judge what the priorities were. However, with no clear terms of reference or guidance, key informants reported how they had observed less-experienced responders focus on what they knew or felt comfortable doing, rather than response priorities.
We ascertained differing views regarding whether specific terms of reference were needed. Needs and priorities change rapidly during emergencies, and the role of the epidemiologist is to adapt to what is needed at the time. Interviewees indicated that having clearer roles and skill definitions would improve performance, especially among less-experienced emergency response epidemiologists.

(ii) Required skills
When discussing skills required by emergency response epidemiologists, interviewed experts overwhelmingly focused on skills that were not traditionally the focus of epidemiology training programmes. Interpersonal skills, particularly communication, listening and the ability to work effectively with a range of people and teams, were reported as being extremely important (Box 2 and Box 3). The interviewees did discuss the need for technical epidemiology skills, such as data collection and analysis; however, interviewees frequently stated that high-level epidemiology skills were not required for emergency response. Instead, what was generally considered to be of higher value was the ability to apply basic epidemiology skills to a range of different health emergencies. Participants reported that the application of technical skills was linked to experience, as well as a clear understanding of their role within a multidisciplinary team and the overall response (Box 3).
We observed that communication was the skill most commonly discussed. Interviewees considered that communication skills were underrecognized, but critical for success (Box 3). Strong communication skills and the ability to work in cross-cultural multidisciplinary teams were reported as the core competencies required of emergency response epidemiologists (Box 3). The discussion around communication covered many areas including listening, cross-cultural communication, communication within and between teams and organizations, and interview skills to obtain required information. Participants reported that the ability to communicate technical findings to local government, responders and communities was also crucial. Interviewees were concerned that, although communication skills are vital, they are highly linked to personality and difficult to teach and learn. Our study participants stated that finding people with both the preferred experience and these critical communication skills was difficult.

Box 1. Interviewee quotes on the role of epidemiologists from study to determine epidemiology workforce needs during emergency response, 2019
"The job title 'epidemiologist' is not specific to the skill set that people bring, so you'll find a huge range of people doing that job. " "There are all sorts of tasks that you might be asked to do within one job description. " "When you're in the field you've got to find the work and create your own work because often people know your job description is a bit loose. " Box 2. Skills needed according to interviewees in study to determine epidemiology workforce needs during emergency response, 2019 Communication "If things don't go well it's less often due to the lack of technical skills and more often due to the lack of ability to communicate effectively and set priorities among the stakeholders. " "There needs to be more space for listening. " The ability to build relationships and to coordinate with peers were also identified as important skills that are not easily taught, but are learnt through experience (Box 3). Interviewees reported that a common challenge was colleagues who worked in a silo (i.e. preferred to work alone) rather than connecting with team members or other agencies. Respondents acknowledged that finding the required combination of skills (Box 2) in one person was rare, and that there was a need to assemble teams in which members could provide complementary skills.

(iii) Leadership and mentoring
We noted that the need for leadership and mentoring during an emergency response was a consistent theme emerging from the interviews. When asked what an epidemiologist needed to respond effectively during an emergency, most interviewees replied "experience". However, interviewees also identified the paradox of this statement: experienced people were not always available, and less-experienced epidemiologists were more readily available but needed guidance. Interviewees acknowledged that an emergency response was not an ideal training environment for someone without experience, but recognized that mentoring and supervisory mechanisms to support less-experienced responders could be a solution (Box 4).
During the interviews we explored how to manage inexperience and provide mentoring during an emergency response. It was recognized that experience is not a skill and cannot be taught in the traditional teaching environment. Interviewees discussed the value of field epidemiology training programmes, which provide hands-on experience during learning; however, not all trainees are exposed to emergency response scenarios. Interviewees discussed the importance of ensuring that, when in the field, performance management and mentoring were available to ensure successful deployments (Box 4). However, our study participants reported that this was often hampered by a high staff turnover, short deployment periods and limited technical briefings before and during deployment.
We also discussed career paths for emergency response epidemiologists during the interviews. Study participants were concerned that the limited options for career progression within emergency response hampered the effectiveness of any response, as well as the opportunity to gain experience and skills as a mentor or team leader. Interviewees described how they had encountered responders who, with limited experience in the field, were tasked with leadership roles that they often were not trained for or supported in.

Discussion
The epidemiology workforce is an important component of emergency response; however, our key informant interviews highlight multiple issues being faced by the epidemiology workforce, limiting the effectiveness of emergency response. An underlying theme in our interviews was the need for emergency response teams that draw on collective competence rather than individual ability. 25 Our interviews revealed that individuals often worked independently, and therefore ineffectively, during emergency response.
Collective understanding of roles within and between teams is important for an effective response. 1,26 Our findings indicate that, despite the clarity of specific tasks (e.g. the epidemiologist's role during rapid needs assessments or as a member of a rapid response team), the overarching role of an epidemiologist throughout the response is not clearly or consistently understood. Clarifying the latter could lead to greater utilization of core skills and competencies, and greater efficiency in the use of often-scarce skilled emergency response human resources. Our results conform with the need to develop competencies and certification for health professionals who respond to public health emergencies, as already identified in reviews of the 2013-2016 Ebola virus disease outbreak response in West Africa. 1,27 The lack of professional accreditation leads to inconsistencies in competencies, knowledge and skills, with a resulting widespread misunderstanding of what an emergency response epidemiologist is and can do. Without clear guidance, the epidemiologist's role has been interpreted differently by health organizations and emergency response teams. This ambiguity creates confusion in the field, and can contribute to reduced effectiveness in team response.
The knowledge and skill requirements of the epidemiology workforce also need to be better clarified and understood. Our study findings identified that epidemiologists, especially those who respond to emergencies, require a wide breadth of skills beyond the core methodological and technical epidemiology understanding. Research has shown that, when responders do not have the necessary technical, cultural or communication skills, there is a risk of causing more harm than good. 28,29 Strong communication skills and the ability to work in cross-cultural multidisciplinary teams are core competencies required of emergency response epidemiologists; however, analysis of our interviews show that these skills are repeatedly identified as lacking. 26,30 Within public health emergency responses, multiple teams with a wide range of technical skills need to work together to ensure appropriate action and control measures are being implemented. 31 Interdependency among and within teams is therefore essential to achieve collective competence. 25 Our interviewees discussed relationship building and coordination as important skills that are not easily taught, but are learnt through experience. Interviewees reported that a common problem was responders focusing solely on their own task and results, rather than connecting with team members or other agencies. Team interdependency is also associated with leadership, mentoring and performance management -all themes that emerged from our interviews. Interviewees discussed how public health   26 student reviews of field epidemiology training 8,32,33 and a study of epidemiology graduates in the USA all reported that leadership was a commonly encountered gap in training. 34 Our study had several limitations. The interviews conducted during our research aimed to understand processes and experiences, not to analyse the distribution of these experiences. 16 Although we aimed to minimize the impact of bias, there exists a limited number of people with the knowledge and experience required to participate in the key informant interviews. Organizational shortlisting of possible candidates may have led to the selection of candidates with certain organizationapproved views on emergency response. Snowballing may also have introduced bias, as participants identified in that way were from the same network as our other interviewees and may have shared certain opinions. 35 The principal inves-tigator of this study has epidemiology emergency response experience, which may have influenced the questions asked and the information obtained. However, our selection criteria of possible participants, multistep sampling method and minimizing of clustering all aimed to reduce bias as far as possible. Further, our study benefited from the semistructured nature of our interviews, enabling interviewees to focus on what they believed to be important.
Our findings indicate that the epidemiology emergency response workforce is currently not achieving collective competence. 25 Addressing the lack of a clear definition of the emergency response epidemiologist requires a focus on strengthening the interdependency within teams. Leadership is required to develop teams in which traditional and non-traditional epidemiology skills are harmonized, and in which those with experience are matched with those who would benefit from a mentor. Epidemiology bodies must consider individual professional accreditation to ensure that the required skills for generalist and subspecialty epidemiologists are being achieved, as well as enabling continual professional development. As the COV-ID-19 pandemic continues, teams need support to optimize the functioning of critical staff. 36