A local public health workforce's willingness to respond (WTR) is an essential component of effective management of public health emergencies. Previous research on local public health agency workers has examined WTR in a pandemic influenza scenario [10
], making this a novel study in its examination of WTR to multiple emergency scenarios among this occupational cohort and its identification of approaches that could be taken to improve their WTR. Although the National Response Framework encourages preparation for emergencies using an all-hazards approach [20
], our results underscore that LHD workers' WTR is scenario-specific. WTR was shown to be greater for naturally-occurring emergency scenarios (weather-related and pandemic influenza) than for terrorism-related emergency scenarios (radiological 'dirty' bomb and anthrax bioterrorism) in all contexts (Table S3). Between the terrorism-related scenarios, workers' surveyed WTR was considerably lower for the radiological 'dirty' bomb.
These results suggest that all-hazards preparedness efforts may not be equally impactful on WTR among different hazards. Implementing effective scenario-based risk awareness campaigns among the LHD worker population may have an impact on increasing their knowledge, and thus their WTR [3
]. Although warranting further study, these findings might also reflect the influences on WTR of scenario-based federal public health funding and related preparedness requisites for LHDs. In the U.S., such scenario-based funding and activities in LHDs have historically focused on bioterrorism (e.g. smallpox and anthrax dispersal) and pandemic influenza threats, which had higher WTR rates than for the radiological 'dirty' bomb scenario in our study.
Despite the geographic variability observed in WTR rates in this study, our findings point to gaps in response willingness as a significant surge capacity concern for public health response across a diverse array of threats. When employees across the eight LHD clusters were surveyed as to their WTR regardless of severity, the percentage of workers indicating they would not
be willing to respond ranged from 14 to 28% for a weather-related event; 9 to 27% for pandemic influenza; 30 to 56% for a radiological 'dirty' bomb; and 22 to 48% for an inhalational anthrax bioterrorism event (Table S3). Given that severe public health threats require all employees at all skill levels, and in light of LHDs' central position within the public health emergency preparedness system, even the lower bounds of these ranges present a threat to this system's operational effectiveness. Moreover, previous research has shown local public health workers to be the most ready and willing among several civil service and hospital professional cohorts to respond to a pandemic influenza event [21
]. In light of this previous research, the suboptimal levels of WTR observed across multiple scenarios among the current study's LHD cohort potentially point to even larger willingness gaps in a variety of responder cohorts, such as law enforcement and fire services. Indeed, multi-scenario-based gaps in WTR among police and fire departments merit further research examination.
We believe that this study is also the first to explicitly compare WTR rates between urban and rural local public health agencies. It is important to include rural LHDs in our investigation since only 4% of U.S. health departments serve populations greater than 500,000 [22
] and approximately 20% of Americans live in rural areas [23
]. Rural jurisdictions are not immune to the broad spectrum of potential public health threats. While urban areas may represent higher profile terrorism targets, rural jurisdictions could be affected by evacuation orders, decontamination considerations, or infectious disease spread. Since many rural areas house critical infrastructure, including elements of the food system and important bridges/roadways, they may themselves be targets of potential terrorism threats.
Our findings suggest rural LHD workers may have significantly higher odds of WTR across scenarios and WTR contexts than their urban counterparts (Table and Table ). Increased levels of social cohesion in rural communities may account for these increased WTR levels, although this warrants further study. Cohesive communities are characterized as sharing a common vision and sense of belonging, possessing an appreciation for the diversity of people's backgrounds, and developing strong and positive relationships among people with different backgrounds in neighborhoods, schools and workplaces [24
According to Durkheim's theory of social solidarity, increased interdependence of individuals within a community may be related to increased levels of social cohesion [25
]. This interdependence may be more pronounced in rural communities that act as independent microcosms of modern society, in which residents rely on one another for daily life essentials. An increased level of social cohesion may increase local public health workers' sense of belonging, duty, and responsibility to neighbors and coworkers, thus potentially explaining the presentation of increased WTR to an emergency situation among rural jurisdictions. Recent research has shown 29% more Florida healthcare workers reported WTR to a bioterrorism attack within their community than elsewhere in their state [26
]. In light of these findings, and the lack of research on the effect of social cohesion on willingness to respond, the likelihood of the local public health workforce's emergency response in the context of social cohesion is seen as a potential area for future investigation.
Local public health agencies have a median staff size of 13 [22
], which emphasizes the imperative that all workers are ready, willing, and able to respond to a public health emergency if needed [6
]. The diminishing numbers of U.S. public health workers [14
] reinforce the need to ensure that LHD employees are sufficiently committed to responding during an emergency. In six of the 12 WTR context/scenario combinations, the ORs that were statistically significant for WTR, comparing female to male respondents, ranged from 0.57 to 0.66. Since the public health workforce is comprised of 82.7% women [22
], this finding has significant implications for local public health surge capacity. In addition, the public health workforce is aging. According to a recent Association of State and Tribal Health Officials (ASTHO) survey, 23% of the current workforce is eligible to retire in 2012 [27
]. In eight of the 12 combinations, the significant ORs, comparing respondents at least 40 years of age to the younger respondents, ranged from 1.26 to 1.58. As more willing local public health responders approach retirement, it is now more important than ever to maximize the willingness of all available personnel to enhance the effectiveness of emergency response.
Given fiscal austerity challenges facing the public health infrastructure [28
], efforts to increase funding for the LHD workforce may be extremely difficult. However, this study's findings can inform the augmentation of current LHD training programs and adaptation of agency policies. According to the EPPM, messages need to convey both threat and efficacy in order to elicit intended desirable protective behaviors [29
]. Comparisons of WTR levels across EPPM categories consistently indicate that regardless of perceived threat, efficacy increased respondents' WTR (Table ). The enhanced effect of efficacy, compared to threat, on WTR is consistent with findings from previous research [10
]. Bandura has modeled behavior change and maintenance as a function of self-efficacy and response efficacy [30
]. A review of the literature shows efficacy to have a strong association with the successful performance of myriad health behaviors, including cigarette smoking, weight control, exercise, and contraception use [31
]. The importance of threat and efficacy in understanding emergency response behavior has been highlighted in recent research in Washington State healthcare workers. In this cohort, self-reported ability was higher than self-reported willingness to report to work for an influenza pandemic, but self-reported willingness was higher than self-reported ability for a severe earthquake event [32
]. This distinction by scenario suggests that perceived threat and efficacy associated with each event has a distinct impact on behavior.
This study's finding of efficacy, as a crucial modifier of response willingness across scenarios, has important implications for designing novel preparedness curricula for LHD employees. Namely, our data suggest that such curricula could usefully employ a variety of efficacy-focused cognitive interventions to achieve the desired affective outcome of increased WTR.
Curricular interventions of this nature could include explicit emphasis on household preparedness-building activities for LHD employees with dependents. Personnel with dependents were shown to have lower odds of self-reported WTR for an emergency (range of ORs: 0.59 to 0.78) than those without this responsibility. To increase the level of WTR among this cohort, preparedness curricula can instruct LHD employees on the essentials of making family preparedness plans and kits, and potentially requiring employees to do so. While this may seem like an unfunded requirement, a curriculum that uses cognitive intervention for achieving affective outcomes could emphasize the benefit outweighing the cost of preparedness plans and kits, by highlighting their importance in optimizing the safety of dependents and enhancing employees' comfort level in reporting to work during an emergency.
LHD employees who perceived themselves as having important roles in their agency's emergency response efforts consistently had higher odds of self-reported WTR to all four surveyed scenarios regardless of severity. Workers who perceived themselves as likely to be asked by their agencies to report to duty also had higher odds of WTR if required. Accordingly, to boost willingness, preparedness curricula might aim to build employees' sense of response efficacy by highlighting how and why each of their roles is important, and emphasizing that each employee be considered a vital contributor to an agency's response. Curricula can enhance self-efficacy by instructing employees on the range of role-specific activities they may be expected to perform, and illustrating how their daily skill sets might transfer readily to this spectrum of response expectations. For example, finance support staff within LHDs would receive role-specific instruction and reassurance on how their everyday activities, (e.g., coordinating daily inventory and payroll) would apply to their public health emergency response efforts (e.g., managing emergency supply inventory and monitoring overtime payroll in a public health crisis). Staffing challenges facing LHDs [14
] only heighten the importance of instilling a mindset of everyone being necessary in a team response, through efficacy-focused preparedness curricula.
Local public health agencies' policies also have the potential to enhance their workers' WTR. Geographic variations across clusters (Table S3) suggest a need for local WTR assessments as the basis for tailored curricular efforts to enhance response willingness rates in LHDs. Despite these variations, however, certain commonalities emerged with generalizable training implications. Across clusters, LHD workers consistently reported increased WTR if they perceived it to be a requirement (Table S3). LHDs may wish to reexamine their policies on employee requirements for responding to different emergencies in order to increase potential likelihood of response. The impact on WTR of policies requiring employees to work, including those imposed by unions, in oaths taken by sworn personnel, and by the health department, local government or state government, needs to be explored in future research.
Further, irrespective of geographic location or rural/urban status, WTR was consistently and markedly lowest for the radiological 'dirty' bomb scenario. This finding suggests a need for intensive and broad-scale efforts to enhance LHD employees' awareness of the role of public health in radiological emergency responses and augment their sense of efficacy in contributing to such responses. Clearly-articulated, LHD policies that directly address LHD employees' concerns about safety at work and at home may enhance their comfort level toward responding to radiological or other threats.
Certain limitations of this study must be acknowledged. First, results are based on survey data and may not be predictive of behavior in an actual, real-world response. Given the unpredictable variability of disasters and inability to control for various confounding factors, a prospective study was conducted to limit bias and yield the most methodologically sound results. Second, the recruitment of proximate LHDs to form the study's clusters was based on convenience and snowball sampling rather than random sampling, having the potential to limit generalizability. This research was not intended to provide representative results as from a nationwide survey, in which case the sampling design would have an impact on the results and associated confidence intervals. While a geographically and demographically diverse set of clusters was included in order to maximize external validity of our findings, conclusions may not be valid in locations not analyzed due to external factors, including past experiences with disaster scenarios or differences in local public health infrastructure. Third, while the four scenarios in the study reflect categories of high-consequence events, the surveyed scenarios do not reflect the entire all-hazards continuum. Fourth, the 2009 H1N1 influenza pandemic overlapped the survey window for all but one of the study's LHD clusters. Actual experience with this event may have influenced responses to this scenario category.