I. BACKGROUND: Following a review of donor funding priorities and concepts of health system strengthening (HSS) and resilience, this dissertation documents health system resilience factors existing in the Liberian health system in late 2014/early 2015 as the Ebola epidemic flared. The effectiveness of the WHO health system building blocks framework in addressing resilience was assessed, and specific factors that can promote health system resilience for Liberia going forward were identified. II. METHODS: Methods applied as part of this intrinsic case study include document and literature review, analysis of health facility and population-level statistics, and key informant and group interviews at the county and national levels. The methodology allowed for an in-depth assessment of how HSS (using the WHO health system building blocks) and resilience factors (using the WHO-defined key aspects of emergency preparedness) exist (or could exist) within the Liberian institutional and cultural context, and for tentative conclusions to be drawn about the importance of system factors to building specific health system capacities and overall health system resilience. III. FINDINGS: While dealing with myriad other public health priorities, public health preparedness went largely unaddressed in pre-Ebola Liberia where effectively none of the 16 key components or their 51 essential attributes listed in the WHO table of emergency preparedness were in place. The lack of integration of public health preparedness into HSS interventions left the country vulnerable to public health emergencies. There are two limitations to the government’s Ebola recovery and investment plan: (1) lack of a holistic approach to addressing emergency preparedness; and (2) not integrating emergency preparedness needs and corresponding activities into the existing national HSS framework. IV. CONCLUSION: By integrating emergency preparedness and response initiatives into HSS activities, health systems in Liberia and elsewhere can be strengthened to be more resilient, and thus better able to anticipate and adapt to challenges, and ultimately improve the system to be able to anticipate new future challenges. However, strengthening health systems so that they are resilient takes resources, including sector-wide, HSS resources that can be used to build functioning, integrated systems and skilled, networked individuals and groups across sectors.

The opinions and expertise of disabled people are often absent from emergency preparedness planning. As a result, when emergencies occur disabled people’s needs may go unmet. While there have been recent efforts to acknowledge the need for disability inclusive planning processes (in, for example, the development of a Disability Inclusive Disaster Risk Reduction framework), more research is needed to understand how efforts to include the perspectives and experiences of disabled people work (or do not work) in practice. In this research, I examine the development of a disability-inclusive emergency preparedness plan in Ontario, Canada. I use semi-structured interviews with key informants from the provincial government and disability organizations to unpack the planning and consultation process. The analysis indicates that while the plan represents an important attempt to include disabled people in emergency preparedness planning, it falls short in a number of ways not least because it rests on a narrow conception of disability as physical limitation. In particular, people with intellectual disabilities are absent from the planning process and final plan, a fact that reflects their broader marginalization within society. I draw on interviews with a small sample of self-advocates living with intellectual disabilities to identify how the plan could be revised to recognize the views and experiences of this population. / Thesis / Master of Arts (MA)

Master of Public Health / Department of Diagnostic Medicine/Pathobiology / Katherine Stenske / Over the past few decades, animal and public health professionals have become increasingly concerned about the global animal population’s vulnerability to Transboundary Animal Diseases (TADs). Through analysis of the lessons learned by the United Kingdom (UK), Taiwan, and Egypt in responding to FMD outbreaks in their countries, it becomes apparent that even with response plans in place at the time of an outbreak, problems still arose as the outbreaks progressed. To better understand why these deviations from the planned course occur, the concept of “disconnects” in the various “domains” of TAD emergency preparedness and response were explored for the United States (U.S.). Particular emphasis was placed on issues related to the collaboration and cooperation between the federal and state levels of government. The domains of communication, knowledge, and resourcing were selected to be analyzed due to their importance in TAD emergency outbreak preparedness and response. The research questions this thesis explores concern three domains of TAD emergency preparedness and response that experience disconnects between federal and state levels of government. They also explore how these disconnects affect Food and Agriculture Security in the U.S. Three different methods were used to research these topics. Literature reviews of lessons learned and after action reports from TAD outbreak exercises and real events were conducted. Direct observations of the author’s experiences at conferences, seminars, and training events were also included. Finally, personal interviews were conducted with Food and Agriculture Security experts. Through this analysis, numerous disconnects emerged in each of the domains. Several disconnects traverse all three domains. These disconnects related to laboratory collaboration with the federal government, the process of declaring a federal emergency, and the roles and responsibilities of individuals and groups involved in TAD outbreak preparedness and response. Overall, the disconnects affect the ability of state and federal governments to rapidly respond to and coordinate response efforts. This affects Food and Agriculture Security by compromising the safety, security, and ongoing operation of the food and agriculture sector. Further study will be needed to alleviate these disconnects so that better cooperation and collaboration can occur between federal and state levels of government.

Due to the emergent and dynamic nature of incidents, the complexity of emergency work is often referred to as a challenge for learning. Another recurrent challenge in emergency work is that of collaboration at and across established organizational boundaries involving actors with specific types of expertise who are operating under different regulations and responsibilities. In addition, training emergency service organizations in collaboration remains a challenge. In light of the difficulties and shortcomings that have been identified in major incident responses, the need for exercises for developing and maintaining collaborative response effectiveness prior to the next incident is often highlighted. The overall aim of this thesis is to understand how full-scale exercises can provide conditions for developing inter-organizational collaboration between the police, ambulance and rescue services at the incident site. Learning activities that carry the potential to support and develop collaborative capacity, and how the alignment of distributed expertise can be trained for, were of particular interest. Interviews with participants in eight full-scale exercises with professionals and interviews and observations of one exercise with senior-level students in Sweden served as the empirical base.Central concepts from Cultural-Historical Activity Theory (CHAT) provided theoretical tools to explore the exercises and understand boundaries between organizations with a wider, systemic approach. The empirical studies show that the participants understood full-scale exercises to be valuable opportunities for becoming involved in response work, making decisions, and acting and interacting in uncertain situations and realistic environments. As in real-life responses, exercises are characterized by the stabilization and confirmation of everyday routines on the one hand, and by improvisation and change on the other hand. The studies also show that exercises tend to focus on specific scenarios,intra-organizational routines, and leadership positions. Infrequent exercises inwhich the participants were only trained in a limited role were perceived to be in adequate for developing preparedness and collaboration. However, the analysis suggested that the way in which exercises were organized and performed had implications for how participants were trained in collaboration.Realizing the potential of boundaries as resources for learning in exercises depends on how boundaries are explicated and approached. Thus, rather than striving to ignore or eliminate boundaries in exercises, the studies illustrated the learning value of explicitly reflecting on the multiple understandings around boundaries. The studies demonstrated that much of the work at an incident site takes place around negotiations. Collaboration at the incident site was not only aquestion about boundary crossing; operational tasks may not always be aligned and have to be prioritized and sequenced. The exercises comprised work situations in which no single motive could explain or determine the collaboration,due to different types of expertise, primary responsibilities and needs forinformation. These factors were understood in terms of the concepts of boundarywork and boundary awareness. These concepts point at a more divergent understanding of collaboration that reaches beyond striving to create mutual understanding between organizations in learning activities. Differences between organizations, such as in terminology, time horizons, priorities, leadership structures, understandings of safety and how intra-organizational decisions and actions could impact the collaborating organizations' work, were central triggers for discussion and negotiation. These differences required explanations in order to make the actions and decisions of one organization understandable and justifiable to another, based on organizational mandates and types of expertise.Giving emergency services the opportunity to work together, to develop an awareness of their expectations of each other in various situations, to use and interpret their own and others' terminologies, and to identify internal hierarchies and motives for prioritizations was essential dimensions of exercises

There is a paucity of literature evaluating mass casualty systems and no clear 'gold standard' for measuring the efficacy of information decision support systems or triage systems that can be used in mass casualty events. The purpose of this research was the preliminary validation of a comprehensive conceptual model for a mass casualty continuum of care. This research examined key relationships among entities/factors needed to provide real-time visibility of data that track patients, personnel, resources and potential hazards that influence outcomes of care during mass casualty events.A modified Delphi technique was used to validate the proposed model using a panel of experts. The four research questions measured the extent to which experts agreed that the: 1) ten constructs represent appropriate predictors of outcomes of care during mass casualty events; 2) proposed relationships among the constructs provide valid representations of mass casualty triage; 3) proposed indicators for each construct represent appropriate measurements for the constructs; and 4) the proposed model is seen as useful to the further study of information and technology requirements during mass casualty events. The usefulness of the online Delphi process was also evaluated.A purposeful sample of 18 experts who work in the field of emergency preparedness/response was selected from across the United States. Computer, Internet and email applications were used to facilitate a modified Delphi technique through which experts provided initial validation for the proposed conceptual model. Two rounds of the Delphi process were needed to satisfy the criteria for consensus and/or stability related to the constructs, relationships and indicators in the model. Experts viewed the proposed model as relatively useful (Mean = 5.3 on a 7-point scale). Experts rated the online Delphi process favorably.Constructs, relationships and indicators presented in this model are viewed as preliminary. Future research is needed to develop the tools to measure the constructs and then test the model as a framework for studying effects and outcomes of mass casualty events. This study provides a foundation for understanding the complex context in which mass casualty events take place and the factors that influence outcomes of care.

Participation in risky behaviors is a common threat to an adolescent's health. Youth engagement (YE), a youth's meaningful and sustained participation in an activity, is a way to help reduce that threat. The Medical Reserve Corps (MRC), a public health emergency preparedness and response organization, has opportunities for engaging youth. However, few adolescents participate in MRC activities, signaling network-wide variations in working with youth. Furthermore, there is a gap in the literature exploring YE in emergency preparedness organizations, including the MRC. The purpose of this dissertation was to better understand youth engagement and development within organizations like these. With the MRC as the example and youth development theories as the lens, YE was examined as well as challenges and benefits of YE, needs, and use of YE strategies within the MRC. An exploratory sequential mixed-methods approach was used to assess YE in the MRC: Phase I- key informant interviews of youth (ages 14-18) and adults in and out of MRC (N=17); and Phase II- a nationwide web-based survey of adult MRC unit leaders (N=215). Qualitative data was analyzed with Microsoft Word and Excel; quantitative data analyzed with Stata 12.0. Results revealed common challenges experienced by MRC units working with youth, including liability concerns. Benefits found include preparation of the youth for future careers and giving youth a focus beyond themselves. A Spearman's correlation found a statistically significant association (r=0.30, N=52, p=0.0288) between the use of the core YE principles and the level of youth participation among the MRC units with youth membership, meaning use of these principles may be helpful in better involving youth. Furthermore, "Building Youth and Adult Capacity" was the top YE principle used among the MRC units that allow youth membership to engage youth. Despite noted challenges, engaging adolescents in the MRC still has many benefits with long-term public health and maternal and child implications for youth in emergency preparedness organizations. These include development of a responsible youth that protects their peers, families, and local communities from public health challenges, positively impacting the community. Recommendations for building student MRC programs across the nation have been provided.

This study addresses the issue of household disaster preparedness. This work contributes two elements to disaster research. The first contribution improve the knowledge of the factors that affect household disaster preparedness. The review of literature yielded three categories of variables that can jointly explain household disaster preparedness: household structure, demographics, and risk-perception factors. In this study 19 variables compose these factors. A second contribution constitutes a theoretical exploration of the concept of disaster preparedness. In this work, four different constructs of disaster preparedness were tested. These constructs include material preparedness, preparedness activities, a combined index, and a weighted and combined index. The study presents the logic and methodology of the index construction and validation. The data used in this study came from households in the Montreal Urban Community (MUC) in Canada. A random sample of 1,003 English- and French-speaking heads of households adequately represents the 1.8 million persons within the MUC. An independent survey firm conducted the interviews in 1996. Results show that the weighted combined household disaster preparedness index constitutes the best construct to represent the concepts under study. Study results also reveal that risk-perception variables (attitudinal factors) offered the strongest explanatory power. Household structure and demographic variables collectively explained less than 8% of the dependent variable. The model used in this study yielded a coefficient of determination of .320, explaining 32% of the variance in the household disaster preparedness level. Concluding this study, the discussion offers implications for both disaster managers and researchers. Researchers should add to their analysis the household perspective as a complement to the organizational one. Also, it is clear that many other conceptual issues must be explored in understanding and measuring disaster preparedness. Disaster managers should base their efforts on sound research rather than on misconceptions about social behavior. Such implications can contribute to bridging the gap and also putting into practice the knowledge drawn from this growing and collective effort of studying disasters.

The purpose of this exploratory study was to operationalize the responses from a sample of the community dwelling older population from Denton County, Texas on disaster preparedness education given by Denton County Health Department (DCHD) personnel. The goals and objectives were drawn from the Texas Public Health and Medical Emergency Management 5-Year Strategic Plan 2012-2016. It was hypothesized that after the disaster preparedness education was received, then comprehension, retention, and application of the information would increase and the goals set forth by the DCHD would be reached. Thirteen sites were used to educate the 224 participants between August 2011 and April 2012. The data were received using a pre-test survey before the training, a post-test immediately after the training, and a follow-up survey call approximately 30 days later. Using Cronbach's alpha, logistic regression and regression analysis through SAS, the data revealed that all DCHD goals were met by this training method and outcome which include the sample population increasing comprehension, retention, and action on the information learned.

Since 2001, increased policy attention and federal funding mechanisms have required more effective disaster response by government actors and private sector organizations, including the health care system. However, there is limited scholarly evidence documenting which structural elements have been associated with efficacious regional coalitions. This study addressed the gap by examining whether the number of different participating disciplines (a proxy for coalition roles), community setting, and prior weather-related disaster declaration influenced the number of activities (a proxy for coalition responsibilities) conducted by the health care coalition. Social network theory was the theoretical lens with which the study results were used to examine the relational structures within coalitions. The quantitative study was based on archival data from a survey in 2011 of 375 acute care hospitals in the United States. A general linear model analysis was conducted, and results suggest a statistically significant relationship between the number of disciplines and the number of conducted activities. As the number of different disciplines increases in a coalition, so do the different types of conducted activities. Based on the analysis, community setting--urban versus nonurban--and the occurrence of a federally declared, weather-related disaster did not influence the number of coalition activities. This study provides evidence that establishing network structures for health care coalitions will advance the field of health care emergency preparedness and disaster response. The findings from this research may promote social change by guiding future policy development and research necessary to develop resilient and efficacious disaster response systems, resulting in reduced loss of life and injury.

This thesis provides a case study of the Government of Canada's former Office of Critical Infrastructure Protection and Emergency Preparedness (OCIPEP) through the lens of horizontal management (part of New Public Management theory). This study demonstrates that the effective use of horizontal management (horizontality) may reduce fragmentation occurring when the goal of critical infrastructure protection requires organizations to work cross-jurisdictionally and in partnerships. This need to collaborate is due to the ownership problem: over 85 per cent of Canada's critical infrastructure is owned by organizations other than the federal government. Research methods include a background survey of literature on critical infrastructure protection, horizontal management and horizontality, and new public management; and interviews using a snowball sample of eight subjects who held various positions within OCIPEP to better understand what the organizational structure appeared to be from within the organization. The research concludes that OCIPEP was not given the resources necessary to successfully fulfil its mandate. Results include the need for administrative and managerial support for horizontal endeavours, to encourage a "cultural context" of horizontality, as there are many organizational barriers to successfully using horizontality and collaborative methods. There were areas of success for OCIPEP, but more areas of weakness. Recommendations include additional study of the organization, a shift into a better-supported organization (which was accomplished with OCIPEP's inclusion into Public Safety and Emergency Preparedness Canada), and clear delineation of roles between the Government of Canada and the owners of the critical infrastructure. / October 2005