The 2009/A/H1N1 pandemic in Australia, Israel and England: a qualitative study in general practice

Background and Purpose of the Research The purpose of the research reported in this thesis was to explore the challenges of managing the 2009/A/H1N1 influenza pandemics in primary care in Australia, Israel and England. The influenza pandemic 2009/A/H1N1 was less devastating than originally anticipated; however, its burden on the health systems of many countries was substantial. It affected 214 countries and territories disproportionally afflicting young children and pregnant women. During this influenza pandemic, the main burden of the pandemic response fell on primary care services, and General Practitioners (GPs) were the ones who diagnosed and treated most of the patients. The prominent role of GPs in the 2009/A/H1N1 influenza pandemic presented an excellent opportunity to investigate the implications of pandemic policies for primary care and to tackle the potential problems that these policies may impose on the ability of GPs to participate effectively in the pandemic response. Method The research design consisted of three complementary studies: a systematic review of the literature, a document study, and qualitative semi-structured interviews with GPs. The systematic literature review (Study 1) was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and applied systematic approach to the literature search, study selection and data extraction. The objective of the systematic review was to examine evidence of challenges that primary care physicians encountered responding to past pandemics or large-scale epidemics. The document study (Study 2) involved analysis of the documents published by the health authorities in Australia, Israel and England during the 2009/A/H1N1 influenza pandemic. Information pertinent for the research question was separated from non-pertinent applying qualitative content analysis approach. Subsequent thematic analysis involved more focused reviewing of the retrieved data, which involved coding and category construction. The objective of the document study was to compare the approaches for management of the 2009/A/H1N1 influenza pandemic in primary care in these three countries. Qualitative semi-structured interviews with 65 GPs in Australia, Israel and England (Study 3) were conducted during June-September 2010. Thematic analysis of the qualitative data was applied. The objective was to explore the views of GPs on challenges they encountered managing the 2009/A/H1N1 influenza pandemic in these three countries. Findings The systematic review of the literature (Study 1) revealed that GPs from different countries experienced similar challenges during past epidemic or pandemic responses. These included: difficulties of communication with the health authorities; limited supply of Personal Protective Equipment (PPE) and difficulties with its use; challenges in performing public health responsibilities; limited support from the authorities; lack of appropriate training. However, the review did not allow a full-scale list of possible challenges of the pandemic response in primary care and yielded little systematic information concerning the nature of the identified challenges. The reasons for these were that only 10 studies met the inclusion criteria of the systematic review; the included studies had different objectives and designs; the studies provided little relevant information needed to consider the differences in patterns of the disease spread and GP involvement in the response in different countries. Study 2 and Study 3 of this thesis were designed to address the identified gap and to investigate the challenges of GP involvement in the 2009/A/H1N1 pandemic response in the selected examples of Australia, Israel and England. Study 2, document analysis, provided systematic evidence concerning the different approaches for involvement of GPs in the pandemic response in Australia, Israel and England. It showed that the involvement of GPs in the three countries differed in timing and allocated responsibilities. Study 3 of the thesis, qualitative interviews with GPs in Australia, Israel and England, elicited challenges in providing the pandemic response in primary care from the respective of GPs. The identified challenges were consistent with the findings of the systematic review of the literature. Systematic collection and analysis of the qualitative data from the three countries allowed identification of a full-scale list of challenges in three fields of the pandemic response: treatment of patients, performance of public health responsibilities and communication with the health authorities. Contribution of the Research to Knowledge This thesis adds to the existing knowledge concerning challenges of the pandemic response in primary care by differentiating between two types of challenges: (i) country specific challenges and (ii) cross country challenges intrinsic to the pandemic response in primary care in general. This was done by collating the data from the document study (Study 2) and qualitative interviews with GPs (Study 3). (i) Country specific challenges. These challenges were found to be influenced by the timing and severity of the disease spread, level of GP involvement in the response, support provided to GPs by the health authorities, and organization of primary care services in a country. (ii) Cross country challenges intrinsic to the pandemic response in primary care in general. These same difficulties were evident in each of the three countries and included difficulties in following pandemic guidelines (barriers affecting knowledge, attitudes and behaviour of GPs) and challenges related to the role delineation during the pandemic response that resulted in role ambiguity and role conflict. Conclusion and Recommendations for Future Pandemic Planning The experience of the 2009/A/H1N1 influenza pandemic management highlighted the centrality of primary care in the pandemic response. The findings of this thesis showed that GPs were intensively involved in the pandemic response in the three investigated countries, despite the differences in the responsibilities that were allocated to them. The connection of GPs to the populations they routinely serve and trust that these populations have in GPs, positioned them as the pivotal figures when people were concerned about their health or the possibility of getting sick. This situation is not likely to change in the future. In order to overcome challenges identified in this research, improvements in planning for involvement of GPs in the pandemic response should be introduced. Based on the thesis findings, the following recommendations were made: First, broader involvement of GPs in the process of planning should be targeted. This includes engagement of GPs and public health representatives in pre-pandemic drills, collaborative meetings and knowledge transfer; engagement of GP representatives and health authorities in pandemic policy evaluation; inclusion of GP representatives in decision making and planning committees. Second, improvement in clarity and strategy of the pandemic policies and guidelines communication to GPs should be introduced. This includes the establishment of one body that is responsible for communicating pandemic policy updates to GPs; making policy updates oriented to primary care by engaging GPs in pre-pandemic policy planning committees; engagement with GP professional bodies that develop and distribute guidelines for primary care; and establishment of mechanisms for GP feedback provision during the pandemic response. Third, planning the support to be provided to GPs during the pandemic response is imperative. This should include planning for rapid distribution of PPE and antiviral drugs in primary care; reimbursement for the pandemic vaccine administration; coordination during the mass vaccination campaign in primary care; and detailed guidelines to treat complicated pandemic cases