their community, the proportion of ICPs with prior training in bioterrorism ... Results: The assessment of the perceived threat of bioterrorism in the United States ...
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Infection control practitioners’ perceptions and educational needs regarding bioterrorism: Results from a national needs assessment survey Brooke N. Shadel, PhD, MPH Terri Rebmann, RN, MSN, CIC Bruce Clements, MPH John J. Chen, PhD R. Gregory Evans, PhD, MPH St. Louis, Missouri Background: The perceived threat that biological weapons will be used in an act of terror against the United States has escalated sharply since the discovery of anthrax-tainted letters after the terrorist attacks of September 11, 2001. These events underscore the critical nature of health care and public health preparedness and the need to augment infection control practitioner education and training. Methods: Between October 2000 and August 2001 a national needs assessment was conducted by use of a 35-question survey. The survey measured infection control practitioners’ (ICPs’) perception of the risk for bioterrorism in the United States and in their community, the proportion of ICPs with prior training in bioterrorism preparedness, and preferences for delivery media of future bioterrorism education. Results: The assessment of the perceived threat of bioterrorism in the United States during the next 5 years (P = .022) and in the ICPs’ work community (P < .001) revealed significant regional differences. Only half (56%) of the respondents reported prior training in bioterrorism preparedness. Respondents reported that the 2 most common barriers to receiving training were lack of training opportunities (70.2%) or no dedicated work time for training (19.4%). Conclusions: The results of this study indicate an urgent need for more resources and opportunities for clinical education in bioterrorism preparedness that will provide continuing education credit. Successful bioterrorism education will require a variety of instructional designs and media delivery methods to address ICPs’ preferences and needs. (Am J Infect Control 2003;31:129-34.)
From the Center for the Study of Bioterrorism and Emerging Infections, School of Public Health, Saint Louis University. This report was supported in part by funds from Grant No. U90/CCU718631-02 from the Centers for Disease Control and Prevention, Public Health Service, US Department of Health and Human Services. Reprint requests: Brooke N. Shadel, PhD, MPH, Center for the Study of Bioterrorism and Emerging Infections, School of Public Health, Saint Louis University, 3545 Lafayette Ave, Suite 355, St. Louis, MO 63104. Copyright © 2003 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/2003/$30.00 + 0 doi:10.1067/mic.2003.56
The perceived threat that biological weapons will be used in an act of terror against the United States has escalated sharply after the discovery of anthraxtainted letters after the terrorist attacks of September 11, 2001. These events underscore the critical nature of health care and public health preparedness and the need to augment infection control practitioner (ICP) education and training. This education must incorporate epidemiologic methods of surveillance, isolation and disease management of primary bioterrorism pathogens, and appropriate reporting and response activities.1,2 In addition, ICPs must identify reliable, accessible sources of information before an emergency occurs and ensure the avail129
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Table 1. Occupation, work setting, and geographic location of participants % (n) Work setting Academic/research Administration Laboratory Long-term care Patient care Public health Infection control* Other† Work for governmental agency Yes No Employer, if not government For-profit institution Not-for-profit institution Other Location of work Rural Urban Suburban No. of states in United States represented
2.6 21.2 1.9 2.7 49.6 6.3 12.4 3.4
(32) (257) (23) (33) (602) (76) (150) (41)
18.2 (229) 81.7 (1030) 24.6 (249) 72.5 (733) 2.9 (29) 36.6 (450) 41.0 (504) 22.3 (274) 50
*Participants who indicated infection control in the “other” category. †Includes participants (n = 16) who indicated more than 1 type of work setting in which they spend most of their time or those who selected “other.”
ability of these critical resources during times of greatest need.3 We conducted a comprehensive needs assessment survey to do the following: (1) evaluate ICPs’ perceptions of the risk of a bioterrorism attack, (2) determine the extent and type of prior education in bioterrorism preparedness that the ICPs had received, and (3) explore the barriers to receipt of such education. We also explored options for the most effective format for quick reference materials on these topics. We describe the instructional design and the delivery media preferred by ICPs and recommend methods of delivery for bioterrorism preparedness materials.
METHODS Study population This study was part of a national needs assessment on biological warfare and emerging infections funded by the Centers for Disease Control and Prevention (CDC). We collected data through a national mailed survey that was distributed to a sample of 4000 ICPs out of 11,308 (35.4%) who were identified as members of the Association for Professionals in Infection Control and Epidemiology (APIC). This professional organization provided a list of professionals in an occupational group that we expected would be at
the forefront of the response to an outbreak resulting from an intentional release of a biological weapon. The Statistical Package for the Social Sciences (SPSS) 10.1 software was used to randomly select 4000 ICPs from the membership list. These surveys were mailed to the participants in October, 2000. Included with the surveys were 2 personal letters, 1 from Saint Louis University Center for the Study of Bioterrorism and Emerging Infections and the other from APIC. Six weeks after the initial mailing, a reminder postcard was sent to APIC members, and they were again asked to complete and return the form if they had not already done so.
Instrumentation Several study investigators worked independently to develop focused questions for this study. These questions were evaluated in 20 qualitative telephone interviews with members of the health care and public health professions. To ensure that all selections were exhaustive and exclusive, categories for the questions were expanded on the basis of responses from the telephone interviews. The survey instrument was pretested for format and content by small groups of infection control and public health professionals. The names of participants of the pilot testing were excluded before the random sample drawing. The Saint Louis University Institutional Review Board approved this study. The survey instrument required fewer than 15 minutes to complete and contained 35 questions in a 4-page booklet. This instrument assessed the perceived threat of bioterrorism, the efficacy of the current public health epidemiologic surveillance system, the extent of the respondents’ past bioterrorism training, and the perceived barriers to such training. It also assessed educational needs. The remainder of the questionnaire addressed the participants’ computer proficiency, access to technology, and the preferred instructional design and medium for delivery of educational opportunities and reference materials. Demographic information such as location, type, and place of employment was obtained. All questions were multiple choice, and a space for comments was included at the end of the survey form to elicit additional responses about these topics.
Data analysis All survey questions regarding perceptions of risk and efficacy of the public health surveillance sys-
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Table 2. Means and standard deviations of questionnaire responses by community size and region Rural How likely do you believe it is that: A terrorist attack with biological agents will occur in the United States during the next 5 years? A terrorist attack with biological agents will occur in the city or county where you work during the next 5 years? The current public health epidemiologic surveillance systems would quickly identify a bioterrorism attack? How likely would you be to seek information on bioterrorism preparedness?
n
Mean (SD)
Urban
n
Mean (SD)
Suburban
n
Northeast
Mean P (SD) value
n
Mean (SD)
South
n
Mean (SD)
Midwest
n
Mean (SD)
West
n
Mean P (SD) value
449
2.21 (1.00)
503
2.19 (1.07)
274
2.18 (1.05)
.923 249
2.19 (1.03)
352
2.05 (0.97)
411
2.27 (1.06)
210
2.23 (1.07)
449
3.84 (1.05)
503
3.03 (1.17)
274
3.14 < .001 249 (1.24)
3.29 (1.19)
352
3.11 (1.21)
411
3.54 (1.18)
210
3.38 < .001 (1.21)
449
2.90 (1.13)
503
2.93 (1.18)
274
2.97 (1.16)
.715 249
2.88 (1.20)
352
2.95 (1.15)
411
2.92 (1.15)
210
2.98 (1.14)
.03
448
1.87 (0.94)
502
1.75 (0.97)
274
1.65 (0.89)
.01
1.75 (0.89)
350
1.68 (0.92)
411
1.87 (1.00)
210
1.72 (0.90)
.829
249
.022
Responses provided on a Likert scale, with 1 being “very likely,” 2 as “somewhat likely,” 3 as “neither likely nor unlikely,” 4 as “somewhat unlikely,” and 5 as “very unlikely.”
tem and the likelihood that the respondent would seek out information about bioterrorism were scored on a Likert scale of 1 to 5 (ie, “very likely” to “very unlikely”).4,5 Data were coded and entered with the double keypunch method; an additional 20% of the surveys were randomly selected to verify accuracy. SPSS 10.1 was used for all analyses. Descriptive statistics (mean, standard deviation, frequency distributions) were computed for each question. Because of the discrete nature of the Likert scale, group comparisons for the questions were analyzed with use of both parametric analysis of variance and the nonparametric approach (KruskalWallis test). Post hoc evaluation was performed with the Scheffé, Tamhane’s, and the Mann-Whitney tests, with the Bonferroni correction for multiple testing. Very similar results were found with both parametric and nonparametric approaches; the parametric results are reported here. The category “other” was coded when a respondent gave more than 1 answer to the questions describing his or her work setting (n = 16). If participants selected more than 2 barriers to training (n = 4) or more than 3 preferred methods of receiving education (n = 121), they were excluded from the sample for those questions.
RESULTS Overall, 1260 of 4000 (31.5%) petitioned participants responded to the survey. Approximately half
of the participants described their primary work setting as “patient care,” with most describing their work environment as an inpatient care facility, opposed to urgent or outpatient care settings (Table 1). Since the survey was anonymous, individual characteristics of the nonresponders could not be directly assessed. Responses were received from participants in all 50 states in an equitable representation across all 4 regions; Northeast (20.4%), South (28.7%), Midwest (33.6%), and West (17.2%). More than two thirds of respondents (72.5%) reported working for a not-for-profit institution, and 41% of the respondents were from urban areas (see Table 1). According to APIC membership data collected in the year 2000, APIC members work in all 50 states, and 75% work at not-for-profit institutions (Debby Timmons, personal communication, November 2000). Perceptions of risk regarding an intentional release of a biological agent occurring during the next 5 years in the United States (P = .475) or in the ICPs’ work community (P = .199) did not differ by type of occupational setting (eg, administration, patient care, public health). Opinions regarding the efficacy of the public health surveillance system also did not differ between the occupational settings (P = .799). Fewer than 10% of each group responded that it was very likely the current surveillance system would quickly detect a bioterrorism event. The likelihood that a respondent would seek more informa-
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Table 3. Preferred method of training for bioterrorism preparedness by location Rural % (n) Professional meeting Video Satellite teleconference Formal class Internet Table top Journal article Case presentation Inservice CD-ROM Grand rounds Audio recording
61.1 38.6 32.4 17.4 25.6 15.7 21.3 17.9 17.4 17.4 3.4 2.2
(253) (160) (134) (72) (106) (65) (88) (74) (72) (72) (14) (9)
Urban % (n) 57.0 27.6 26.5 25.3 19.5 24.7 23.1 21.7 16.6 13.0 8.1 4.3
(254) (123) (118) (113) (87) (110) (103) (97) (74) (58) (36) (19)
Suburban % (n) 62.0 30.2 29.4 26.1 22.0 25.7 19.2 20.0 15.9 11.8 6.5 1.2
(152) (74) (72) (64) (54) (63) (47) (49) (39) (29) (16) (3)
Table includes participants who selected 3 or fewer preferred methods for delivery of educational materials.
tion about bioterrorism preparedness was affected by the respondent’s occupational setting (P < .001), with significant differences between those working in administration and those working in patient care (P < .001). A smaller proportion of ICPs working in administration (40.9%) were very likely to seek out information on bioterrorism compared with those working in patient care settings (50.2%). Significant differences were found between regions when we assessed the perceived potential threat of bioterrorism in the United States during the next 5 years (P = .022) and in the ICPs’ work community (P < .001) (Table 2). ICPs from the South were significantly more likely to believe that a bioterrorism attack would occur in the United States during the next 5 years than those in the Midwest (P = .013). Eighty percent of the ICPs from the South believed that a terrorist attack with biological weapons in the United States was very likely to somewhat likely compared with three quarters or fewer of the ICPs in the Northeast (74.3%), Midwest (71.8%), and West (71.4%). Only one third (32.2%) of all ICPs believed that a bioterrorism attack in their community in the next 5 years was very likely to somewhat likely (South, 40.9%; Northeast, 33.3%; West, 28.1%; and Midwest, 26.5%). ICPs in the Midwest were significantly less likely than those in the Southern region (P = .013) to believe that a terrorist attack with biological agents would occur in the next 5 years in the city or county where they work. In addition, ICPs in the Midwest (79.5%) were less likely than those from the South (86.6%) to seek out information on bioterrorism preparedness (P = .045).
No significant differences by community size (rural, urban, suburban) were found when ICPs ranked the perceived risk of a terrorist attack with biological agents in the next 5 years in the United States (P = .923). However, responses differed when participants assessed the risk in their own community (P < .001) (see Table 2). Participants were more likely to believe that a terrorist attack with biological agents was very likely to somewhat likely to occur in the United States during the next 5 years than within their own community (74.4% vs 32.0%). How likely (“very likely” to “somewhat likely”) the participants believed it was that a terrorist attack with a biological weapon would occur in their community in the next 5 years differed significantly (P < .001) between communities of different sizes, as shown in the following: rural (16.1%), suburban (40.1%), and urban (42.0%). Differences were found between ICPs in rural, urban, and suburban communities regarding how likely they would be to seek information on bioterrorism preparedness (P < .01). Fewer than half (41.7%) from a rural community reported that they were very likely to seek out more information (see Table 2). Approximately half (56%) of the respondents reported prior training in bioterrorism preparedness. Those who reported prior bioterrorism preparedness training were more likely to believe that a bioterrorist attack would occur in the United States during the next 5 years than those who had not received prior training (79.2% vs 68.1%) (P < .001). Most of the participants who had received training in bioterrorism indicated that their work primarily involved direct patient care (51.8%), which was followed by those in administration (19.1%). When those who reported no prior training in bioterrorism preparedness were asked what were the 2 most common barriers to receiving training, the 2 most common responses were no training opportunities (70.2%) and no dedicated work time for training (19.4%). Approximately 17% of those reporting no prior training indicated training in bioterrorism preparedness was not their responsibility. Of those who did report prior training, most had attended a session on bioterrorism at a professional meeting (56%), obtained information through a journal article (54.5%), or attended an inservice (33.4%). The 3 preferred training methods were the following: lecture at a professional meeting (59.6%), training video (32.3%), and satellite teleconference (29.2%). We noted a few differences in preferences for methods of receiving education by location and occupa-
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tion. For example, a larger proportion of members from rural communities selected video (38.6%) or CD-ROM (17.4%) as a preferred method for education delivery than those in urban (27.6%, 13.0%) and suburban areas (30.2%, 11.8%), respectively (Table 3). Members working in public health preferred satellite teleconference and table top formats more than those who work in patient care or administration. The proportion of responses from those in government, not-for-profit, and for-profit institutions were similar regarding training preferences. Respondents who provided fewer than 3 answers for the preferred quick reference materials during a suspected bioterrorism crisis most often mentioned hotlines/helplines (57.3%), the Internet (48.0%), and textbooks (26%). More than two thirds of the participants responded that offering continuing education credit was important (“very important” [39.2%] and “somewhat important” [34.5%]). Most participants responded positively when describing computer proficiency (29.6%, very proficient; 60.1%, somewhat proficient; and 10.4%, not proficient or do not use a computer). More than 95% of the ICPs had access to a computer at home or work, although only 43.4% of the respondents reported satellite teleconference capability at either location (Table 4).
DISCUSSION Since the terrorist events of September 11, 2001, members of the health care and public health communities have been evaluating US levels of preparedness for a biological attack. Weaknesses in the system have been documented.6 The findings from this study suggest that approximately half of the ICPs who belong to APIC had received training in bioterrorism preparedness before the terrorist events in the fall of 2001. The ICPs who reported no prior training in bioterrorism preparedness indicated lack of opportunities for training and no dedicated work time for education as barriers to receiving this training. The results of this study indicate a need for more resources and opportunities for targeted education in bioterrorism preparedness for ICPs. These opportunities should provide continuing education credit. For this to occur, ICPs would need the support of their administrators to allocate time and resources for training. However, this study suggests that administrators were less likely to seek information on bioterrorism preparedness than those working in patient care,
Table 4. Access to technology at work or home
Technology access Computer with CD-ROM Computer with Internet Fax machine Satellite teleconference VCR
Work % (n) 27.8 88.0 94.5 42.7 90.6
(350) (1109) (1191) (538) (1141)
Home % (n) 78.3 82.0 32.2 4.8 91.0
(987) (1033) (406) (60) (1147)
Either location % (n) 88.1 96.2 95.9 43.4 96.6
(1110) (1212) (1208) (547) (1217)
which may suggest that administrators are less aware that their community is at risk for such an event. Furthermore, it may indicate that administrators are less aware of the consequences that an unprepared facility may face if a bioterrorism event occurred in their community. In a previous study7 with APIC members, many participants described administrators’ reluctance to allocate resources for bioterrorism preparedness. This perception of reluctance emphasizes the need to inform administrators. A larger percentage of ICPs (74.4%) compared with the national sample of physicians (52.6%) believe that a terrorist attack with biological agents was “very likely” to “somewhat likely” to occur in the United States during the next 5 years.8 However, when assessing the risk in the ICPs’ own community, only one third (32.2%) believed that their community was at risk. As a result of the recent terrorist events, a greater number of ICPs may be aware of the threat of bioterrorism and the consequences it may have on a community; however, some groups may continue to believe that their own community is not at risk. For example, those in rural communities and the Midwest were the least likely to report that a bioterrorism event might occur in their community. Fewer than half of the respondents from rural communities responded that they were very likely to seek out more information. Increased vigilance may be needed to raise the awareness of groups who may not believe that they are at risk and to ensure that professionals in health care and public health throughout the United States are aware of the potential threat in their community and are prepared to respond appropriately to such an event. For example, if an intentional release of a biological agent occurred in an airport, it would require real-time surveillance in communities of various sizes and locations across the United States to quickly identify the release and to implement a rapid, effective response. As health care and public health institutions recognize the need for more information and education to
134 Vol. 31 No. 3 enhance bioterrorism preparedness in their communities, they must consider the recipients’ preferences for content, instructional design, and delivery media of this education and the barriers to receiving the information. Although more than half of the ICPs in this study preferred education through annual professional meetings, we may need to initiate other educational interventions immediately, such as through the use of quick reference sheets, videotaped lectures, the Internet, and CD-ROMs to facilitate timely access to information. The findings of this study suggest that most ICPs could access educational material at home or at work since most have a VCR and a computer with Internet access. Most ICPs had access to technology for CD-ROMs at home, but only one quarter had access at work. Therefore, references in the form of textbooks and pocket cards may be needed in the work setting. In addition, preferences for format or time of delivery may differ among particular groups and must be considered. It is interesting to note that satellite teleconferencing was 1 of the top 3 preferred methods of receiving bioterrorism preparedness training for ICPs; however, in a national sample8 of physicians, it was one of the least preferred methods of delivery. This suggests the need to assess educational delivery preferences for specific professional groups to ensure accessibility. In addition to having access to training materials, ICPs need quick access to reference materials that are updated regularly and are available in multiple medias. Even though ICPs in this study most often selected a hotline or Internet site as the source for quick reference material they would most likely refer to in a crisis, ICPs also need access to materials that are independent of electricity and phone lines because during a crisis, these technologies are often not available. Therefore, we should also consider alternative media such as software for a personal data assistant that links to a frequently updated Web site, textbooks, quick reference cards, and pocket guides. A covert bioterrorism attack may present like an outbreak of a new or re-emerging infection. However, fewer than 10% of the ICPs in this study reported confidence in the public health system’s surveillance efficacy. The public health infrastructure on which the surveillance system relies must be strengthened to ensure confidence in the system for those who provide information to it, such as ICPs. A few limitations of this study must be noted along with the discussion of its strengths. The individuals surveyed were all members of APIC; thus, the find-
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ings may not be generalizable to all ICPs in the United States. However, this group of ICPs represents a large percentage of ICPs who would be at the front line of detection and who would be involved in controlling the spread of an intentional release of a biological agent. Therefore, this large group of ICPs should be targeted for educational opportunities. This randomly selected national sample, which included representatives from all 50 states, provided the opportunity to evaluate whether differences existed regionally, by community size, and by ICP occupational setting. Anonymity provided the best opportunity to assess the risk perception of these participants; however, it limited the information that could be collected from the nonrespondents.
CONCLUSION Health care institutions in the United States are facing unique challenges in this new era of bioterrorism. It is apparent that more educational opportunities and immediate access to reference materials are needed to enhance the preparedness of the nation. Future funding for education in bioterrorism preparedness and improvements in health care and public health infrastructure may have a dual benefit because they will augment the system’s capacity to identify and respond to new and re-emerging infections, whether they be of intentional or natural origin. More research through focus groups and other data collection methods may provide additional insight into the content priorities and preferences of specific ICP groups. Staff at the Center for the Study of Bioterrorism and Emerging Infections wish to thank the members from the APIC Bioterrorism Task Force who facilitated acquisition of the APIC membership list for this project.
References 1. Eitzen EM Jr. Education is the key to defense against bioterrorism. Ann Emerg Med 1999;34:221-3. 2. Leggiadro RJ. The threat of biological terrorism: a public health and infection control reality. Infect Control Hosp Epidemiol 2000;21:53-6. 3. Macintyre AG, et al. Weapons of mass destruction events with contaminated casualties: effective planning for health care facilities. JAMA 2000;283(2):242-9. 4. Nunnally JC. Psychometric theory. 2nd ed. New York: McGrawHill; 1978. 5. Aday LA. Designing and conducting health surveys. 2nd ed. San Francisco: Jossey-Bass; 1996. 6. McCarthy M. Attacks heighten US concern about threat of bioterrorism. Lancet 2001;358:1071. 7. Shadel BN, Clements B,Arndt B, Rebmann T, Evans RG.What we need to know about bioterrorism preparedness: results from focus groups conducted at APIC 2000. AJIC 2001;29:347-51. 8. Shadel BN, Clements B, Rebmann T, Chen JJ, Lawrence SJ, Evans RG. Physician’s perceptions and educational needs regarding bioterrorism: results from a national needs assessment survey. Under review with Arch Intern Med, February, 2001.
