Factors influencing the effectiveness of public health emergency preparedness: a cross-sectional study from China

doi:10.21203/rs.3.rs-3120304/v1

To identify the factors that impair the effectiveness of public health emergency drills in China by assessing staff perspectives for improvements, we conducted a cross-sectional survey in Heilongjiang, a province in northeastern China by stratified cluster sampling. The staff perceived the inadequacy of equipment and facilities for scenario training (practice drills) to be the most important factors that impair response capacity. Conversely, integrated knowledge and skill-oriented emergency skills were enhanced during scenario training, as well as if such training were repeated periodically. We found that funding constraints, lack of departmental coordination, and insufficient leadership attention adversely affect the response capacity and effectiveness. A greater focus on emergency training and participation in simulated drills improves the preparedness of public health personnel to face crises. We consider the equipping of CDC staff with practical skills to face complex emergencies a priority, which will require a strategic decision to increase funding for equipment, leadership training support, and effective emergency coordination.

public health emergency

emergency drill

Considering the unpredictable nature of disasters and crises, risk analyses and responsive disaster planning in response to likely disaster scenarios are imperative.[1] Plans should be tested through practice-based simulations to improve personnel preparedness, and emergency drills are useful tools in this context.[2, 3]Emergency drills are an opportunity for departments and individuals to test their responsiveness to the kind of crises they are likely to encounter in the field.[4] Since these drills are planned to occur without warning, emergency personnel must respond quickly and accurately.[5, 6] Drills that simulate emergency situations are an essential component of any effective emergency preparedness program.[7]They are intended to be part of a larger continuous cycle of planning, training, exercising, analyzing shortcomings, and identifying areas requiring improvement, as well as subsequently taking corrective actions. In addition, they further enhance the management skills of emergency response personnel.[8, 9]However, despite a strong desire to assess the current state of preparedness efforts, the science supporting how best to acquire observational data during drills is not adequately advanced. This is so because the data gathered from the evaluation of public health system drills is often narrative in form, rather than quantitative or standardized. [10, 11]

After the outbreak of severe acute respiratory syndrome in 2003 and the 2008 Wenchuan earthquake, the Chinese national government focused its attention on the establishment of a coordinated national emergency response system to anticipate, assess, mitigate and, wherever possible, prevent and manage crises.[12] According to the public health emergency response law and regulations,[13] in coping with major public health emergency events, CDCs are required to take major responsibilities in emergency response to public health emergencies, information management of epidemic situation, and health related factors, as well as play a role in major natural and man-made disaster rescue works to prevent any secondary epidemic or public health crisis. All levels of CDCs (National, Provincial, Municipal, and County levels) must prepare for public health emergencies, providing technical support for emergency reserves, setting up emergency teams, conducting personnel training and drill, and offering technical guidance.[14] Whenever a public health emergency occurs, CDCs have the primary responsibility to communicate and coordinate with all local health care institutions and other resources to address the health care needs of the population affected by the crisis, and to coordinate with national resources such as the People’s National Army, if required. The CDCs at Municipal (especially district level) and county level take the major responsibility to handle the outbreaks of major diseases and health problems in both urban and rural areas; therefore, they are regarded as the “first on-site responders” to many public health emergencies.[15] During last several decades, China has launched several rounds of nation-wide training programs for capacity building of local level CDCs. All professional staff is required to participate in health emergency related trainings and drills in order to prepare for emergency response.[16]

In the first two decades since the SARS outbreak in China, majority of trainings mainly included short-term lectures that had repetitive and nonspecific.[17] In addition, the composition of the participants is complicated and the sense of participation is not strong, which makes it difficult for the training to meet the actual needs.[18] The importance of emergency drills has been apparent for nearly a decade. Studies have pointed out that critical elements in the design, conduct, and structure of drills impact their utility in testing and improving emergency preparedness. It is thought that well-designed drills can serve as a useful approximation of a real emergency or incident.[19-22] Numerous studies have demonstrated that adequate equipment and facility support can enable us to simulate sudden catastrophic events in real time,[23] enabling emergency personnel to be fully prepared to react when confronted with real-life situations. For example, a four-day emergency drill, conducted for a new flu virus in New South Wales, Australia, involved ample equipment guarantee and technical support, and more than 300 participants. A complex scenario was simulated, which was fully monitored to maintain pressure and authenticity.[24] Only eight months later, there was an outbreak of H1N1. In the face of a sudden public health crisis, the emergency personnel performed as well as they had during the drills, which not only improved the efficiency of the emergency response but also reduced economic loss.[25] In addition, more frequent participation in exercises may result in improved overall response.[8]

Previous studies have explored major issues in emergency training and the factors that influence it,[26-29] but in China, few studies have focused on emergency drills—a new mode of capacity building and its effectiveness. Although within the last decade, emergency drills have become increasingly popular and been widely accepted as a quicker and a more effective way to enhance responders’ hand-on skills. However, few studies have documented its progress in applications, the modes of emergency drill, their effectiveness, and the factors that hinder them. Therefore, we conducted this survey to identify the factors that impair the effectiveness of public health emergency drills in China by assessing staff perspectives for improvements, as well as demonstrate the importance of scenario-based training to enhance disaster preparedness.

Study population and data collection

A face-to-face survey was conducted by researchers from the Department of Social Medicine of Harbin Medical University in Heilongjiang Province, China. Heilongjiang is located in northeast China with an area of 473,000 km² and a population of more than 38 million. There were a total of 174 CDCs in 13 jurisdictional regions (municipality) in Heilongjiang Province.[30] In each municipality, there are 5-10 counties. Many public health emergencies were confirmed and directly reported on the internet in Heilongjiang Province up to 2018, including 15 infectious disease events, 36 food poisonings, one occupational poisoning, three unexplained poisonings, 19 environmental events, one mass unexplained disease event and one provincial wide big flooding.[31-32]

In order to test the research design and solicit opinions on the rationality of the questionnaire, a pilot study was conducted with 20 public health emergency responders from four local CDCs prior to the formal survey. Some necessary adjustments were made in light of the responses. The full-scale survey was then conducted. Considering the geographical and jurisdictional diversity, and the fact that each municipality has 5-10 counties, we adopted the stratified cluster sampling method that selected 2–4 sampled counties in each municipal region at random in the same proportion (40%). Finally, 40 CDCs were sampled. All staff of the 40 CDCs were invited to participate in the survey, except for the non-professional staff. Quality control was ensured by supervisors throughout the study. All participants indicated their willingness to participate, both verbally and in consent forms signed before the commencement of interviews. In total, 1,889 CDC staff members were sampled and 1859 individuals completed the questionnaires (response rate：98.41%）.

Measures

Outcomes

The effectiveness of emergency drills for public health emergency responders was assessed on a five-point scale (1 = “very poor,” 2 = “poor,” 3 = “average,” 4 = “good,” 5 = “very good”). The scores were recoded into two categories: “high effectiveness” (scores ≥ the mean of 3.16) or “poor effectiveness” (scores < the mean of 3.16) for the purpose of logistic regression modeling.

Independent variables

Independent variables included in the model were demographic variables (gender, age, education, and work experience) (Table 1), training experience (the number of training sessions and training effectiveness), emergency drill management elements (financial support, personnel guarantee, drill site guarantee, equipment and facilities guarantee, security guarantee, leaders’ focus, and coordination between departments), types of emergency drills applied in the past five years (tabletop drill, operation-based drill, functional drill, and comprehensive drill), and emergency drill disposal skills (emergency drill plan designing skill, emergency drill script writing skill, emergency drill forms designing skill, and emergency drill needs assessment skill). The response options for the number of training sessions were “None” and “≥ 1,” for training effectiveness “Not so good” and “Good,” and for emergency drill management elements “Yes” or “No.” The answer choices for whether to use the drill type is “Yes” or “No.” The level of skill was originally measured using a 5-point Likert scale (very poor, poor, average, good, very good). In the modeling, these were collapsed into two groups: “good” (good and very good) and “not good” (very poor, poor, average).

Of the four types of emergency drills applied in the past, a tabletop drill refers to discussing different measures based on a hypothetical scenarios, an operation-based drill refers to the experience of actual combat in a real-life setting, a functional drill refers to a drill performed based on an emergency response function or some of its emergency response actions, and a comprehensive drill is designed for all or most of the emergency response functions in an emergency plan.

Since emergency drills were only recently introduced in China, there was a significant contrast between these drills and the traditional way of emergency training that was mainly delivered through coursework or lectures. The skills needed to develop a high-quality emergency drill plan were very complicated and multiple. Through brainstorming, the CDC experts identified detailed skills mix that are highly critical for accomplishing qualified emergency drills. Besides the ability to design a complicated drill plan that can reflect the dynamic scenario as a crisis evolves, additional skills are needed to develop and write an operational script according to the changing situation for CDC staff to follow during emergency drills. In addition, according to the nature and requirement of various types of emergency drills, skills to design the role, responsibility, and tasks for different actors are also needed.

Statistical analysis

Survey data were organized and analyzed using SPSS statistical software V.19.0. Initial univariate descriptive statistics were obtained for the entire study. Pearson’s χ² was used to examine demographic factors associated with self-assessment of the effectiveness of emergency drills. The associations that were found to be significant (p < 0.05) were then analyzed with multivariate logistic regressions and a stepwise logistic regression method was used to eliminate the collinearity between variables. Odds ratios (ORs) and their 95% confidence intervals (CIs) were estimated to assess the relationship between the predictors and overall effectiveness of emergency drills. The OR refers to “the odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure.”[33]

Types of emergency drills

Of the four main types of emergency drills applied in the past five years, the exercises that CDC staff most frequently engaged in were operation-based drills (36%), followed by tabletop (31%) and functional drill drills (20%). The ones they engaged in the least were comprehensive drills (13%).

Emergency drill disposal skills

It was found that 24.32% of responders were skilled in emergency drill plan designing, 16.93% of responders in emergency drill script writing, 13.42% of responders in emergency drill forms designing, and only 11.70% in emergency drill needs assessment (Figure 1).

Perception of importance of training methods in emergency drills

Responders self-reported eight training methods used in emergency drills over the last year. The top three methods were training class (42.27%), on-the-job training (16.03%), and academic lectures (14.82%). Sharing experience and web-based training had the lowest utilization rates, with 3.14% and 3.35%, respectively (Figure 2).

Characteristics of respondents and self-rated effectiveness of emergency drills

Of the1,859 respondents, more than half (59.1%) were females, 15.6% were over the age of 50, 84.0% had received college or higher education, and 37.7% had work experience of 20 years or more at the time of the survey (Table 1).

Chi-square tests revealed that self-rated effectiveness of emergency drills was associated with gender, education, number of training sessions, training effectiveness, fund guarantee, equipment and facilities guarantee, leaders’ focus, coordination between departments, tabletop drills, operation-based drills, emergency drill plans designing skill, emergency drill scripts writing skill, emergency drill forms designing skill, and emergency drill needs assessment skill (Table 2).

Table 1. Characteristics of respondents (N = 1859)

Variable		N (% of 1859 )
Gender	Male	761 (40.9)
	Female	1098 (59.1)
Age	≤ 30	238 (12.8)
	30~39，	558 (30.0)
	40~49	773 (41.6)
	≥50	290 (15.6)
Education	Junior college and below	297 (16.0)
	College and above	1562 (84.0)
Work experience	1~9 years	666 (35.8)
	10~19 years	491 (26.4)
	20~29 years	521 (28.0)
	≥30 years	181 (9.7)

Table 2. Outcomes of self-rated effectiveness of emergency drills (N = 1859)

Variable		High effectiveness n (% of 869 )	Poor effectiveness n (% of 990 )	Χ²	P
Gender	Male	393 (45.2)	368 (37.2)	12.412	0.000
	Female	476 (54.8)	622 (62.8)
Age	≤ 30	114 (13.1)	124 (12.5)	0.305	0.959
	30~39，	261 (30.0)	297 (30.0)
	40~49	362 (41.7)	411 (41.5)
	≥ 50	132 (15.2)	158 (16.0)
Education	Junior college and below	118 (13.6)	179 (18.1)	6.987	0.008
	College and above	751 (86.4)	811 (81.9)
Work experience	1~9 years	325 (37.4)	341 (34.4)	2.363	0.500
	10~19 years	228 (26.2)	263 (26.6)
	20~29 years	231 (26.6)	290 (29.3)
	≥ 30 years	85 (9.8)	96 (9.7)
Number of training sessions	None	396 (45.6)	337 (34.0)	25.757	0.000
	≥ 1	473 (54.4)	653 (66.0)
Training effectiveness	Not so good	442 (50.9)	379 (38.3)	29.701	0.000
	Good	427 (49.1)	611 (61.7)
Fund support	Yes	612 (70.4)	790 (79.8)	21.926	0.000
	No	257 (29.6)	200 (20.2)
Personnel guarantee	Yes	452 (52.0)	484 (48.9)	1.808	0.193
	No	417 (48.0)	506 (51.1)
Drill site guarantee	Yes	338 (38.9)	351 (35.5)	2.349	0.125
	No	531 (61.1)	639 (64.5)
Equipment and facilities guarantee	Yes	412 (47.4)	683 (69.0)	89.021	0.000
	No	457 (52.6)	307 (31.0)
Security guarantee	Yes	254 (29.2)	285 (28.8)	0.044	0.834
	No	615 (70.8)	705 (71.2)
Leaders’ focus	Yes	474 (54.5)	647 (65.4)	22.582	0.000
	No	395 (45.5)	343 (34.6)
Coordination between departments	Yes	373 (42.9)	533 (53.8)	22.070	0.000
	No	496 (57.1)	457 (46.2)
Tabletop drill	Yes	81 (9.3)	66 (6.7)	4.478	0.039
	No	788 (90.7)	924 (93.3)
Operation-based drill	Yes	91 (10.5)	75 (7.6)	4.773	0.034
	No	778 (89.5)	915 (92.4)
Functional drill	Yes	49 (5.6)	45 (4.5)	1.152	0.283
	No	820 (94.4)	945 (95.5)
Comprehensive drill	Yes	34 (3.9)	28 (2.8)	1.688	0.198
	No	835 (96.1)	962 (97.2)
Emergency drill plan designing skill	Good	614 (70.7)	765 (77.3)	10.579	0.001
	Not good	255 (29.3)	225 (22.7)
Emergency drill script writing skill	Good	431 (49.6)	538 (54.3)	4.177	0.041
	Not good	438 (50.4)	452 (45.7)
Emergency drill form designing skill	Good	387 (44.5)	385 (38.9)	6.073	0.014
	Not good	482 (55.5)	605 (61.1)
Emergency drill needs assessment skill	Good	279 (32.1)	394 (39.8)	11.856	0.001
	Not good	590 (67.9)	596 (60.2)

Factors associated with the self-rated effectiveness of emergency drills by logistic regression model

The independent variables with statistical significance in the Chi-square tests were entered into the logistic regression model. “Equipment and facilities guarantee” appeared to be the most significant predictor of self-rated effectiveness of emergency drills, followed by training effectiveness, leaders’ focus, number of training sessions, skilled in emergency drill plans design, fund guarantee, and coordination between departments.

The effectiveness of emergency drills was significantly associated with the availability of equipment and facilities. The perceived effectiveness of the emergency drills that received adequate equipment and facilities was 2.324 times (95% CI 1.884 to 2.867) higher than the emergency drills that received insufficient equipment and facilities. The participants who had obtained more and effective trainings were 1.765 times more effective in their responses in emergency drills than these who had poor quality trainings. The drills that leaders focused on and paid careful attention to were more likely to achieve better performances (OR=1.585) than those that did not receive leaders’ attention. Respondents who had a previous training experience were 1.539 times (95% CI 1.258 to 1.882) more likely to react more effectively than those who had no training experience. Emergency drill plan designing skill (OR=1.494), sufficient funds (OR=1.407), and good coordination between departments (OR=1.335) were also significant predictors of self-rated emergency drills effectiveness (Table 3).

Table 3. Factors associated with the effectiveness of emergency drills in public health emergency responses

Variables	Wald	P	OR	95% CI
Number of training sessions (≥ 1) vs (none)	17.616	0.000	1.539	1.258	1.882
Training effectiveness (good) vs (not so good)	31.066	0.000	1.765	1.445	2.155
Fund guarantee vs no fund guarantee	8.047	0.005	1.407	1.111	1.781
Equipment and facilities guarantee vs no equipment and facilities guarantee	62.015	0.000	2.324	1.884	2.867
Leaders’ focus vs lack of focus	17.174	0.000	1.585	1.275	1.971
Coordination between departments vs no coordination between departments	7.480	0.006	1.335	1.085	1.641
Skilled in emergency drill plans designing vs unskilled	11.151	0.001	1.494	1.180	1.890

Adequate equipment and facilities are the basic requirements for conducting emergency drills

Our data indicated that the equipment and facilities supply is the most significant factor affecting the effectiveness of emergency drills. For example, emergency drills should arrange for emergency personal protective supplies and portable labs for detecting pathogens, equipment and facilities for medical treatment, disposal of medical refuse, as well as vehicles for coping with the outbreak of infectious diseases. For catastrophic events like earthquakes, rescue and rehabilitation sites should also be set up. All these measures depend on equipment and facilities guarantee as well as sufficient fund support, which often deemed as quite resource demanding activity.

Emergency drills will undoubtedly provide practical experience to the participants. However, it is impossible to have frequent rehearsals due to the limitations in the provision of many important resources. Plan designing, site selection, and scenario setting of each emergency drill, the preparation of event sites, such as the preparation of scene props, the establishment of on-site audio signal transmission system, the establishment of emergency response command platform, etc., all require substantial human, as well as material and financial resources. In addition, a successful emergency drill requires complete and tight planning, which requires high quality, knowledgeable, and skillful personnel and technological support. They are needed to design a complicated and effective emergency drill plan, which is one of the most difficult tasks. If the planning of the drill is too simple or divorced from reality, it will not reflect the purpose of the drill.

Those issues can be addressed by computer assisted simulation technology, which can make the exercise more effective. In order to have more accurate predictions of human behavior, simulated emergency response processes are needed to judge whether a certain design is reasonable;[34] it can help save a lot of money and avoid risk. In this technological era, without the support of electronic technology such as 3D simulation system or VR system, cost-effective emergency drills cannot be conducted.[35] At present, there is a shortage of several kinds of emergency supplies in China; in addition, some emergency materials do not meet the required standards.[36] Therefore, it is of paramount importance to improve the quantity and quality of emergency stockpile and provide adequate facilities and equipment for emergency drills to improve their overall performance.[37]

The combination of knowledge-oriented learning and skill-based operation is the most effective method of emergency training

Training is of vital importance in all high-risk professions,[38] and a disaster situation should not be a surprise or a threat to disaster managers and emergency responders.[39] Our survey results suggest that qualified and effective training is the second most significant factor (OR=1.765) that influences emergency preparedness; besides, quantity of training also made a difference(OR=1.539). There is a positive correlation between the effect of emergency drills and the number of training sessions. A previous study also demonstrates the requirement of training to improve knowledge levels and build up the consciousness required for emergency preparedness.[40]

Moreover, our study demonstrates that there are many deficiencies in training methods. Currently, one of the dominant emergency training modes is knowledge-oriented learning, which is mainly provided through course, lectures, on-the-job training, and seminars. The other mode is skill-oriented training, which is mainly conducted through practical operations. However, skill-based training only accounts for a small part of the entire training. Hands-on experience is closely related to skill-based operation, but this type of training is insufficient. Besides, most training methods involving old-fashioned, traditional approaches have failed to keep abreast with the latest developments in the technologies used in crisis response, which has resulted in the poor quality of emergency training. Effective training for emergency drills must combine knowledge enhancement with skill practice in order to improve emergency personnel’s ability to react when faced with unexpected events. Practical training for staff members via simulation drills is an important component of training programs. It is necessary to continue providing training in order to increase staff’s awareness of disaster defense and improve their skills.[41]

A qualified design of emergency drill plan is the key

The emergency drill plan should function as the blueprint for drills. The results of logistic regression have proved that the design of the emergency drill plan is one of the most important factors affecting emergency drills (OR=1.494). It serves as the basis for conducting the drill as different disaster scenarios can be plotted through it, and it may directly influence the effect of emergency drills and the improvement of their management.[42, 43] Preparing hypothetical scenarios requires a comprehensive plan, and this is often the key to the success or failure of emergency drills.

However, at present, there are serious defects in the overall design of emergency drill plans. Most designs do not rise above the ordinary, ignoring the aspect of the suddenness of public health emergencies, which is why emergency drills lack authenticity and a scientific basis. In order to solve this problem, the rehearsal plot design should be as comprehensive as possible, thus guaranteeing the quality of emergency drills.

Establish multi-sectorial coordination mechanism and strengthen the leadership’s attention

At present, emergency drills are basically departmental activities. The administrative departments are separate from each other and lack a multi-sectorial coordination mechanism.[44] Further, there are still problems of coordination in emergencies of interregional complexity.[45] The results of our survey indicated that the rate of comprehensive exercises that can strengthen the joint capacity of different departments is the lowest, which means that the interdepartmental coordination is another weak link.

Multi-agency emergency drills can establish and reinforce relationships and bring people from different areas together to work as a team, realize clear goals, understand roles and responsibilities, and know and respect each agency’s strengths and weaknesses.[46, 47] Intersectoral collaboration has been clearly shown to be a crucial tool in the prevention and control of diseases.[48] Lack of coordination, coupled with conflict among agencies, often leads to tremendous loss of time, waste of resources, duplication, and uncoordinated and inappropriate responses.[49] To improve effectiveness, teams should be trained as a whole to develop knowledge, skills, and attitudes; improve coordination; foster shared mental models and accurate expectations of the requirements of the team; and encourage adaptability and flexibility.[50] Besides, more comprehensive exercises should be carried out. According to a previous study, tabletop exercises are inadequate to expose operational and logistical gaps in disaster response, and comprehensive exercises should be routinely performed to adequately prepare for catastrophic events[48]since they can help in identifying the communication gaps between responsible authorities.[51]

In China, the authority for allocating government budget were mainly in the hand of the financial departments at central, provincial, municipal and county levels. Due to decades of decentralization reforms, local government was responsible for financing local health and other social affairs. Although it is the national policy that requires local CDCs to undergo emergency training, but only those wealthy provinces and municipalities that had more money and resources, and whose leaders paid more attention to it, might provide sufficient support to emergency drills. Compared to traditional approach of knowledge-oriented training through lectures, courses, or workshops, which used to be a nation-wide earmarked program that often received money from the central government, the skill-oriented emergency drills seldom received funds from the central government. Hence, the financing responsibility mainly rested on the shoulders of local governments, which means the need for additional human resources, as well as material and financial resources. If leaders in poor areas fail to recognize the important and irreplaceable role of emergency drills, and deemed it as a waste of resources, they might be reluctant in providing extra money for them.

This study has several limitations. Data were collected using self-assessment tools, and therefore, the perceptions of the effectiveness of emergency drills in public health emergencies may have been overestimated. The survey was conducted only in Heilongjiang Province owing to limited resources; therefore, these findings cannot be generalized to other regions in China. Further studies are needed to develop a more comprehensive evaluation tool and enhance the effectiveness of emergency drills in improving public health emergency responders’ preparedness.

We believe there is insufficient emphasis on probable scenario training using desktop planning or unannounced emergency drills, which, coupled with inadequate training, has resulted in personnel unfamiliar and ill-prepared for crisis response in terms of leadership, flexibility, creativity, deployment capacity, and appropriate equipment. More attention should be devoted to the guarantee of equipment and facilities supply, and continued hard work is required to eliminate barriers with respect to technologies, resources, funds, and personnel to improve public health emergency preparedness. One important priority is the need to focus on equipping CDC staff with practical skills to face complex emergency situations, in addition to increasing funding, leadership support, and supervision.

ACKNOWLEDGMENTS

The authors thank all the professionals worked in various levels of CDC who provided the information necessary for completion of the study. They also acknowledge Editage for editing the manuscript.

Ethics approval and consent to participate

As principal investigator and on behalf of the working group, I declare that the data collection has been carried out in respect to the privacy of participants and the improvement project complies with the Declaration of Helsinki. The informed consents were accepted and signed by all participants of the study. The Ethics Committee of Harbin Medical University approved the study.

COMPETING INTERESTS

The authors declare no competing interests.

FUNDING

This work was supported by the Scientific Research of Ministry of Health of China (Grant No. 201002028), the National High Technology Research and Development Program of China (Grant No.2006AA02Z460), and the Natural Science Foundation of China (Grant No.71173064).

AUTHOR CONTRIBUTIONS

Conceptualization: Qunhong Wu; Formal analysis: Ruiqian Zhuge, Jingjing Liu, Na Chang, Xing Wang, Xinye Qi and Zheng Kang; Methodology: Ruiqian Zhuge, Jingjing Liu, and Na Chang; Project administration: Qunhong Wu; Supervision: Qunhong Wu; Visualization: Jingjing Liu; Writing – original draft: Ruiqian Zhuge and Jingjing Liu.

OPEN ACCESS

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No competing interests reported.

Highlights.docx

Factors influencing the effectiveness of public health emergency preparedness: a cross-sectional study from China

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