Surveying the local public health response to COVID-19 in Canada: Study protocol

Background Public health services and systems research is under-developed in Canada and this is particularly the case with respect to research on local public health unit operational functioning and capacity. The purpose of this paper is to report on a study that will collect retrospective information on the local public health response to COVID-19 throughout Canada between 2020 and 2021. Methods/Design The goal of the study is to develop and implement a study framework that will collect retrospective information on the local public health system response to the COVID-19 pandemic in Canada. This study will involve administering a mixed-method survey to Medical Health Officers/Medical Officers of Health in every local and regional public health unit across the country, followed by a process of coding and grouping these responses in a consistent and comparable way. Coded responses will be assessed for patterns of divergent or convergent roles and approaches of local public health across the country with respect to interventions in their response to COVID-19. The Framework Method of thematic analysis will be applied to assess the qualitative answers to the open-ended questions that speak to public health policy features. Discussion The strengths of the study protocol include the engagement of Medical Health Officers/Medical Officers of Health as research partners and a robust integrated knowledge translation approach to further public health services and systems research in Canada.


Thank you for your time and interest in this research.
A.1. Do I have your permission to start audio-recording to obtain your oral consent for the interview?
If no, stop the interview and ask interviewee how they would like to proceed.
If yes, start audio-recording and proceed.
A.2. Have you read the Participant Information Sheet and Consent Form and do you understand the purpose, procedures and the possible risks of the study?
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A.3. Do you consent to participate in this interview?
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By way of introduction, the focus of this research is on interventions and capacity to address COVID-19 at the local public health level. We are aware of public health interventions at the federal and provincial/territorial levels but, in this interview, we want to specifically learn about local public health level interventions and capacities.
There are many ways local public health is organized across the country. In this study we are interested in the lowest or most embedded level of public health administration of programs and services to a defined population. In some instances this may be called a local public health unit and in others the term "sub-provincial" may be used. Throughout this interview, we will refer to the "defined population" served by a local public health system as a "region." We acknowledge, however, that not all "regions" in this sense are contiguous, as is the case for several systems serving First Nations.

The interview is organized into 5 main sections:
The first section is focused on local public health leadership and governance, and this is followed by sections on local public health interventions that address COVID-19, partnerships and collaborations within and beyond the health system to address  and population health, and finally, a section on financial and human resources to manage the pandemic.

B. LEADERSHIP AND GOVERNANCE
This first section of this survey is about local public health leadership and governance.
B.1. How would you describe the organization of local public health in your region in terms of leadership and governance? For example, please describe levels and positions that would appear in an organizational chart for local public health in your region or the reporting structures.

This second and largest section of the interview is about local public health interventions implemented over the course of the COVID-19 pandemic.
We use the term "Interventions" as a catch-all term to include all policies, programs, services, initiatives, measures, strategies, approaches, and laws and regulations implemented either directly or indirectly at the local level.
We want to study interventions from the perspective of local public health in your region and the role of the Medical Health Officer and staff who report to them.
We categorize interventions into the following 5 sections: 1. Health protection and communicable disease control, 2. Public health communication, 3. Health equity-related interventions, 4. Emergency preparedness and response, and 5. Emergency social services.

C.1. HEALTH PROTECTION AND COMMUNICABLE DISEASE CONTROL INTERVENTIONS TO ADDRESS COVID-19
First, I will ask questions about health protection and interventions specific to communicable disease prevention and control to address COVID-19. There are three areas of interest: restrictions and regulations, contact and case management, and vaccination.

Restrictions and regulations
C.1.1.1. Was the Medical Health Officer or staff who reported to them consulted on the development and implementation of restrictions and regulations specific to closures and openings in various private and public sectors in your region? By private and public sectors we mean: businesses, schools, health care offices, bars, etc. Please explain your answer.
C.1.1.2. Was the Medical Health Officer or staff who reported to them directly responsible for the inspection and enforcement of restrictions and regulations specific to closures and openings in various private and public sectors in your region? Please explain your answer.
C.1.1.3. In general, were restrictions and regulations specific to closures and openings in various private and public sectors adapted in any way to meet the specific needs or circumstances of your region? If yes, what kinds of adaptations were made?
This next question is about restrictions and regulations specific to individual, family and community behaviour over the course of the pandemic, like masking, physical distancing, restrictions on gatherings, etc.
C.1.2.1 Was the Medical Health Officer or staff who reported to them consulted on the development and implementation of restrictions and regulations specific to individual, family and community behaviour in your region? Please explain your answer.
C.1.2.2. Was the Medical Health Officer or staff who reported to them directly responsible for the inspection and enforcement of restrictions and regulations specific to individual, family and community behaviour in your region? Please explain your answer.
C.1.2.3. In general, were restrictions and regulations specific to individuals, family and community behaviour adapted in any way to meet the specific needs or circumstances of your region? If yes, what kinds of adaptations were made?

Contact and case management
Now we will be talking about contact and case management, so everything involving individual patients from contact tracing, testing, and isolation, to outbreak management across various settings.

This section is about emergency response to address COVID-19:
C.3.1.1. Was the Medical Health Officer or staff who reported to them consulted on the development and implementation of the emergency response to COVID-19 in your region? Please explain your answer.
C.3.1.2. What was the role of the Medical Health Officer or staff who reported to them in the implementation of the emergency response to COVID-19 in your region? Please explain your answer. C.3.1.3. In general, was the emergency response to COVID-19 different from the responses to past emergencies in your region? Please explain your answer.

C.4. EMERGENCY SOCIAL SERVICES
In this section I will ask you about emergency social services that occurred during the COVID-19 pandemic, for example, initiatives involving housing, shelters, and food security.
C.4.1.1. Was the Medical Health Officer or staff who reported to them consulted on the development and implementation any emergency social services in your region? Please explain your answer. C.4.1.2. Was the Medical Health Officer or staff who reported to them directly responsible for the implementation of any emergency social services in your region? Please explain your answer.
C.4.1.3. In general, were emergency social services adapted in any way to meet the specific needs or circumstances of your region? If yes, what kinds of adaptations were made?

C.5. HEALTH EQUITY
In this section I will ask you how health equity factored into the local response to COVID-19.
C.5.1.1. Has the Medical Health Officer or staff who reported to them consulted on explicitly addressing health inequities in the COVID-19 response in your region? Please explain your rating.
C.5.1.2. Was the Medical Health Officer or staff who reported to them directly responsible for the implementation of measures designed to explicitly address health inequities in the COVID-19 response in your region? Please explain your answer. C.5.1.3. In general, was the COVID-19 response modified to address health inequities in your region? For instance, have interventions targeted differential impacts of COVID-19 on vulnerable populations? Or targeted specific social determinants of health? Please explain and provide examples.

D. PARTNERSHIPS AND COLLABORATION
In the following questions, we will ask you to report on the extent of partnerships and collaborations between local public health in your region and various local and regional service providers. I will ask that you rate the extent of these partnerships and collaborations by selecting from one of the following three options: "to no extent," "to some extent," or "to a great extent." Please let me know if you want me to reread this list at any time.
D.1.1 Please rate the extent to which local public in your region has partnered and collaborated within the broad health care sector to address COVID-19 with respect to the following:

E. SURVEILLANCE AND MONITORING
In this section of the interview I will ask you questions about monitoring and surveillance of local population health. E.1.1. I will read a list of categories of health data. Please state yes or no as to whether the Medical Health Officer or staff who reported to them have had timely access to these types of data during the pandemic.

F. RESOURCES
This is the second to last section of the interview and here I will ask you about the financial and human resources of local public health in your region to address COVID-19.
F.1. How did developments in the governance of local public health in your region prior to the pandemic impact the local response to the pandemic? Please explain your answer.
F.2. How did developments in the resourcing of local public health in your region prior to the pandemic impact the local response to the pandemic? Please explain your answer. F.5.1. This question will get at the impact of COVID-19 on routine public health programs and services. I will provide a list and please answer whether programs or services were stopped, adapted or enhanced, or whether programs or services in this area were not previously provided: Are there other public health programs or services that were stopped, adapted or enhanced that we did not just explicitly ask you about? Please list them.

G. FINAL COMMENTS
This is the last section of the interview and here I ask five general questions about local efforts to address COVID-19 in your region.
G.1.1. What have been the most significant enabling or facilitating factors with respect to the local public health response to COVID-19 in your region? G.2.1. What have been the most significant challenges or constraints with respect to the local public health response to COVID-19 in your region?