Emergency medical service interventions and experiences during pandemics: A scoping review

Abstract

Background

The global impact of COVID-19 has been profound, with efforts to manage and contain the virus placing increased pressure on healthcare systems and Emergency Medical Services (EMS) in particular. There has been no previous review of studies investigating EMS interventions or experiences during pandemics. The aim of this scoping review was to identify and present published quantitative and qualitative evidence of EMS pandemic interventions, and how this translates into practice.

Methods

Six electronic databases were searched from inception to July 2022, supplemented with internet searches and forward and backward citation tracking from included studies and review articles. A narrative synthesis of all eligible quantitative studies was performed and structured around the aims, key findings, as well as intervention type and content, where appropriate. Data from the qualitative studies were also synthesised narratively and presented thematically, according to their main aims and key findings.

Results

The search strategy identified a total of 22,599 citations and after removing duplicates and excluding citations based on title and abstract, and full text screening, 90 studies were included. The quantitative narrative synthesis included seven overarching themes, describing EMS pandemic preparedness plans and interventions implemented in response to pandemics. The qualitative data synthesis included five themes, detailing the EMS workers’ experiences of providing care during pandemics, their needs and their suggestions for best practices moving forward.

Conclusions

Despite concerns for their own and their families’ safety and the many challenges they are faced with, especially their knowledge, training, lack of appropriate Personal Protective Equipment (PPE) and constant protocol changes, EMS personnel were willing and prepared to report for duty during pandemics. Participants also made recommendations for future outbreak response, which should be taken into consideration in order for EMS to cope with the current pandemic and to better prepare to respond to any future ones.

Trial registration

The review protocol was registered with the Open Science Framework (osf.io/2pcy7).

Background

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), was first discovered in humans in Autumn 2019. By February 2020 it had spread around the world and was declared to be a global pandemic on March the 11^th by the World Health Organization (WHO). The global impact of COVID-19 has been profound and attempts to manage and contain the virus have placed increased pressure on healthcare systems and Emergency Medical Services (EMS) in particular. Lessons learnt from previous pandemics, such as Severe Acute Respiratory Syndrome (SARS-CoV) in 2002, as well as the current COVID-19 pandemic, are essential for informing global pandemic preparedness plans [1], which are key tools for fighting the current and any future pandemics as well.

Emergency Medical Services, in particular, have a vital role within emergency preparedness systems as they are on the front line of responses to the urgent medical needs of patients. There have been few studies investigating EMS’ role in pandemic preparedness prior to the COVID-19 pandemic, but there has been a flurry of evidence since the current pandemic started. For example, one study [2] investigated EMS personnel’s willingness to respond to an influenza outbreak and found that those workers who were concerned, but confident in their abilities and knowledge in flu as well as in workplace safety, were more likely to report for duty. A more recent study [3], aiming to assess EMS’ available resources, including personal protective equipment (PPE) availability, and institutional policies and practices during the COVID-19 pandemic found there was a need for better education and training around clinical symptom recognition and origins of the disease, as well as about decontamination of personal items, such as stethoscopes, and EMS equipment.

In addition, Labrague and colleagues [4] published a systematic review of preparedness levels for future disaster response, but their population of interest was nurses and not EMS personnel. To date, based on our preliminary searches and to our knowledge, there has been no attempt to bring together all the studies that discuss EMS preparedness levels and understand how the evidence translates into practice. Two scoping reviews have been published recently, but one review [5] focused solely on the value of call-centre dispatch and ambulance-based syndromic surveillance for infectious disease detection, whereas the second study [6] only explored applications of quality improvement at public health agencies (not EMS) during the COVID-19 pandemic. Finally, a narrative review [7] investigated the global increase of EMS calls due to COVID-19 and the reasons behind the bottleneck of EMS calls during the early phase of the pandemic. A scoping review of all available evidence on current and past EMS pandemic preparedness interventions, as well as exploring EMS personnel’s experiences and perceptions, would be crucial to identify gaps in the design and implementation of current pandemic preparedness interventions. Furthermore, lessons learnt so far can help provide recommendations for future EMS pandemic preparedness planning.

Aim and research questions

The aim of this scoping review was to identify and present the available quantitative and qualitative evidence of EMS pandemic preparedness, and how this translates into practice. This included studies of EMS pandemic preparedness plans, intervention implementation and evaluations, and importantly perceptions of EMS staff and patients. The findings of this scoping review will be used to inform future research to strengthen EMS pandemic preparedness planning.

Our research questions were:

1. What interventions (e.g., infection control, PPE) have been implemented within the Emergency Medical Services (EMS) in response to/during pandemics and what outcomes are reported relating to such interventions?

2. What evidence is there describing the experiences of EMS staff and patients during pandemics?

Methods

We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist [8] and the Arksey & O’Malley framework [9] for conducting this scoping review. The review protocol was registered with the Open Science Framework (osf.io/2pcy7). See Supporting Information for the completed PRISMA-ScR checklist (S1 PRISMA-ScR Checklist) and a copy of the review protocol (S2 Open Science Framework Protocol Registration).

Inclusion criteria

Studies were eligible for inclusion if they reported on original (primary or secondary data analysis), quantitative, qualitative or mixed-methods studies within which ambulance service/EMS personnel and patients were engaged (including papers with mixed samples, provided that the majority of the participants were EMS staff members and/or patients) during epidemic or pandemic disease outbreaks. For studies to be considered eligible they had to meet the following inclusion criteria: Participants: Ambulance service or EMS staff, pre-hospital patients, attended by ambulance service or EMS staff during epidemics or pandemics and their relatives; Concept/phenomena of interest: any type of intervention implemented in response to epidemics or pandemics within prehospital EMS/ambulance services, as well as the experiences of EMS staff and/or pre-hospital patients during epidemics or pandemics; Context: All global prehospital EMS/ambulance services; Types of study: Quantitative approaches including, but not limited to, interventional studies, feasibility studies, observational studies (cohort and case control), quasi-experimental studies, cross sectional studies and surveys, As well as qualitative designs including, but not limited to, phenomenology, grounded theory, ethnography, and a generic qualitative approach. Finally, multi-methods studies that met the qualitative and/or quantitative inclusion criteria specified above. Data from multi-methods studies were extracted into the respective quantitative and/or qualitative arm of this review and synthesised accordingly.

Studies were excluded if: they were conducted in the emergency department or hospital; the participants were non-EMS personnel (e.g., hospital nurses, General Practitioners, etc.); the interventions were not implemented during an epidemic or pandemic; and/or the papers were published in a language other than English, due to lack of resources for translation of such papers.

Information sources and search strategy

Electronic database searches were performed in MEDLINE, PubMed, CINAHL, Cochrane Library, PsycINFO (including content from PsycARTICLES), and Web of Science Core Collection. All database searches were supplemented with internet searches (i.e., Google Scholar), and forward and backward citation tracking from the included studies and review articles. PROSPERO was also searched for protocols of existing (completed or ongoing) systematic reviews. Databases were searched from inception to July 2022. The search strategy used in all the above databases was a combination of the following keywords and related terms: ambulance; emergency medical services; and pandemic. The search terms were entered using Boolean operators and truncation. Medical Subject Headings (MeSH) were also employed in forming the search strategy. For the full search strategy used for each of the databases, see Table 1.

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Study selection and data charting

All references were reviewed and screened independently by seven reviewers (working in pairs, with one reviewer [DL] forming part of more than one pair of reviewers). Titles and abstracts were initially screened for relevance and final eligibility was assessed through full-text screening against the inclusion criteria, using a pre-designed study selection form. Any disagreement between the reviewers over the eligibility of references was resolved through discussion between the entire team of reviewers.

A standardised, pre-piloted form was used to extract data from the included studies for data synthesis. Extracted information included: study details (title, authors, date, country), methods (aims, objectives, research questions, study design, setting, data collection methods, intervention characteristics,), participant characteristics (demographics, inclusion/exclusion criteria, method of recruitment, sample selection, sample size), and study findings (main and secondary outcomes, data analysis, conclusions). One reviewer extracted data and a second reviewer checked the data extractions for accuracy. Any discrepancies were resolved through discussion.

Data synthesis

A narrative synthesis of all quantitative eligible studies was performed and structured around the study design/methodology adopted and aims, key findings, as well as intervention type and content, where appropriate.

Qualitative data from the qualitative studies were also synthesised narratively and presented thematically, according to meaning and content.

Results

The search strategy identified a total of 22,599 citations and of these 90 were included in this scoping review. Fig 1 presents a flowchart illustrating the results of the selection process.

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Out of the 90 included studies (summarised in Tables 2–9), 71 were purely quantitative and 12 were purely qualitative studies. In addition, four studies were mixed-methods [10–13] that involved both a quantitative and qualitative design. One of these studies [11] used interviews only to describe the model for the deployment process of EMS procedures and, as such, only the quantitative arm of this study will be included in this review. In addition, only the qualitative arm of the study by Petrie and colleagues [12] will be included in this review, as their quantitative arm did not meet our inclusion criteria. Similarly, only the qualitative arm of the study by Vilendrer and colleagues [13] will be included in this review, as this study did not report on any relevant demographic and user data, due to restrictions in their data use agreements. Findings of the study by Alwidyan [10], the fourth mixed methods study, will be presented and discussed under the quantitative and qualitative sections of the results below, depending on which type of design is being presented.

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Two studies [14, 15] conducted surveys with open-ended questions and described their design as a cross-sectional [15] or mixed-methods [14] study, but analysed their findings qualitatively. One study [16] was a reflection/text and opinion paper. The study characteristics and results of these three studies [14–16] will be presented and discussed as qualitative studies.

Seventy four out of the 90 included studies (82.2%) were conducted and published since the COVID-19 pandemic had started.

Quantitative synthesis

Study characteristics.

The 73 quantitative studies (including the quantitative arms of two mixed-methods studies) (Tables 2–8) were published between 2004 and 2022 and were from the USA (n = 24; 32.9%) or Canada (n = 2; 2.7%), Europe (n = 21; 28.8%), Asia (n = 22; 30.1%), and Australia (n = 3; 4.1%), while one Delphi study [17] included an international panel of experts (1.4%).

A large proportion of studies (n = 15; 20.5%) were cross-sectional, questionnaire studies. Sample sizes (excluding those analysing EMS call volumes, dispatches and/or response times) ranged from 10 to 15,339 participants ([18] did not specify their final sample size). One study [19] only included male participants and many studies had either data missing or did not report gender data. Ages ranged from 19 to over 80 years, with many studies not reporting any relevant data. Only 8 studies (11%) included details on their participants’ ethnicity, with the majority identifying as White.

Most studies included combinations of paramedics and Emergency Medical Technicians (EMTs) or other types of EMS personnel (such as nurses or physicians), while some studies defined their participants as emergency prehospital medical care workforce [20, 21], EMS personnel [22, 23] or first responders [24, 25]. One study [17], using a systematic Delphi procedure, included a multidisciplinary group of experts on outbreak preparedness. Various studies included only patients, while two studies included patients and paramedics [26, 27]. Two studies recruited healthy volunteers [28, 29].

Quantitative narrative synthesis.

After considering each included study’s aims, outcomes, and major findings, we developed seven overarching themes, describing EMS pandemic preparedness plans and interventions implemented in response to pandemics.

Willingness to work, treat patients and get vaccinated. Seven studies (9.6%) [2, 10, 20, 30–33] asked EMS staff members about their views on working during disease outbreaks/pandemics and factors influencing their decisions. Most respondents would be willing to report for duty in case of a disease outbreak or pandemic, with corresponding percentages ranging from 56.3% [20] to 93% [2]. One further study [24], conducted since the COVID-19 pandemic begun, found that willingness to respond to alarms was lower during the pandemic (with or without PPE). Despite that, most participants were willing to perform chest compressions, defibrillate using an automated external defibrillator, ventilate a patient using a bag and mask and an appropriate airway filter, and ventilate a patient using a face mask.

Most papers identified predictors of reporting for duty, such as operating in a state that had emergency preparedness laws [34]; first responders knowing and being prepared to perform their responsibilities in a pandemic [2, 32]; knowing that one of their colleagues had been exposed to suspected or a known case of pandemic human influenza [20]; confidence about safety at work [2, 10, 20, 32] or that the employer would provide appropriate training, an effective treatment and vaccine when available [10] or adequate PPE [30, 31]; receiving prophylaxis for themselves and their family members [31, 32]; having adequate knowledge and training for disease outbreaks [2, 20, 30]; being concerned about self or family safety [10, 20, 30, 33]; having family prepared to function in their absence [10]; lack of confidence in emergency health preparedness and lack of PPE availability [33]; and, believing their co-workers were likely to work [32]. Other predictors of a greater likelihood of reporting for duty were younger age, male gender, single status, and having no young children [31].

Finally, one study [35], exploring the COVID-19 vaccination acceptance of EMS personnel, found that 57% of participants were willing to be vaccinated and 27.6% were undecided. Participants who showed higher willingness to be vaccinated tended to be male, of higher education level, older age, and felt more strongly that they were personally burdened by the pandemic.

Preparedness to face pandemics/recommendations. Three cross-sectional, questionnaire studies (4.1%) [3, 18, 33] found that EMS workers exhibited low levels of knowledge and training about infectious diseases, as well as compliance with practices (such as selecting and removing PPE) [3, 33]. Often, they had limited access to PPE equipment and regular decontamination of EMS equipment after each patient contact was not a regular practice [3]. On the contrary, a study by Jadidi and colleagues [18] revealed that Iranian EMS’ efficacy and preparedness levels to face Ebola were higher than standards, as represented by factors such as triage, diagnosis, isolation processes, using PPE, as well as transporting and providing care during transfers.

One study [36] used discrete event simulation models to evaluate the resource requirements during the peak of the pandemic, by estimating number of beds needed in the ED, number of ambulances required to maintain pre-pandemic response times for emergency patients, as well as to study the effects of ED boarding time for COVID-19 patients. They found that a strict testing policy increased the bed requirements in the ED, while it led to decreased ambulance response times. They also showed that when boarding is considered, the effects were most prominent during night and weekends.

One further study [37] developed and evaluated a dedicated paramedic surveillance and quarantine program, during a Severe acute respiratory syndrome (SARS) outbreak. They determined the number of paramedics on quarantine each day, the type of quarantine, and the development of SARS-like symptoms, and concluded that their program could provide a useful means to managing the paramedic resource during that and any future SARS outbreaks.

Finally, Belfroid and colleagues [17] employed a systematic Delphi procedure and presented 18 recommendations for future pandemic preparedness.

Knowledge & education. Thirteen studies (17.8%) [20–22, 32, 33, 38–45] explored issues around EMS staff members’ pandemic knowledge and training.

Most studies [21, 32, 33, 40, 45] found low levels of pandemic-related training and knowledge including that of infection transmission. Most studies [33, 40, 45, 46] found that PPE use was inconsistent and knowledge about PPE requirements low, e.g., how N95 masks worked or the correct PPE removal sequence. Practices employed to alter the environment within the ambulance, such as ensuring the desired airflow when transporting a patient with an airborne illness or disinfection of the ambulance at any time were inconsistent, despite respondents reporting that ambulances were routinely cleaned [40].

Only two studies (2.7%) [38, 42] reported adequate levels of training on patient and practitioner safety related to infectious and communicable diseases (including routes of exposure) [42]; how to screen and provide emergency medical treatment for such patients [42]; and respirator use during the COVID-19 pandemic [38]. The main barriers to adequate awareness/training included part-time employment, providing 9-1-1 response service, working at a non-fire-based EMS agency, and working in a rural setting [38]. Some participants did express an interest in having more quality training and not feeling confident enough to respond to diseases with the magnitude or severity of Ebola virus disease [42].

In addition, four studies (5.5%) [22, 41, 43, 44] investigated the effectiveness of various educational interventions. These interventions were effective in increasing knowledge and behavioural intentions to use respirators, get vaccinated and willingness to report for duty during a potential pandemic [41]; increasing adequate choice of PPE [43, 44], especially for those student paramedics who were also actively working in an ambulance company [44]; and increasing comfort levels in managing respiratory failure in suspected/known COVID-19 patients, as well as non-COVID-19 patients [22].

Finally, one study [39] showed that a simulation software environment (SPECTRa) provided a feasible alternative approach to live prehospital simulation and showed potential for remote healthcare research and training during the COVID-19 pandemic.

Infection risks & control. Three studies (4.1%) focused on the safety of ambulances and their role in EMS crew COVID-19 infections [47–49]. Their results showed that negative pressure ambulances can help decrease the number of new, confirmed COVID-19 cases [47]; that the most frequently contaminated areas in ambulances were the left front door’s outer handle, driver’s handle, gear lever, and mat, the rear door, rear door lining, and handle over the roof [48]; as far as personnel is concerned, the most frequently contaminated areas before the removal of PPE are the lower chest to the belly area, bilateral hands, lower rim of the gown, and shoes, and after PPE removal, traces of fluorescence were observed over the neck, hands, and legs [49]; and that when both crew and patient wore respirators or a cloth mask during a simulated ambulance transfer, these practices reduced predicted mean infection risks by 85% (which was a higher reduction than when only one of them wore a respirator or a cloth mask) [49].

Two further studies (2.7%) [19, 27] examined various factors associated with COVID-19 infection risks in EMS staff members. Results showed that EMS providers’ positive tests for COVID-19 (after having been exposed to patients with COVID-19) were not attributed to occupational exposure from inadequate PPE and that programmatic strategies were associated with a temporal increase in adequate PPE use and a decrease in EMS provider exposures [27]. Results also showed that the factors mostly correlated with the increasing risk of COVID-19 in EMTs were having two EMTs taking care of patients, working with a confirmed case teammate, using personal items (e.g., mobile phone or jewellery) despite protective clothing, contact with the outer surface of clothing while removing PPE, not taking precautions such as seal check after wearing the mask, and not covering the hair with a medical hat [19].

Making improvements regarding resources & PPE. Six studies (8.2%) evaluated the use of improved resources or PPE during COVID-19 [28, 29, 50–53]. Three of these studies [28, 29, 53] found that negative pressure devices (a powered air purifying respirator helmet called AerosolVE; a procedural tent called AerosolVE BioDome; and a portable, reusable, transparent vinyl chloride shield together with suction to generate negative pressure, respectively) can filtrate or reduce aerosol dispersion and exposure to airborne particles, thus, making ambulances potentially safer for EMS personnel. Another study [51] showed that a compact atmospheric plasma device could be used successfully to disinfect ambulances.

In addition, Małysz and colleagues [52] showed that chest compressions with LUCAS 3 can increase the chest compression quality (when compared with manual chest compressions and the TrueCPR), as evidenced by the depth and rate of the compressions, as well as chest recoil. Finally, one study [50] evaluating the influence of PPE with different types of filtering face piece (FFP) masks on attention and dexterity of EMS personnel during basic life support procedures found that neither of these two neuropsychological components were affected by FFP mask use.

Call volumes, ambulance response times and triage (logistics of service delivery). Twenty five studies (34.2%) [11, 24, 54–76] looked at the impact of the COVID-19 pandemic on EMS utilisation and how implementing a variety of COVID-19-related interventions (such as changing coding calls and protocols for assessment or care; developing coronavirus EMS support tracks or web-based self-triage systems, etc.) affected EMS utilisation.

Data analysis of most studies revealed that despite an initial increased demand on EMS resources (especially in relation to call volume), EMS response remained, on the average, relatively controlled, as demonstrated by overall call volume [67, 75], response times [24, 66], daily ambulance diversion rates [68], and the number of out-of-hospital cardiac arrests [67].

Other studies, however, found less positive results related to a sustained increase of EMS calls [58, 69, 70, 73], queue times (though the significant increase in the total EMS call volume was mitigated by the implementation of a coronavirus EMS support track) [60], EMS dispatches [69, 73], EMS processing times [62], prehospital times (except for the scene time of cardiac arrest patients) [68], and response times/interval [70, 72]. Mulyono and colleagues [11], employing an agent-based simulation model, found that the main factors contributing to increased response times were the process of preparing crew and ambulance during the pandemic (relating to the safety procedure in handling patients), service coverage area, traffic density and crew responsiveness. The recommended coverage area for maintaining a low response time was 5 km.

Twelve studies (16.4%) [54–57, 59, 61, 63–65, 71, 74, 76] explored ways of managing the response to emergency calls (during the COVID-19 pandemic) by implementing a range of technology and protocol/systems interventions. These were: applying Business Intelligence to the management of EMS [74]; using the Internet of Things to design a relief supply chain network to address multiple suspected cases during the pandemic [76]; applying a novel Deep Self-Learning Approach to Artificial Orca Algorithm and based on mutation operators to address ambulance dispatching and emergency calls covering problems [55]; applying two Swarm Intelligence Algorithms (Artificial Orca Algorithm and Elephant Herding Optimization) to organize and manage the dispatching of emergency vehicles while respecting the cover of calls during a crisis [56]; running a first-stage optimization model to designate ambulances to serve only infected patients and suspected cases [71]; and, using information and communication technology for emergency medical services (ICT-EMS) systems to improve the transportation of emergency patients [64]. A few interventions [6.8%] also focused on phone or video triage [54, 59, 61, 63, 65], with positive results. A study [57] evaluating the safety of a new EMS protocol directing non-transport of low-acuity patients during the COVID-19 pandemic reported large deviations from the novel non-transport protocol and that several patients had to be admitted to hospital, both when the protocol was used correctly and when it was used incorrectly.

Identifying patients, testing & vaccinations. Ten studies (13.7%) investigated the diagnostic accuracy of EMS in identifying COVID-19 patients [23, 46, 65, 77– 82] or predicting death from pre-hospital vital signs [83].

According to their findings, initial vital signs (with the exception of body temperature) [82], prehospital triage tools [81], and telephone screening processes/surveillance tools used by emergency medical dispatchers [46, 65, 77, 80] had little to moderate predictive value for the identification of COVID-19 patients and/or death.

Other studies (n = 4; 5.5%) have found more encouraging results, such as the lowest recorded pre-hospital oxygen saturation being an independent predictor of mortality in COVID-19 patients [83]; rapid antibody testing helping to diagnose COVID-19 in both asymptomatic and symptomatic EMS personnel [23]; newly developed clinical criteria for identifying COVID-19 patients showing a strong degree of correlation between such emergency transports and new hospitalizations [79]; and, a prehospital sit-stand test identifying stable, suspected COVID-19 patients in risk for later deterioration [78].

Two studies (2.7%) [26, 84] explored how EMS can help facilitate testing for COVID-19 by evaluating the implementation of drive-through COVID-19 testing facilities operated by EMS. Results from both studies showed that COVID-19 testing performed by EMS staff can be efficient and safe to operate for both the staff and the patients [26, 84], as well as cost-effective [84].

Finally, two studies (2.7%) looked at the role of EMS in mass vaccinations and concluded that EMS providers were “uniquely equipped to participate in mass immunization efforts” [85] and played an important role in planning and logistics, patient screening and observation, vaccine preparation and administration, and home vaccination efforts [86].

Qualitative synthesis

Study characteristics.

The 18 qualitative studies (including the qualitative arms of 3 mixed-methods studies, the surveys that analysed their findings qualitatively, and the text and opinion paper) (Table 9) were published between 2018 and 2022 and were predominantly from the USA (33.3%). Sample sizes ranged from 3 to 424 participants and included both male and female participants (27.8% did not report any data on gender). Participants were EMS staff members or community members. One study included EMS providers [16] but did not report any more information about their participants. Two studies [13, 87] also reported the perceptions and experiences of hospital healthcare workers and essential workers (e.g., gas station and grocery store employees), respectively, whose views, however, will not be included in this review, as they did not meet the study’s criteria for inclusion.

Only 12 studies (66.7%) presented information about the participants’ age, with ages ranging from 22 to 78 years old for emergency services personnel; community members’ ages ranged between 35 and 64 years old [88]. Only two studies (11.1%) [13, 89] specified the ethnicity of their participants, with the majority identifying as White.

Most studies were based on individual semi-structured interviews (61.1%) and two studies were PhD theses (11.1%) [10, 90]. One study [16] was a reflection/text and opinion paper that included excerpts of participants but gave no additional information about their data collection methods and did not include any formal analysis. Various methods of analysis were employed, with seven studies using thematic analysis (38.9%).

Qualitative data synthesis.

We used narrative synthesis to summarise and explain the findings of this scoping review.

Motivation, confidence, and feelings about working during pandemics. Working during a pandemic was a traumatic experience for many staff members [16, 91], who felt that they were often faced with significant challenges [13, 16, 91, 92], such as not knowing how to properly treat patients, not feeling safe due to poor PPE or the constant changes in protocols and procedures [16]; being unable to socialise and take comfort in colleagues and friends [12, 16]; as well as having less contact with their families [12, 13, 16, 90].

When asked about their feelings about working during pandemics, EMS personnel reported feeling a myriad of different emotions, such as stress [12, 13, 16, 25, 87, 89–91, 93, 94], anxiety and fear [10, 12, 13, 15, 16, 25, 87–96], as well as feelings of frustration [13, 91, 94] or failure, when they couldn’t save a patient [16]. They also felt they were faced with difficult clinical and ethical decisions in their practice, such as having to decide between prioritising their own safety and the safety/care of the patient [92].

Despite these negative emotions, many participants also felt positive about the experience of caring for patients and reported feeling proud [87], excited [87, 89], or even safe and protected [87]. They also mentioned what they felt were the positive outcomes of pandemics, such as giving them a chance to test their protocols and increasing their team spirit [87], as well as encouraging the use of technology across the healthcare system [91] and using what they’ve learned to help expand prehospital care [16].

As a result, the majority of EMS personnel were willing to report for duty during a pandemic [10, 13, 16, 89] and often felt they had a high professional and ethical obligation to work under any and all situations [10, 13, 16, 88, 89, 91].

There were others who were unwilling to report for work or provide care for patients [10, 88, 89]. Some of the main reasons behind their unwillingness to report for duty were not understanding the cause and modes of transfer of a disease [10], not having been provided with appropriate PPE [10], not feeling confident in their skill set [10], role ambiguity [90], lack of trust in their employer [90], and being concerned about their own or their family’s safety [10, 89, 90]. On the contrary, some of the factors that would positively affect someone’s willingness to report for duty were receiving adequate education and training, having appropriate PPE and equipment, and transparent protocols [10, 89].

Balancing safety and risks. Overall, participants felt that being an EMS staff member was inherently risky work [10, 89, 90, 92, 94] but understood and accepted the risks and felt a duty to perform their jobs despite this [10, 16, 88, 89, 91, 94].

Various participants expressed concerns about their own safety [10, 12, 15, 16, 25, 90–92, 94–96], not having adequate training or PPE [10, 93–95], and the risk of transmitting the disease to their family [10, 12, 13, 15, 16, 25, 87, 89–92, 94–96]. As a result, they often took extra care and precautions to limit their risk of exposure [10, 15, 90]. Similarly, families of EMS personnel were also anxious about their safety and that of their working relative [87]. Finally, one study [97] found that fear of exposure and infection delayed EMS utilisation among patients with chronic health conditions and was also a concern for patients with acute health conditions (although they did continue to access services as required).

Despite participants’ need for and greater feeling of safety with PPE, they also discussed the negative side of wearing PPE while providing care for patients (especially during hot weather), such as experiencing stress and anxiety, profuse sweating, shortness of breath, local pain, restricted movement, or discomfort due to fogging goggles and/or prolonged use of masks [90, 95, 96]. Similarly, patients and their carers also discussed how communicating with EMS staff wearing PPE was challenging, especially for those who were deaf or hard-of-hearing [97].

The limits to personal moral duty. Even though most participants felt that EMS personnel had a duty to report for work, many also felt that there were potential limitations on duty to treat [88, 91]. Some of these acceptable limitations were their own physical health (such as pregnancy or pre-existing chronic conditions) or that of a family member [88, 91]; having mental health problems [88]; being a single caregiver with dependents or when both parents were healthcare workers [88]; as well as work-related factors, such as lack of appropriate PPE, anti-viral medication or appropriate vaccines during infectious disease outbreaks/pandemics, lack of appropriate quarantine facilities away from the home, and lack of relevant training [88].

One paper [88] also discussed community views on risk-taking by EMS personnel. Community members had differing views; some felt that EMS personnel shouldn’t be expected to put themselves at risk to treat patients during a disaster, pandemic, or even on a normal day, whereas others felt that there was a certain level of duty or obligation that comes with being an EMS worker [88].

Need for information, communication, and support. First responders expressed a desire for infectious disease information (such as routes of transmission, incubation period, infection rates, policies and protocols) [10, 90, 93, 95], as well as follow-up information regarding a transported patient’s health status and detailed, localised data that could help them understand the geographic spread of cases throughout their area [13]. However, many also felt that receiving too much and constantly changing information was overwhelming and challenging [13, 14, 91] and that there was a lot of misinformation and lack of reliable data (in regard to COVID-19), which often made them sceptical about the information they were receiving [13, 16, 25, 90–92].

Participants also highlighted the importance of proper communication during disease outbreaks [10, 12–14, 16, 87, 89–91, 94] and how they felt that it was their employer’s responsibility to keep them (and their families) informed with the most up-to-date information about the disease and what they were expected to do [10, 12, 87]. Despite many participants reporting feeling adequately informed by their employers [10, 91], but some felt that there was lack of communication by leadership, management, and politicians [12, 16, 94]. Participants said they would have liked to receive more consistent and transparent information about the disease [12–14, 87, 89–90, 92], the provision of support in case of illness [94], and any protocols for triaging and transporting patients [12, 13, 87, 89, 90, 93, 94]. Others felt that there was lack of communication and collaboration between departments and organisations, such as the emergency department and EMS or the hospital and coordinating centres such as the Centre for Disease Control in the United States [13, 14, 16, 89, 92, 94].

Another topic discussed in various papers was the importance of support from employers, colleagues and managers. Participants felt that building a relationship of trust between colleagues was an important element in the EMS [10, 90] and reported often turning to their colleagues and team managers for emotional support and for stress relief [10, 13, 16, 87]. In contrast, participants found it particularly tough when they could not socialise or take comfort from their teammates, for example during COVID-19 [16].

EMS personnel also recognised that their organisations put effort into their comfort and safety, and knowing that their organisation was continuously reviewing and improving procedures made them feel safe and protected [87]. They also expected organisations to provide them with resources, necessary materials and PPE, training and communication during disease outbreaks [10, 87, 92], as well as prioritising testing to keep them safe and to enable them to return to their duties [13]. In addition, some felt that it was the employer’s responsibility to provide a “safe haven” to their families as well, including offering them vaccines and/or treatment, if available [10]. Some EMS workers, however, felt unsupported and “left alone to fend” for themselves [12–14, 16, 94].

Regarding mental health support, opinions were also divided. Some would have liked to have received such support [12, 87, 93], while others felt either that they did not need it or that they could get it from other sources (e.g., family, friends, colleagues, private counsellors, the service Chaplain, etc.) [91]. Finally, EMS personnel found lack of financial support in the case of illness a major challenge, especially for those who were new in their role or couldn’t take any sick days, and often led to people hesitating to get tested, as they wouldn’t be able to take any time off work [13].

Requirement for resources, training, guidance, evaluation & solutions. Participants felt that adequate and up-to-date training and education were important [10, 12, 87, 89, 95] and could influence their willingness to report for work [10, 89]. Most participants were satisfied with the training they received, as they felt it prepared them well for their tasks [87, 89], while others were not satisfied [10, 12, 89, 90, 91], especially when it was lecture-based and not hands-on training [10].

Participants also felt that having clear, transparent, and simple protocols was equally important [87, 89, 90, 93] and that it helped them remain calm by following the instructions [87]. In addition, lack of transparency about how the protocols were designed [89] and the constant protocol changes (e.g., about PPE) as the pandemic evolved, only added to their anxiety, frustration, and confusion [12–14, 16, 90, 91, 93–95] and made them concerned about whether the new protocols were sufficient [87]. Some also thought that these changes in clinical practice and guidance were rushed [91], that the quality of care was being compromised [91] and they felt ethically challenged, as the new protocols were asking them to deviate from what they were taught [16]. Participants also felt that their organisations and the governments were overall ill prepared to face a pandemic, such as COVID-19 [12, 95].

Regarding the provision of resources and equipment to keep them safe and to ensure that they are able to carry out their job properly, various participants reported not having access to appropriate or up-to-date PPE during the COVID-19 pandemic and that this was a major concern for them [12, 13, 90–92, 94–96]. Participants also mentioned that in some cases EMS workers did not comply to wearing PPE, mainly due to force of habit, not being used to having PPE on, not recognizing when it is the appropriate time to use the PPE, and/or thinking they won’t need them since they may not directly contact the patient [10]; this study, however, was conducted prior to the COVID-19 pandemic. Concern about and frustration with lack of compliance with hand hygiene routines (during the COVID-19 pandemic) was also discussed [15]. The main factors affecting hygiene compliance were the unpredictable work environment, situations where time is critical, worries about the risk of using new protective equipment (e.g., gas masks, which were introduced in the ambulance service during the pandemic), and having initiatives supported by their managers/organisations [15]. Having access to testing was also considered important for workers to be able to return to their duties, but many reported challenges in scheduling testing [13].

Finally, participants made a series of recommendations for future outbreak response. Participants felt that it would be best to have specialised teams dealing with outbreaks, such as a permanent infectious disease response team that would be responsible for maintaining and updating protocols, the training of personnel, and the “institutional readiness of disease outbreaks and epidemics” [89]. Participants also highlighted the importance of continuous training and education for pandemic preparedness [12, 89] and suggested using a tiered training model (or even a peer training approach), where a few selected staff members would be trained comprehensively, who would, in turn, train others based on what their roles would be [89]. They also thought it would be a good idea to have regular “drills for the triage and transport of infectious patients, similar to that of mass casualty and disaster drills”, as well as to have training on how to use different types of PPE, to ensure that everyone is always prepared for a future pandemic [89]. Other suggestions were to have a dedicated app, through which accurate, up-to-date information (including localized infection rates and spread) could be delivered directly to EMS personnel, holding local question and answer sessions, or using social media to keep them informed [13].

Discussion

This scoping review explored the available quantitative and qualitative evidence of EMS pandemic preparedness (i.e., to be able to respond and take action effectively on a personal and organisational level), and how this translates into practice. The findings of the review have shown that the majority of the EMS personnel are prepared and willing to report for duty during pandemics, despite their concerns for their own and their families’ safety and the many challenges they are faced with.

More specifically, participants reported being willing to report for work during pandemics and the main factors impacting their willingness were: their levels of training for and knowledge of disease outbreaks, and confidence in their skills; feeling that it’s their responsibility to work; confidence about safety at work (including adequate PPE, availability of treatment and vaccines); being concerned about their own or their family’s safety; and mistrust with the employer. Results also showed that the participants’ knowledge was often marginal (especially about infection transmission mechanisms and use of PPE), they had limited training on pandemic response, and either had issues accessing appropriate PPE or using PPE consistently. Lack of proper disinfection of the ambulances was also reported. Past studies have also shown moderate levels of perceived preparedness for the next pandemic, especially in reference to training and confidence in skills, of both social workers in hospital settings [98] and nurses [4]. In our review, various educational interventions were found to be effective in improving participants’ knowledge levels and intentions to use PPE, as well as improving management of respiratory failure in COVID-19 patients and could be considered appropriate means of educating EMS personnel on future pandemic preparedness issues.

Numerous studies also looked at infection risks and control and found that negative pressure ambulances can help reduce numbers of new COVID-19 cases; which areas in an ambulance are the most frequently contaminated areas during transfer of a patient with an infectious respiratory disease (including which areas of the EMS workers’ body are most frequently contaminated before and after the removal of PPE); the ability of face masks worn by both crew and patients to reduce predicted mean infection risks; that proper use of appropriate PPE can decrease occupational exposure; a portable, reusable, transparent vinyl chloride shield for use in an ambulance, together with suction to generate negative pressure, can reduce aerosol dispersion and exposure to airborne particle (without interfering with ventilation in the ambulance or endotracheal intubation in the emergency department); and, that chest compressions with LUCAS 3 can increase the chest compression quality. Also, the factors mostly correlated with the increasing risk of COVID-19 in crew members were having two crew members taking care of patients, working with a confirmed case teammate, using personal items (e.g., mobile phone or jewellery) despite protective clothing, contact with the outer surface of clothing while removing PPE, not taking precautions such as seal check after wearing the mask, and not covering the hair with a medical hat.

In addition, many studies looked at the impact of the COVID-19 pandemic on EMS utilisation and found that, although there was an initial increase in call volumes (and sometimes response times), on average, most ambulance dispatches remained relatively controlled (or even decreased in some cases, especially during later waves of the pandemic). Often this was the result of the different interventions that were implemented after the pandemic had started, such as having a coronavirus support track or using Business Intelligence models to identify infection clusters and relocate vehicles and personnel accordingly to these areas where it was more needed, to name a few. A past scoping review [5] on the utility of emergency call centre, dispatch, and ambulance data for syndromic surveillance of infectious diseases also concluded that data timeliness, high level of data standardization, and the clinical value of call-centre dispatch and ambulance data can help detect infectious disease outbreaks.

Other studies explored the diagnostic accuracy of EMS personnel in identifying patients or predicting death from pre-hospital vital signs, as well as how EMS can help facilitate testing for COVID-19 and mass vaccinations. Accordingly, results showed that initial vital signs (with the exception of body temperature) and prehospital triage tools (qSOFA, NEWS, NEWS2 and PRESEP) have little predictive value for the identification of COVID-19 patients or death, intensive care unit admission, and disease severity of COVID-19 patients, respectively. In addition, it was shown that rapid antibody test can help diagnose COVID-19 in both asymptomatic and symptomatic EMS personnel, but sensitivity could be enhanced when used together with other diagnostic methods, such as RT-PCR test or chest CT-scan. Finally, it was shown that EMS staff are uniquely equipped to perform COVID-19 testing and participate in mass immunization efforts efficiently and safely, for both the staff and the patients.

The qualitative synthesis resulted in similar narratives among EMS workers, who felt they had gone through a traumatic experience, especially those working during the COVID-19 pandemic, and had to face various challenges (e.g., insufficient knowledge and training, poor PPE, constant protocol changes, concern regarding their own and their families’ safety, etc.) but were willing to report for duty, as they understood and accepted the risks and felt a duty to perform their jobs. They did, however, feel there were acceptable limitations to this, such as having physical and mental health issues, lack of appropriate PPE, anti-viral medication, or appropriate vaccines, etc. In addition, participants expressed a strong need for reliable, trustworthy information, training, access to adequate and up-to-date PPE, proper communication from their organisations, and transparent protocols. The need for policies that are up-to-date, clear, and transparent was also highlighted by another recent publication [99] that investigated the public health regulations and policies dealing with preparedness and emergency management during the COVID-19 pandemic in Italy. They also concluded that more funds should be allocated in prevention, training, and information activities to make sure that we are better prepared for the next pandemic.

Participants stressed the importance of supportive relationships with significant others and their colleagues, as well as recognising that their organisations put effort into their comfort and safety, which they valued and which made them feel safe. Others, though, felt tired and “left alone to fend” for themselves as they had to perform procedures outside of their job description and scope of practice or felt like they didn’t receive enough support or information about getting tested (for COVID-19) nor any mental health or financial support from their employers. The importance of support (especially organisational support) in safeguarding frontline workers’ mental health and well-being during the COVID-19 pandemic was also highlighted in a recent study [98] that explored the perceived support and pandemic preparedness among social workers in hospital settings in Israel. According to their results, only half of the social workers perceived receiving high levels of support during the COVID-19 pandemic; a finding echoing some of this review’s results as well.

This review has also identified various gaps in current literature and the need for future research across various areas. None of the included studies reported on the experiences and views of patients that had been attended to by EMS during a disease outbreak/pandemic; this could be an area for future research to help us understand better the needs of this population. In addition, the majority of the reviewed studies were conducted in high-income countries, with predominantly White participants. More studies are, therefore, needed in low- and middle-income countries, with participants from diverse ethnic backgrounds, to evaluate whether the same interventions can be successfully implemented across different countries and populations. Further research with more diverse populations is also needed to explore potential factors affecting EMS providers’ experiences, views, and attitudes towards working during pandemics. Equally, it would be crucial to investigate the long-term impact of working in a pandemic on the well-being and working conditions of emergency medical services and how these may be affected by the trajectory of the disease outbreak. Finally, the majority of the included studies did not report any or had missing data on the age, gender and/or ethnicity of their participants. Better reporting is, therefore, needed of demographic characteristics of the participants in published papers in the future.

Strengths and limitations

This is the first scoping review of published studies that discuss EMS preparedness levels and aims to understand how the evidence translates into practice. This review has brought together papers discussing EMS preparedness during various disease outbreaks (including the current COVID-19 pandemic) and evaluating different types of interventions, as well as exploring EMS personnel’s experiences of working during pandemics, and has synthesised them for the first time. The study followed a rigorous pre-specified protocol (registered with Open Science Framework), which ensured that the review process was transparent and replicable. We identified 90 studies for inclusion. The final development of themes (both quantitative and qualitative) was undertaken through discussion with the wider review team, consisting of reviewers from different backgrounds (e.g., medicine, nursing, and psychology).

This scoping review has some limitations. We are still learning to live with COVID-19 and more studies will be conducted and published as a result; therefore, the findings of this review are subject to change as more studies are being added to the existing literature base. Despite our efforts to be as inclusive as possible, studies and journal articles that have not been published yet, or are only available in languages other than English, have not been included in this review. Another limitation of this review was the absence of a subject librarian review of the search strategy, as this would have made for a stronger methodology. That said, many search terms were searched for in full text fields and there were further supplementary searches conducted to identify any additional references, which produced a high number of references to be screened. Finally, our synthesis of the 18 qualitative papers led to five main themes and various sub-themes, but we did not conduct a detailed analysis, such as a content or thematic analysis. Future reviews could focus on, analyse and synthesise EMS personnel’s experiences only and publish these as a systematic review and meta-synthesis study.

Implications for policy and practice

Synthesising this literature has allowed us to explore EMS pandemic preparedness in various countries around the world, as well as to identify what interventions have been successfully implemented and to better understand the experiences of EMS staff during pandemics.

An important aspect of pandemic preparedness is making sure that EMS workers are able and willing to work during pandemics. Our findings have shown that the main factors affecting EMS personnel’s willingness to report for duty are having adequate PPE and having access to vaccines for themselves and, ideally, their families as well. Other important factors were knowing and feeling prepared to perform their responsibilities (including having adequate knowledge and training for disease outbreaks), confidence about safety at work and trust in their employer. EMS organisations, therefore, should make sure they are appropriately equipped with up-to-date PPE and that they offer training on how to correctly use this equipment on a regular basis. Having the funds to procure enough vaccines and treatments, if available, for those who need it would also be essential for making EMS workers feel safer in case of a future pandemic. Participants also highlighted the importance of continuous training and education for pandemic preparedness. Therefore, detailed and frequent training on various aspects of infection control practices would also be advantageous, especially about basic knowledge of infectious diseases (including routes of transmission and signs/symptoms), patient and practitioner safety related to infectious and communicable diseases, and how to properly decontaminate and disinfect ambulances after each patient contact. Conducting regular pandemic exercises or having skill-based drills (similar to that of mass casualty and disaster drills) might also be helpful in increasing EMS personnel’s knowledge levels and maintaining their skills, as this was suggested by the participants as well [89].

Participants also felt that having clear, transparent, and simple protocols was very important and that it helped them remain calm by following the instructions and guidelines, while at the same time knowing that their organisation is continuously reviewing and improving procedures made them feel safe and protected. Hence, EMS organisations should aim to develop agency/department-specific infection control policies and procedures (e.g., PPE requirements and the proper use of masks and respirators) that EMS workers can implement during routine calls, but also during a pandemic. Such initiatives would also increase trust in their employers, which as they stated was an important factor impacting their willingness to report for duty. Misinformation, lack of reliable data/information and communication about the pandemic from their employers was another one of the main concerns of the EMS workers; therefore, providing clear, up-to-date and accurate information (including detailed, localised data that could help them understand the geographic spread of cases throughout their area) on a regular basis would be imperative as well. This process could be facilitated by having a dedicated app or using social media, through which information could be delivered directly to EMS personnel, or even holding local question and answer sessions, as was suggested by the participants themselves [13]. Better communication and collaboration between departments and organisations, such as the emergency department and EMS, would also be helpful in ensuring that there is seamless continuation of care and less frustration for everyone involved.

Most participants also reported feeling stress, fear, anxiety, as well as feelings of frustration or failure, when they couldn’t save a patient. Although opinions were divided and not everyone expressed a need for mental health support, offering such opportunities for employees who need it would be important for their overall well-being. This is true especially given the fact that participants also reported not being able to socialise and take comfort in colleagues, while at the same time having less contact with their families, which they also found to be challenging. Peer support groups that can take place face-to-face or on-line, if needed to maintain social distancing rules, may be an ideal solution not only for the individuals (who have expressed the need for support from their team members and colleagues), but also for EMS organisations, as the financial cost would be minimal. Employers could also support EMS workers further by prioritising testing to keep them safe and to enable them to return to their duties, as well as by offering financial support in the case of illness, as participants also reported being unable to take any time off work in case of exposure and/or infection during the pandemic.

Many of the included papers in this review also implemented interventions that showed evidence of benefits in helping EMS services manage the COVID-19 pandemic and should be considered for further evaluation and adoption. These interventions included negative pressure ambulances and devices [28, 29, 47, 53]; a compact atmospheric plasma device [51]; and, performing chest compressions with the LUCAS 3 mechanical chest compression device [52]. In addition, having a dedicated COVID-19 EMS support track and/or video triage systems were found to be effective in handling the increased need for contact with EMS on call volume during the COVID-19 pandemic [54, 59, 61, 65] and similar triage measures could be applied to better manage future pandemics as well. Using discrete event simulation models [36] or first-stage optimization models [71], swarm intelligence algorithms [55, 56], Business Intelligence models [74] and/or the Internet of Things [76], could also help EMS to successfully manage the response to emergency calls.

Finally, our results showed that EMS staff are uniquely equipped to perform COVID-19 testing and participate in mass immunization efforts efficiently and safely. Therefore, EMS personnel can be a valuable resource in providing further services as well and help increase the number of persons that can be tested (even in more remote, underserved areas), while diminishing exposure to health care workers and other patients as well.

Conclusions

Despite concerns for their own and their families’ safety and the many challenges they were faced with, especially knowledge and training gaps, lack of appropriate PPE and constant protocol changes, EMS personnel were willing and prepared to report for duty during pandemics. Participants also made recommendations for future outbreak response, which should be taken into consideration in order for EMS to be better prepared to respond to any future pandemics.

Supporting information

S1 File. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.

https://doi.org/10.1371/journal.pone.0304672.s001

(DOCX)

S2 File. Ambulance (emergency medical service) interventions in response to pandemics: A scoping review protocol.

https://doi.org/10.1371/journal.pone.0304672.s002

(DOCX)

Acknowledgments

We would like to thank Dr Withanage Iresha Udayangani Jayawickrama and Dr Sarathchandra Kumarawansa for their help conducting the initial searches for this scoping review. We would also like to thank the members of the Community and Health Research Unit (CaHRU) study review group (University of Lincoln) for their valuable comments on a draft of this paper.

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Citation: Laparidou D, Curtis F, Wijegoonewardene N, Akanuwe J, Weligamage DD, Koggalage PD, et al. (2024) Emergency medical service interventions and experiences during pandemics: A scoping review. PLoS ONE 19(8): e0304672. https://doi.org/10.1371/journal.pone.0304672

About the Authors:

Despina Laparidou

Contributed equally to this work with: Despina Laparidou, Ffion Curtis, Nimali Wijegoonewardene

Roles: Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

Affiliation: Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Brayford Pool, Lincoln, United Kingdom

ORICD: https://orcid.org/0000-0002-5427-7422

Ffion Curtis

Contributed equally to this work with: Despina Laparidou, Ffion Curtis, Nimali Wijegoonewardene

Roles: Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Validation, Writing – review & editing

Affiliation: Department of Health Data Science, Liverpool Reviews & Implementation Group (LRiG), Institute of Population Health, University of Liverpool, Liverpool, United Kingdom

ORICD: https://orcid.org/0000-0001-6843-8568

Nimali Wijegoonewardene

Contributed equally to this work with: Despina Laparidou, Ffion Curtis, Nimali Wijegoonewardene

Roles: Formal analysis, Investigation, Writing – review & editing

Affiliations: Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Brayford Pool, Lincoln, United Kingdom, Ministry of Health, Colombo, Sri Lanka

Joseph Akanuwe

Roles: Formal analysis, Investigation, Writing – review & editing

¶‡ JA, DDW, PDK and ANS also contributed equally to this work.

Affiliation: Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Brayford Pool, Lincoln, United Kingdom

Dedunu Dias Weligamage

Roles: Formal analysis, Investigation, Writing – review & editing

¶‡ JA, DDW, PDK and ANS also contributed equally to this work.

Affiliations: Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Brayford Pool, Lincoln, United Kingdom, Ministry of Health, Colombo, Sri Lanka

Prasanna Dinesh Koggalage

Roles: Formal analysis, Investigation, Writing – review & editing

¶‡ JA, DDW, PDK and ANS also contributed equally to this work.

Affiliations: Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Brayford Pool, Lincoln, United Kingdom, Ministry of Health, Colombo, Sri Lanka

ORICD: https://orcid.org/0000-0001-8037-9409

Aloysius Niroshan Siriwardena

Roles: Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Writing – review & editing

E-mail: [email protected]

¶‡ JA, DDW, PDK and ANS also contributed equally to this work.

Affiliation: Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Brayford Pool, Lincoln, United Kingdom

ORICD: https://orcid.org/0000-0003-2484-8201

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