Teamwork and Cultures of Safety

### **Chapter 6**

## Adverse Events Capture Systems, Checklists and Teamwork as Relevant Tools to Reduce Complications and Increase Patients' Safety in Spinal Surgery

*Giovanni Barbanti Brodano, Cristiana Griffoni, Alessandro Ricci, Sandra Giannone, Daniela Francesca Ghisi and Alessandro Gasbarrini*

#### **Abstract**

Adverse events in Hospitals are often related to surgery and they represent a relevant problem in healthcare. Different approaches have been introduced during the last decade to address the problem of patient safety, especially in the surgical environment. The teamwork is crucial in all these actions which aim to decrease adverse events and improve clinical outcomes. We analyze in particular the use of adverse events capture systems in spinal surgery and the use of checklist systems, starting from the Surgical Safety Checklist introduced by the World Health Organization (WHO) in 2008.

**Keywords:** adverse events, checklist, outcome, safety, teamwork

#### **1. Introduction**

In Hospitals adverse events are not rare. Most of these adverse events are related to surgery. The incidence of surgical complications has remained largely unchanged during the past two decades. Inherent complexity in surgery, new technology possibilities, increasing age and comorbidity in patients may contribute to this. The incidence of surgery-related adverse events combined with the increasing volume of surgery results in a relevant healthcare problem [1].

In a review of adverse events incidence, preventability, and outcome conducted by deVries and co-workers [2], the median incidence rate of adverse events was 9.2% with a probable preventability of 43.5%. Adverse events that led to permanent disabilities were 7%.

The most common surgical complications are related to surgical techniques, infections, and postoperative bleeding [3, 4]. Equipment-related failures contribute to a significant part of errors in the operating room and it has been observed that the use of checklists reduces equipment errors by 48.6 to 60.7% [5].

#### *Teamwork in Healthcare*

One of the first large- scale studies on checklists use in healthcare (the Keystone study) was carried out in Michigan in 108 intensive care units, where Provonost and co-workers introduced a series of interventions, including a checklist to improve communications [6]. The intervention reduced venous catheter-related bloodstream infections from 2.7 to 0 after 18 months. However, these results could not be replicated in a large-scale United Kingdom program, revealing a particular attention to the context and implementation strategies in improvement programs [7].

#### **2. The use of surgical safety checklist and other checklist systems**

To improve care and safety for surgical patients, a checklist, similar to those used in aviation, aeronautics and product manufacturing, was developed by the World Health Organization (WHO). The Surgical Safety Checklist (SSC) consists of 19 items and it is used at three critical perioperative moments: induction, incision and before the patient leaves the operating room (**Figure 1**). The items contain an oral confirmation by the surgical team of the completion of some key steps necessary to ensure safe delivery of anesthesia, antibiotic prophylaxis, effective teamwork and other essential practices in surgery [8, 9].

Although several investigators have challenged the efficacy of the SSC, it has shown repeated success in reducing preventable intraoperative and postoperative complications, length of hospital stay and overall mortality [10–12]. In addition, the investigators have concluded that the implementation of the SSC in multiple institutions has improved communication, efficiency, and attention to routine details in the operating room.

In a systematic review published on 2014 Bergs and co-workers [10] analyzed the results reported in six studies to assess the effectiveness of the WHO SSC. The results of this meta-analysis suggest that the WHO SSC reduced postoperative complications, including mortality. Meta-analysis demonstrated a significant effect of the checklist on any complication, mortality and surgical site infection. It also suggested that sites with adequate compliance with aspects of patient's care related to the checklist were more likely to demonstrate a significant reduction in postoperative complications. Haynes and colleagues [13] showed that improvements in postoperative outcomes were associated with improved perception of

#### **Figure 1.**

*World Health Organization- Surgical Safety Checklist (2008).*

#### *Adverse Events Capture Systems, Checklists and Teamwork as Relevant Tools to Reduce… DOI: http://dx.doi.org/10.5772/intechopen.94430*

teamwork and safety climate, suggesting that changes in this attitude may be partially responsible for the effect of the checklist. Also the team's compliance with the checklist is as important as evaluating outcomes.

During the last decades we analyzed the complications occurring in our Spine Surgery Department and reported an overall incidence of complications of 17.3% during three years [14]. Indeed, spinal surgery complications are a relevant and unsolved problem. The incidence of complications in spinal surgery literature ranges between 7% and 20% [15–22].

Nasser et al. [17] performed a systematic evidence-based review of 105 published studies (84 retrospective, 21 prospective) and found a higher incidence of complications (19.9%) in prospective studies compared with retrospective studies (16.1%). The incidence of complications varied widely in spinal surgery literature, even in prospective studies. Rampersaud et al. [23] reported an overall incidence of intraoperative adverse events of 14% (98 adverse events in 700 patients), but only 23 adverse events led to postoperative clinical sequelae. Yadla et al. [16] reported a very high rate of early complications, occurring within 30 days of surgery: global incidence of 53.2%, with a minor complication incidence of 46.4% and a major complication incidence of 21.3%.

It has been also observed that there is no standard definition of complications in spinal surgery literature [23], so it is difficult to compare studies. The Clavien-Dindo and SAVES capture and grading systems [24–26] divide the surgical complications into levels of severity based on the grade of treatment required to face the complication. Glassman et al. classified complications as major or minor: significant complications requiring reoperation or leading to permanent deficit were considered major complications. Other perioperative adverse events with time-limited effect were considered minor complications [27].

To date, few studies have evaluated the effect of complications on clinical outcomes [27–29]. Glassman et al. analyzed a prospective multicenter database for adult spinal deformity to investigate the effects of major and minor complications on disability, pain, postoperative quality of life at 1 year follow up and found that major complications negatively affected the quality of life [27]. However, Fritzell et al. found no significant differences of effects of major and minor complications on 2-years outcomes in three different types of fusion surgery [28]. Grainger et al. examined the relationship between severity of complications and outcomes following Clavien-Dindo classification of complications, and found that the severity of perioperative surgical complications does not appear to influence 1- or 2-years pain and disability outcomes [29]. Lambat et al. performed a large retrospective study and observed that ODI (Oswestry Disability Index) at 2- years follow up was not statistically different between patients having no complications, minor complications or major complications. However, the minimum clinically important difference (MCID) for ODI resulted significantly smaller in the major complication group (31%) than in the minor complication (51%) and no complication groups (65%), demonstrating an impact of complications on the functional outcome [20].

Chen et al. [30] recently performed a 10-week prospective study where SAVES V2 and OrthoSAVES capture systems were used by six orthopedic surgeons and two independent, non-MD clinical reviewers to record adverse events after all elective procedures. They compared the complications rate among groups of patients undergoing spine, hip, knee and shoulder surgery. The first relevant result of this study was the highest rate of complications in spinal surgery compared to the other surgeries; but the most important observation of this study was that overall 99 adverse events were captured by the reviewers, compared with 14 events captured by the surgeons. Surgeons adequately captured major adverse events, but failed to record minor events that were captured by the reviewers; in the spinal surgery group, reviewers captured 45 adverse events versus 8 events captured by surgeons [30].

#### *Teamwork in Healthcare*

Considering the high incidence of complications in spinal surgery and their relevant impact for the patients and the health system, during the last years several authors focused their attention on the risk factors related to the onset of complications and on predictive models of complications after spinal surgery [31–35].

Moreover, several preventive measures have been studied and recently described in order to reduce complications in spinal surgery, concerning intraoperative neuromonitoring, blood loss reduction, infections and thrombosis prophylaxis [36–40]. Sethi and co-workers [41] described the application of Lean methodology in spinal surgery. Lean methodology was developed in the manufacturing industry to increase output and decrease costs and then applied in many areas of health care. The authors illustrated a step-by-step process designed specifically to optimize and standardize preoperative, intraoperative and postoperative care for patients undergoing complex spine surgery and they reported a significant reduction of overall complication rate [41].

We proposed to analyze the impact of the introduction of the WHO Surgical Safety Checklist in our Spine Surgery Department, as preventive measure to reduce complications [14].

We retrospectively evaluated the clinical and radiological charts prospectively collected from 917 patients who underwent a spinal surgery procedure from January 2010 to December 2012. The aim of this study was to compare the incidence of complications between two periods, from January to December 2010 (without checklist) and from January 2011 and December 2012 (with checklist) in order to assess the checklist's effectiveness.

We found no correlation between diagnosis and overall complications' incidence. We found a rate of early complications (arising within 1 month after surgery) of 43.3%, a rate of complications requiring surgical revision of 7.6% and a rate of neurological sequelae causing permanent damage of 2.4%. These types of complications have a relevant impact on the health system and, especially the last two categories, on the patients' quality of life and clinical outcomes.

We observed a reduction of the overall incidence of complications following the introduction of the WHO Safety Surgical Checklist: in 2010 without the use of the checklist, the incidence of complications was 24.2%, while in 2011 and 2012 following the checklist introduction, the incidence of complications was 16.7% and 11.7%, respectively (mean 14.2%).

Despite some limitations of our study, the WHO Surgical Safety Checklist resulted to be effective in reducing complications in our Centre.

We recent analyzed also the rate of re-admission and re-operation following spinal surgery. A systematic review [42] of the data concerning the "thirty-day readmission" in spinal surgery indicated percentages between 4.2% and 7.5%, with a variability associated to the presence of one or more centers in which the study takes place and to the type of vertebral pathologies treated. This high frequency is associated with a significant impact from a social and economic point of view, which primarily affects the patient and the National Health System. The most common cause of re-admission was wound complication (39.3%), even if a pooled analysis of risk factors and causes of re-admission was limited by the lack of reporting in spine literature.

Re-admission is very often associated with a re-intervention, or a re-intervention can also occur within the same hospitalization. Our Center treats a wide variety of spinal diseases of oncological, degenerative, traumatic and infectious origin. Therefore we proposed to analyze the rate of re-intervention and surgical revision in the treatment of these pathologies and the causes of these re-operations.

From January 2017 to December 2019, 1260 surgeries were performed at our Spine Surgery Department. Among these, two patients underwent 5 operations,

#### *Adverse Events Capture Systems, Checklists and Teamwork as Relevant Tools to Reduce… DOI: http://dx.doi.org/10.5772/intechopen.94430*

four patients underwent 4 operations, twenty patients underwent 3 operations, 124 patients underwent 2 operations, for a total of 150 patients who underwent more than one spine surgery in a period of three years in the same center (10.7%).

We are now analyzing the causes of these re-operations, which can be a relapse of the disease in the case of oncological pathologies or, for all diagnosis, they can be complications occurring during the follow up period.

A surgical revision is a particularly relevant aspect in assessing the degree of severity of a complication, due to the impact on patient's recovery, and it is relevant also for the economic impact on the National Health System.

We think that a checklist system should be introduced also during the preoperative and post-operative phases, in order to highlight all the key steps where complications can arise, not only during surgery. The introduction and validation of these checklists, implemented for pre-operative, intra-operative and post-operative phases, should be followed by the identification of targeted actions to prevent complications, improve patients' safety and reduce the economic impact.

Following the WHO Surgical Safety Checklist, a checklist for the complex process of ward round (WR) was developed by Caldwell et al. in 2011 [43] and it has been recently implemented and evaluated through different studies. The prime objective of ward round is to assess the clinical state of the inpatient and plan further management. For WR assessment it is fundamental the gathering of new information and reviewing of information already available. Additional information are provided by verbal communication with the patient and the family, nursing staff, medical colleagues, patient examination, clinical charts, pathology and radiological investigations. Such assessment allows a rational approach to further management including the alteration of therapy, arranging further investigations or surgery, referral to other specialists, planning the discharge. In a busy surgical ward round there is the potential to overlook important aspects of care, their documentation and communication. So the use of a checklist during medical ward round has been described by Caldwell [43] with consideration of key aspects of care being bedside consultation, patient safety, chart review, planning and appropriate documentation. Pitcher et al. [44] implemented and evaluated the WR checklist: they identified the deficiencies in general surgical WRs and the benefits of a checklist approach in overcoming this. Initially, members of the surgical team were unaware of the checklist and some deficiencies were detected. Subsequently, the team was prompted against the checklist and during the ward rounds a designated member of the team acted as 'prompter' if aspects of care were not considered according to the checklist. A structured ward round progress form was developed and it was assessed before and after specific education in its use. This form was based on the original checklist and became an integral part of the medical record. Following the use of the checklist and prompting during ward rounds, a significant improvement occurred for the majority of criteria included in the checklist, all of which reached statistical significance. The introduction of the structured progress form, even with prompting, did not initially improve documentation but this was substantially improved with specific education. The authors concluded that the use of a checklist during surgical ward rounds improved consideration of most key aspects of care and education in the completion of a structured progress form substantially improved documentation. A randomized controlled trial of the impact of surgical WR checklist conducted in a simulated environment showed improved standardization, evidence-based management of post-operative complications and quality of ward round [45].

A WR checklist was introduced also on orthopedic ward round and evaluated by a prospective cohort study [46]. The authors observed that after introduction of the checklist, daily documentation of surgical details improved from 38.6% to 85.3%

of patient encounters. Fasting status documentation improved from 9.1% to 70.6% of patient encounters. Venous thromboembolism prophylaxis documentation increased from 6.8% to 92.6%. Documentation of weight-bearing status improved from 11.4% to 83.8%. Thus, the use of a structured checklist during orthopedic ward rounds led to significant improvement in both the consideration and the documentation of key aspects of surgical care.

These findings were recently confirmed by Krishnamohan and co-workers [47] who implemented and assessed a surgical WR checklist for daily surgical ward rounds. The authors observed that the overall documentation of the six parameters analyzed improved following implementation of the WR checklist (from 26% pre-checklist to 79% post-checklist). In particular, documentation of assessment of fluid balance improved from 8–76%. The key parameters analyzed were: VTE prescribed, Antibiotics reviewed, Fluid balance reviewed, Blood tests reviewed, Patient observations, Drug chart. These selected parameters were identified as often overlooked or inadequately reviewed during surgical WR. The checklist helped bring focus to these aspects of care and the number of adverse events reported decreased following WR checklist implementation. Subsequent audit at 3 months post-checklist implementation maintained improvement with documentation at 72%. The authors concluded that the WR checklist benefits patient safety. It improves communication, documentation and ensure that key issues are not missed at patient assessment on WRs.

#### **3. Conclusions**

The data reported underline the relevance of checklist systems to improve patients' safety and clinical outcomes. Effects on morbidity and mortality after introduction of safety checklists have been investigated in several studies [10, 48–51]. Systematic reviews find evidence in favor of checklist use having effects on patient outcomes such as reduced complications [10, 49, 50], wound infections [50] blood loss [50] and mortality rates [49, 50]. Checklist use suggested improved outcomes in high-risk pediatric surgery in developing countries [51].

Their use also contributes to improved information transfer and communication in different phases of surgery [52]. Very few studies report any negative patient outcome effects when using checklists [53], but implementation requires time and effort [2] because a "culture of safety" is required. Still, some studies report no reduction of complications or mortality [54, 55]. A more recent publication reported a lowered mortality rate but no changes in complication rates [56]. Russ et al. [57] observed that the quality of operating room teamwork and communication was improved due to more sharing of case critical information, better decision-making and team coordination, openness about knowledge gaps, and improved team cohesion. In a climate of greater safety for the patient and improved outcome, the use of checklists should influence the operating room (or ward round) work processes so as to have an impact on patient outcome and in this context the teamwork is crucial.

During the last decade, teamwork has been addressed as interprofessional practice or collaboration and described by attributes of this practice such as: interdependence of professional actions, focus on user needs, negotiation between professionals, shared decision making, mutual respect and trust among professionals, and acknowledgment of the role and work of the different professional groups. Teamwork and interprofessional collaboration are considered as a strategy for effective organization of health care services because the complexity of healthcare requires integration of knowledge and practices from different professional groups. *Adverse Events Capture Systems, Checklists and Teamwork as Relevant Tools to Reduce… DOI: http://dx.doi.org/10.5772/intechopen.94430*

Health organizations in western countries are committed to improving patient safety through education of staff and teamwork education programs, including the use of checklists and other tools dedicated to improving clinical outcomes.

### **Acknowledgements**

The authors thank Carlo Piovani for his helpful collaboration.

### **Funding**

The research was partially funded by the grant "Ricerca Finalizzata 2016" from the Italian Ministry of Health.

### **Conflict of interest**

The authors declare no conflict of interest.

### **Author details**

Giovanni Barbanti Brodano1 , Cristiana Griffoni1 \*, Alessandro Ricci2 , Sandra Giannone2 , Daniela Francesca Ghisi2 and Alessandro Gasbarrini1

1 Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy

2 Department of Anesthesia and Intensive Care, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy

\*Address all correspondence to: cristiana.griffoni@ior.it

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 7**

## Learning from Errors

*Gabor Xantus and Laszlo Zavori*

#### **Abstract**

The authors of this chapter have worked in emergency care in 5 countries on 4 continents in the past 9 years. In their experience, acute care anywhere in the world shares two main features; strong teamwork and tremendous mental, physical, and psychological stress. The significant workload, both on individual and team levels, render the care system vulnerable to human errors, which can unfortunately be detrimental to patients and staff alike. Due to the commonalities it is not surprising that health care professionals tend to make similar mistakes irrespective of economic, cultural, religious aspect or healthcare settings. We opine that mistakes are not necessarily and exclusively bad things, but invaluable opportunities for improvement. In this chapter, the authors aim to introduce the concept of learning from errors to the readers. Numerous studies and books have already been published on the subject, so anyone could rightfully ask, why read another study? The answer is straightforward, unlike other articles, this chapter invites the reader to work together with the authors through a real-world case. The text will guide the reader through the topic painlessly in a step-by-step fashion offering plenty of opportunity to practice and reflect on the newly acquired knowledge. Global healthcare is facing significant changes these days. Learning from errors may be the initial step to help move away from the blame and shame culture and build a new system which should be based on solid partnership and respect between patients and carers. Such a new, supportive and compassionate system could provide higher quality care and at the same time, protect practitioners from burnout and stress ensuring that healthcare jobs are not only work but a life-long fulfilling career.

**Keywords:** human factors, human error, adverse event, risk assessment, root cause analysis, feedback loop

#### **1. Introduction**

What is human error and how can we learn from them?

According to UK hospital literature data, at least one in ten patients is certain to suffer some level of harm during their care [1]. If true, it is a terrifying proposition, resulting in about 600,000 incidents per year in Great Britain alone. This is in comparison to the aviation industry, where fatalities have never exceeded 0.6 cases per million flights (14 deaths) [Civil Aviation Authority]. In the aviation sector, each incident must be investigated by law, however, there are no similar legal obligations for health care providers despite the significantly higher numbers of incidents and fatalities.

How can we improve healthcare related harm? Shall we introduce additional protocols and checklists similar to practice ibn the aviation sector? Does each complaint or error need a thorough analysis to better understand what could have led to the incident at both individual and organisational level? Is this data applicable to

different health care systems or UK specific? If this proportion of harm is not country specific, how can we learn from each other?

**1.1 Adverse event recognition**

*DOI: http://dx.doi.org/10.5772/intechopen.94126*

*Learning from Errors*

**Workbook 1.**

**Box 1.**

steps.

**91**

Result of the usual approach: Result of the ergonomic approach:

*The summary of the clinical incident.*

Result of the repeated ergonomic assessment:

In the UK, Australia, Canada and the USA, dedicated systems are in place to facilitate incident recognition and reporting. Most enable users to anonymously (or named) report any adverse occurrence. The systems are designed to alert man-

In the next paragraphs, we present an incident from a real ED (**Box 1** and **2**). The reader will be asked to review the incident and use their experience to work up the error as normal (according to local protocols/experience). An ergonomic flow chart will then be shown and the reader should compare the two approaches and

**Incident Log entry**: A patient complained to a senior nurse on the Clinical Decision Unit of the Emergency Department during a busy shift. The nurse made an entry to the incident log saying: "*a patient*

*complained that the senior doctor referred her to Mental Health Services without consulting her"*.

ager levels and prompt actions according to pre-set protocols.

**Broader context (for those unfamiliar with UK Mental Health protocols)**

to help people make their own decisions, whenever it is feasible.

any mental health diagnosis) might be seen stigmatising and shameful.

The Mental Capacity Act (MCA) was designed to protect and empower people who may lack the mental capacity to make their own decisions about their care and treatment. It applies to people aged 16 and over. The MCA refers to decisions about day-to-day situations and giving consent to medical interventions including surgery. There are 5 principles of the MCA and all practitioners must act in the best interest of the patients and presume that anybody under their care has the capacity to make a decision themselves, unless it's proved otherwise. Furthermore, any health care worker must make sure

In this case, despite the registrar believing to have acted in the best interest of the patient, he breached the protocols by not discussing his working diagnosis of potential postpartum depression and the steps he deemed necessary to help the patient. As the MCA states people must be encouraged "to express their preferences for care and treatment" the registrar should have discussed all available options detailing the presumed benefit and exploring the patient's understanding of the help offered. In addition, the registrar should have assessed potential cultural barriers, as in some cases, depression (or

In incident management, sometimes multiple answers are available for the same question. To give the benefit of doubt, the reader is asked to repeat the ergonomic exercise using the other arm of the process. If, during the above, the reader

responded that the error was "Intentional Non-Compliance" (i.e., the junior doctor knowingly violated departmental regulations by failing to record vital parameters, to seek senior advice before transferring the patient and did not hand over the patient to the nurse in charge of the clinical decision unit) they should consider choosing the alternative path of "Inadvertent error/incomplete knowledge" (the junior was not aware of the regular transfer process and/or undervalued the patient's condition). One must realise that both solutions (and even a combination of the two) are equally conceivable however, each involves different corrective

mark their thoughts in the below workbook.

The authors opine that there is no single good answer, but rather a series of answers, which together can help to understand and solve the problem of accidental, preventable harm in healthcare. In this chapter, we present a real-life incident and aim to guide the reader to implement both an industrial and a health care related algorithm to recognise, analyse and synthesise the learning points of the exemplary error. We also would like to spark further discussions and invite any interested readers to a best practice sharing session at the end of the chapter. We encourage everybody to join/start any blog in this topic to spread the word about the importance of learning from errors in health care.

The fast pace of modern medicine is mostly driven by patient's demand for a quick fix, however this tempo does not result in a faultless operation. The oftenunreasonable hurry is likely one of the reasons why the emergency speciality has unfortunately claimed a silver medallist position on the podium of litigation, not far behind the surgical disciplines [2, 3]. Clearly, other factors, like the immense stress, the constant pressure to make back-to-back decisions and perform various procedures under severe time pressure are also inherently incident prone. Speed comes at a price that is mostly paid by the patient but often the health care provider as well (second victim). The other element that attracts mistakes is the number of interruptions during the process of care. A typical patient journey in the emergency department includes countless stops, each with a brief handover between providers of different qualifications (ambulance, triage nurse, doctor, etc.). Handovers are knowingly dangerous in medicine. Everyone knows the Chinese whisper when a sentence conveyed ear-to-ear in a line of people. By the time the message reaches the end, the original text is barely recognisable. Unsurprisingly, according to regulatory bodies, one of the most common errors in emergency departments is loss of data [4, 5].

Human errors are events when a planned action fails to achieve the desired result due to a human failure. In this chapter we introduce both an ergonomic based industrial approach and hospital protocols used in the UK. Both methods are excellent not only for recognising an error or even a near miss. They are also useful at mitigating consequential damage, mapping the factors leading to the incident, and also preventing possible future occurrences and instigating the necessary corrective measures (**Figure 1**). The explicit goal of the ergonomic approach is the optimization of equipment design and reduction of work-related stress to minimise chances of human errors (International Civil Aviation Organisation). Even though similar initiatives are seen in medicine, as of yet there is no overarching authority to enforce necessary measures.

#### **Figure 1.**

*Ergonomic flowchart for processing human omission categories.*

#### **1.1 Adverse event recognition**

In the UK, Australia, Canada and the USA, dedicated systems are in place to facilitate incident recognition and reporting. Most enable users to anonymously (or named) report any adverse occurrence. The systems are designed to alert manager levels and prompt actions according to pre-set protocols.

In the next paragraphs, we present an incident from a real ED (**Box 1** and **2**). The reader will be asked to review the incident and use their experience to work up the error as normal (according to local protocols/experience). An ergonomic flow chart will then be shown and the reader should compare the two approaches and mark their thoughts in the below workbook.

**Incident Log entry**: A patient complained to a senior nurse on the Clinical Decision Unit of the Emergency Department during a busy shift. The nurse made an entry to the incident log saying: "*a patient complained that the senior doctor referred her to Mental Health Services without consulting her"*.

#### **Box 1.**

*The summary of the clinical incident.*

#### **Workbook 1.**

Result of the usual approach: Result of the ergonomic approach: Result of the repeated ergonomic assessment:

#### **Broader context (for those unfamiliar with UK Mental Health protocols)**

The Mental Capacity Act (MCA) was designed to protect and empower people who may lack the mental capacity to make their own decisions about their care and treatment. It applies to people aged 16 and over. The MCA refers to decisions about day-to-day situations and giving consent to medical interventions including surgery. There are 5 principles of the MCA and all practitioners must act in the best interest of the patients and presume that anybody under their care has the capacity to make a decision themselves, unless it's proved otherwise. Furthermore, any health care worker must make sure to help people make their own decisions, whenever it is feasible.

In this case, despite the registrar believing to have acted in the best interest of the patient, he breached the protocols by not discussing his working diagnosis of potential postpartum depression and the steps he deemed necessary to help the patient. As the MCA states people must be encouraged "to express their preferences for care and treatment" the registrar should have discussed all available options detailing the presumed benefit and exploring the patient's understanding of the help offered. In addition, the registrar should have assessed potential cultural barriers, as in some cases, depression (or any mental health diagnosis) might be seen stigmatising and shameful.

In incident management, sometimes multiple answers are available for the same question. To give the benefit of doubt, the reader is asked to repeat the ergonomic exercise using the other arm of the process. If, during the above, the reader responded that the error was "Intentional Non-Compliance" (i.e., the junior doctor knowingly violated departmental regulations by failing to record vital parameters, to seek senior advice before transferring the patient and did not hand over the patient to the nurse in charge of the clinical decision unit) they should consider choosing the alternative path of "Inadvertent error/incomplete knowledge" (the junior was not aware of the regular transfer process and/or undervalued the patient's condition). One must realise that both solutions (and even a combination of the two) are equally conceivable however, each involves different corrective steps.

**Example 1**. The patient attended two consecutive days with back pain. She was post-partum (3 weeks) and was alone with her first baby. During her previous attendances she was sent home with analgesia and referral to physio. Last night was admitted for "rest and review" as she claimed that the pain killers were ineffective. In the morning ward round, the patient was seen by a locum registrar, who suspected social isolation (husband was abroad and there was no family support for the patient) and potential post-partum depression. The registrar ran his clinical judgement by the consultant in charge who agreed on referral to social/psychological support. The registrar called social services and was informed by a secretary that postpartum patients are seen by the Crisis Team. The secretary recorded the patient details and promised the registrar that someone will call him back from her team. After the referral was made the registrar tended to his further duties on the Clinical Decision Unit (CDU).

The incident log entry said: "*a patient complained that the senior doctor referred her to Mental Health Services without consulting with her"*.

**Question 1: What type of error do you anticipate?**


#### **Box 2.** *The full extent of the incident.*

#### **1.2 Background events and risk analysis**

Once an incident was recognised, the immediate harm was mitigated the background and context needs further assessment. Again, the health care approach is different to the ergonomic one. Without a detailed understanding of the circumstances and background facts, causes cannot be fully determined. Without fully exploring the causes, potential future recurrence of similar incidents cannot be prevented. Therefore, it is in the best interest of any system to learn the crucial details.

The reader shall review the below two charts (**Figure 2**; **Table 1**) and mark their ideas on risk assessment in Workbook 2.

#### **Workbook 2.**

Ideas generated by the ergonomic approach Ideas generated by the healthcare approach

**Figure 2.** *Ergonomic flow chart for risk assessment.*


#### **Table 1.**

*Incident likelihood and risk scoring (risk scoring = consequence x likelihood).*

#### **1.3 Investigating the causes**

The UK hospital practice has currently advocated three methods to identify causation: the formal "Root Cause Analysis" (RCA), the "fishbone" approach, and the "5 - why" (5 W) method. There are no set rules as to when to implement a certain method, however, a rule of thumb is that an RCA is used to analyse complex, severe, and/or frequently recurring problems, while the "fishbone," or 5 W method, is reserved for simpler incidents [6–8].

As in our present example, the patient did not suffer permanent health impairment and the number of involved of staff was less than 5 people. The 5 W method was used in the investigation process. The advantages of this approach are that it does not take a long time but creates an opportunity for a layered analysis. The technique is simple; the investigator should ask a minimum of 5 questions starting with "Why". If the problem cannot be explored in depth even after the 5th question then either, additional questions can be raised or a new method is needed to investigate further. The disadvantage of the 5 W method is its subjectivity: no matter how unbiased the investigator, their cultural, cognitive, and emotional factors can affect the result. To address this source bias (if resources allow), two independent investigators are advised to be put on the case. Given the length of the article, the fishbone and RCA approach cannot be presented at this time, however, the reader is encouraged to review these methods based on the references provided.

The reader is asked to formulate their own 5 questions and enter in the workbook. Once finished, please review the questions raised by the hospital investigator (see **Table 2**). Compare the questions and make notes of the differences. What does the difference suggest to the reader?

**Table 2** Summary of the given clinical incident according to the 5 W method.

**Workbook 3.**


The differences between the readers and the investigators questions:

1. **Why** was the patient admitted to CDU last night?


Please reflect on the differences


#### **Table 2.**

*Summary of the investigators "5-whys" of the above error.*

#### **1.4 Significance of the adverse events**

The previous paragraphs helped the reader to review a real-world, potentially dangerous incident, identify the involved parties, have a detailed background check, categorise the error leading to the incident, perform a quick risk assessment, and address immediate threats. In the next section, we will determine the learning points and decide who shall learn to prevent further occurrences.

This is a key step in the process, as the severity of any particular incident is determined by the weight of the consequences and the frequency of potential reoccurrence. These evaluation steps will also reveal the nature of necessary corrective actions on both an individual and organisational level. In Anglo-Saxon areas, health care institutions use a very similar nomenclature/protocols for reporting incidents: minor events ("near miss", "quasi-damage", or "minimal damage") should only be reported to the immediate supervisor (as is practical, but preferably within 12 hours), whose task it is to investigate, resolve or take it forward. However, moderate/severe incidents should be reported immediately not only to the line manager, but the director in charge. In most cases, the reporting system automatically notifies the appropriate level. "Serious" or "catastrophic" events should be immediately taken to the hospital directorship level. The reader is asked to review

#### *Learning from Errors DOI: http://dx.doi.org/10.5772/intechopen.94126*


#### **Table 3.**

*Incident likelihood and risk scoring (risk scoring = consequence x likelihood).*

**Table 3**, which summarises the categories used by a UK tertiary hospital. In the workbook please enter the differences between the reader's system and the UK system to reflect on the advantages/disadvantages of both.

#### **Workbook 4.**

Summary of the reader's local system Reflection on differences between the UK and the reader's own system (if applicable)

#### **1.5 Closing the loop, feedback to the team**

Identifying and classifying adverse events, analysing the relevant risks, determining the likelihood of recurrence and determining lessons at both individual and organisational level is pointless without communicating the result to the individuals involved and (while maintaining anonymity) with the entire team. If this step is missed, the opportunity to learn from error will be lost forever, not to mention that the incident will surely reoccur [9].

In the author's experience, the UK is at the forefront of recognising, managing and learning from errors and incidents with a nearly two decade-long history in the NHS. The National Quality Committee issued a document in 2013 (Concordat 2013) promoting the culture of learning from errors, the importance of timely feedback and the culture of candour. While the concordat is mostly a manifesto, another national organisation, the National Reporting and Learning Service, developed a seven-step tool to help with the practical application of this relatively new concept into the day-to-day operation.

However, even the English system has minor flaws. NHS England does not have a uniform reporting system and procedure, rather, it is left to hospitals to choose the best method. Most Trusts have their own classification system, which may differ significantly from one another. Unfortunately, these differences can conceal system-wide problems, so many advocate the need in favour of a unified, national system. Inarguably, a single system, similar to aviation, would simplify detection, facilitate detection and management of adverse events, as well as provide all level healthcare staff with transferable skills that can be applied in practice and used anywhere in the country.

Using **Table 4** as a guide the reader should review the example of a clinical error and mark their recommendation in the workbook. Once the exercise is complete please review their answers against the hospital investigator's recommendations (**Table 5**) and reflect on the differences.

#### **Workbook 5.**


#### **1.6 Barriers to learning from errors?**

In the final section of the chapter we will have a quick trouble-shooting runthrough to identify the potential barriers. At the moment, in the Anglo-Saxon territories incident recognition is based on voluntary reporting hence can only be as effective as often it is used.

The first difficulty stems from the inherent weakness of any self-reporting voluntary system; any non-mandatory, non-punitive, but at the same time nonincentivising activity depends solely on the level of motivation of those carrying out the activity. Not surprisingly, the sensitivity of hospital incident reporting systems (i.e. how many events does the system detect at all) is around 30% [10], while its specificity (i.e. how the detection rate relates to actual errors) is even lower: 14% [11].

To explain the poor sensitivity and specificity, similar answers were found throughout the world, regardless of political setting, religion, culture, or even



**Table 5.**

*The investigators recommendation based on the above NRLS tool.*

#### *Learning from Errors DOI: http://dx.doi.org/10.5772/intechopen.94126*

clinical setting, whether inpatient and outpatient care, hospital or GP practice. This similarity highlights the importance of the human factors in reporting. A USA primary care survey found [12] that the time spent writing a report was inversely proportional to the frequency of reporting. Iranian authors [13] found that hospital workers reported only half of serious medication errors. According to their results, fears of accusations, retaliation, and the reporting burden ("it takes too long to write") were the main disincentives behind non-reporting. It was also clear from the responses that almost all practitioners stated in unison that "there is no need to report if there was no problem with the patient". The barriers of reporting seem to be similar in Canada: according to a hospital study [14], the timing of the reports was proportionate with factors perceived important by the responders: incidents endangering patient or staff safety, while the time spent writing the report, or the user unfriendly reporting interface significantly slowed down reporting speed. According to the study, professional identity, lack of information, unclear organisational relationships, and fear of retaliation also proved to be important barriers. Another Iranian article [15] concluded that the main barriers to reporting were the lack of effective reporting systems, complicated forms and the lack of collegial support. They also concurred with other studies that incidents perceived as minor were less frequently reported. The study highlighted significant differences between genders and occupations: women tend to report earlier than men, and nursing staff are more likely to report in writing than doctors. Most studies emphasised that reporting success was also positively influenced by timely, useful feedback. This is probably a common human trait, and the lack of effective communication of results or recommendations can easily cool an individual's enthusiasm, as no one likes to work unnecessarily.

In conclusion, the success of reporting is proportional to low reporting burden and the accessibility to information. Thus, when designing an ideal system, cognitive- (understanding the importance) and emotional factors (enthusiasm, fear, satisfaction, etc.) as well as technological, organisational, and cultural aspects must be taken in consideration to facilitate easy and efficient reporting.

#### **2. End note, wider context**

By adopting the concept of learning from errors, medicine has taken the initial step to eliminate the "blame and shame" culture. However, there is still a long way ahead before openly admitting mistakes and capitalising on improvement potential of errors become the new norm. To build a new world, where the truth of "to err is human" is rediscovered, the full support of both mass and social media will also be needed. Presently, health-related news in the media can be frightening. Articles and interviews have never highlighted the fact that many important, forward moving changes in medicine were actually triggered by serious, even fatal errors. The attitude of the media and also the public opinion must be changed to acknowledge that it takes enormous courage and honour to openly admit mistakes instead of waiting out the consequences. Such moral strength may drive development in both individual and organisation level. Only such new, non-punitive but supportive systems are likely to be able to overcome deep-rooted emotional barriers such as fear, anxiety, guilt and appraise compassionate performance.

The authors of the chapter are also convinced that medical and media professionals alone will surely not be able to create this new system: the patients must to be given more weight in planning and design of care systems, as ultimately, we are working with them, not for them. In this new structure, patients (and caregivers) are more likely to receive high level of partnership-based carewith practitioners

standing a better chance that a one-off error may not be ruining an otherwise immaculate long service careers of dedicated, talented professionals who dedicate their time and knowledge to helping others [16, 17].

### **3. Tasks and exercises**

#### **3.1 Exercise 1**

What systems are in place in your setting to report harm? How are Datix, RIDDOR and Patient Liaison reports are collated and reported to you and your team? How many entries did you make in the adverse event log during the last year? How many should you have reported?

#### **3.2 Exercise 2**

Please ensure you are familiar with the risk assessment tools in your department? Are there any differences compared comparing to the above model? Is your tool better or worse than the tool above?

#### **3.3 Exercise 3**

How are adverse events dealt with in your organisation? How are the learning points communicated to your team?

#### **3.4 Exercise 4**

Are you aware of the effectiveness of root cause analysis within your organisation? If yes, what is the result?

### **4. Questions to consolidate knowledge**

#### **4.1 Question 1**

How would you manage your team and in similar situation described in Box 2?


#### **4.2 Question 2**

What are the most common strategies to communicate errors and consequent recommendations to the team in your organisation?


*Learning from Errors DOI: http://dx.doi.org/10.5772/intechopen.94126*

### **Author details**

Gabor Xantus<sup>1</sup> \* and Laszlo Zavori<sup>2</sup>

1 Cardiff University, Cardiff, United Kingdom

2 Salisbury NHS Trust, Salisbury, United Kingdom

\*Address all correspondence to: gabor.xantus@gmail.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Vincent, Charles. Essence of patient Safety. Patient Safety. *BMJ Books*. Online: http://www.iarmm.org/ IESRE2012May/Vincent\_Essentials.pdf

[2] https://www.coverys.com/ Knowledge-Center/a-dose-of-insightemergency-department-risks

[3] https://resolution.nhs.uk/wpcontent/uploads/2018/08/NHS-Resolution-Annual-Report-2017-2018. pdf

[4] Friesen, MA et al. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Chapter 34: Handoffs: Implications for Nurses 2008; 156–174

[5] Joint Commission: Patient Safety Systems Chapter 12, Sentinel Event Policy and RCA2. 2018; 41–49

[6] Root Cause Analysis. Institute for Health Care Improvement. Online. Available at: https://www.med.unc.edu/ ihqi/resources/root-cause-analysis/

[7] Cause and effect diagram. Institute for Health Care Improvement. Online. Available at: http://www.ihi.org/ resources/Pages/Tools/CauseandEffect Diagram.aspx

[8] 5 Whys: finding the root cause. Institute for Health Care Improvement. Online. Available at: http://www.ihi. org/resources/Pages/Tools/5-Whys-Finding-the-Root-Cause.aspx

[9] Murf HJ, Patel VL, Hripcsak G. et al. Detecting adverse events for patient safety research: a review of current methodologies. Journal of Biomedical Informatics 2003; 36(1): 131–143

[10] Hewitt T. és Chreim S. Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting. BMJ Quality and Safety 2015; 24(5): 303–310.

[11] Cullen DL, Bates DW, Small SD. et al. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv. 2011;(12):541–52

[12] Elder NC, Graham D, Brandt E. et al. Barriers and Motivators for Making Error Reports from Family Medicine Offices: A Report from the American Academy of Family Physicians National Research Network J Am Board fam Med. 2007;20(2):115–123

[13] Bayazidi S, Zarezadeh Y, Zamanzadeh V. et al. Medication Error Reporting Rate and its Barriers and Facilitators among Nurses Journal of Caring Science 2012; 1(4): 231–236

[14] Hartnell N, MacKinnon N, Sketris I. et al. Identifying, Understanding and Overcoming Barriers to Medication Error Reporting in Hospitals: A Focus Group Study. BMJ Qual Staf. 2012; 21 (5):361–368.

[15] Pooralaj J, Rezaie S, Aghighi N. Barriers to medical reporting. International Journal of Preventive Medicine 2015; (6):97–104

[16] Z. Wolf, R. Hughes. 2015 Patient Safety and Quality: An Evidence-Based Handbook for Nurses**.** Chapter 35. Error Reporting and Disclosure. 333–379

[17] Wu AW. Medical error: the second victim. BMJ 2018; (320):726–727

Section 3

Teamwork Implementation: Case Specifics

#### **Chapter 8**

## Teamwork in a Surgical Department

*Nikolai Ramadanov*

#### **Abstract**

Teamwork is essential in surgery. A surgeon alone cannot fulfill his daily tasks. Surgical departments are divided into surgical teams: the surgical team in the operating theater, the surgical ward team, and the surgical emergency team. The common task of those teams is adequate patient care. The characteristics of team members describe necessary abilities such as: open communication, effective coordination skills, collaboration willingness, interdependency, mutual performance monitoring, backup behavior, adaptability, team orientation, and personality type. Team processes are recurring and ongoing short-term courses that occur in the team. The team developmental model separates the development of a team in four stages over a longer period of time. In the last stage, the team reaches the highest level of teamwork performance. Each team must be assessed for their nontechnical skills with team measurement tools. Surgical teams are insufficiently measured. There are possible disadvantages in teamwork, which must be considered and discussed versus the obvious benefits. Leadership is a process where the leading team member sets the direction for the others. There are different styles of leadership, whereby the dominant role of the leader is more or less pronounced. Leadership and teamwork are not contradicting characteristics of teams in the surgical department.

**Keywords:** teamwork, surgical department, leadership, surgical ward, operating theater

#### **1. Introduction**

Surgery is a major medical specialty that uses manual techniques to treat a pathological condition in patients. The classic surgical department of a hospital requires operating theaters with a professional surgical team to perform operations. A surgical team is made up of a surgeon, a surgeon's assistant, an anesthetist, a nurse anesthetist, a circulating nurse, and a surgical technologist. The surgical ward is occupied by those patients who have already undergone surgery, as well as those who are about to or might undergo surgery. These patients are cared for by the surgical ward team. A surgical ward team is composed of at least one surgeon and one surgical ward nurse. Furthermore, the classic surgical department often provides physicians for the treatment of emergency patients in the emergency room or supports emergency physicians with consultations in surgical emergency cases. Teams are obviously essential in all areas of the surgical department, since a single surgeon without additional personal support cannot work effectively.

#### **2. Collaborative effort of a team to achieve a common goal**

The collective effort of a group of people, a team, to achieve a common goal is called teamwork [1, 2]. Teamwork is used in any aspect of life where a group of people are working together for a common goal [1, 2]. Teamwork is commonly applied in sports, in industrial organizations, in school, in political parties and healthcare system. A team consists at least of two members. The team size is fixed, or it can vary depending upon the phase and complexity of the common goal. Still, every member must have a defined role within the team in order to be productive and to have a clear purpose within the team [3, 4]. The level of teamwork varies from low to high depending on the aspect of life it is applied. For example, soccer requires a high level of teamwork, whereas tennis requires significantly less teamwork. Good teamwork is linked to improved patient outcomes, better medical staff satisfaction and a reduced incidence of burnouts [5–7]. On the other hand, worse teamwork is linked to poorer patient outcomes due to adverse events, lack of coordination and higher costs [8–10]. Improvement of teamwork ability in operating theaters leads to reduced technical errors [11] and lower perioperative mortality [12]. However, most medical workers lack adequate training in teamwork in healthcare [13]. Some authors call for an emphasis on teamwork training in medical education [14]. In contrast to teamwork in acute cases, teamwork in nonacute patient cases is rarely trained. As chronic diseases place an increasing burden on health systems [15–17], the lack of team training needs to be adapted for long-term treatments [18].

Over the past decade, the efforts to perform better surgical performance increased [19]. Expectations for more transparency from operation results [20], better patient satisfaction and error reduction are rising [19]. In the context of our ongoing strive and expectations to improve health care, the facts paint a troubling picture. Operating theaters are a challenging area in the surgical department where human error can cause a great iatrogenic harm in a hospital [21, 22]. These unintentional adverse events have been reported to be up to 11% in British hospitals [23]. In 1999 the US Institute of Medicine estimated that 44,000 to 98,000 deaths occur in US hospitals annually, at least partially due to avoidable adverse events [24]. Up to two thirds of these events are due to surgical care [25, 26]. Communication errors have been identified as one of the main causes of these adverse events [24, 27]. Furthermore, e.g. it was reported that medication errors in emergency medicine of up to 31.1% were caused by surgeons and internists [28]. Communication problems in the emergency teams are discussed as a possible cause of incorrect drug administration. There have already been successes. E.g. promoting safety checklists has enhanced patient outcomes and reduced errors by improving teamwork [29]. In surgery in particular, the World Health Organization (WHO) has drawn up a safety checklist to enhance teamwork [30]. The improvement of teamwork, that is, nontechnical skills, might be one possible approach to achieving these goals.

The following pages are intended to give the reader an overview of teamwork in the surgical department. This chapter will clearly define the functions of the team members as well as different team constellations. It will describe the main characteristics of the team members. It will explain the team processes and the team development model. It will propose measurement tools for evaluating teamwork. It will discuss the benefits and drawbacks of teamwork and the necessity of strict leadership in the surgical department. It will propose approaches for a better patient outcome by improving teamwork.

### **3. Teams in the surgical department**

Teamwork is essential in surgery. A surgeon alone cannot adequately fulfill his daily tasks, neither in the operating theater nor on the surgical ward. Classic surgical departments consist of several different types of surgical teams with different tasks in everyday hospital life. The common task of those teams is the adequate care for their patients. In general, we can distinguish between three important teams. There is the surgical team in the operating theater, the surgical ward team and the emergency surgical team.

#### **3.1 The surgical team in operating theater**

The operating team in the operating room consists of a surgeon, an anesthetist, a surgeon's assistant, a nurse anesthetist, a circulating nurse, and a surgical technologist. There is a clearly structured hierarchy in the team in the order of the members just mentioned. The tasks of each member are clearly defined. The level of leadership is particularly pronounced in the surgical team in operating theater [31]. The work of the surgical team has a direct impact on patient outcome. The privilege and burden of decision-making is primarily focused on the surgeon. The overall environment in the operating theater, the performance and the collaboration between the individual team members largely depend on the behavior, knowledge and interpersonal skills of the surgeon. The level of stress in the operating room is much higher compared to teams in other areas of life. It is therefore of the utmost importance that every member, apart from the self-evident technical competence and preparation, has a high level of teamwork and reliability. The surgical team in the operating theater is a very well-coordinated and professional team. Beginners are subjected to a comprehensive and strictly controlled training until they reach the stage of being able to master their part of the task with confidence. Frequent changes to the members of the core team must be avoided. They negatively affect surgical performance [32]. Frequent changes of core team members must be avoided. They have a negative influence on surgical performance [32].

#### *3.1.1 Surgeon*

The surgeon is a physician with completed residency in surgery, who possesses all certifications required for practicing general or specialized surgery. He often is specialized in a particular area of surgery such as abdominal surgery, trauma surgery, pediatric surgery, vascular surgery, thoracic surgery, plastic surgery and cardiac surgery. The task of the surgeon is primarily to lead the operation and the surgical team. Furthermore, the surgeon needs to have full knowledge of the operational procedure and the instruments required. Especially the surgeon bears the responsibility for the successful outcome of the operation. Therefore, his leadership role in such an important team brings him advantages and a great burden at the same time.

#### *3.1.2 Anesthetist*

The anesthetist is a physician with completed residency in anesthesiology, who possesses all certifications required for performing narcosis and local anesthesia. The professional interest and responsibility of the anesthetist extends to the patient's overall health before, during and after surgery. In addition to ensuring a

#### *Teamwork in Healthcare*

painless operation, the most important task of the anesthetist is to monitor and maintain the vital functions of the patient during the operation. Constant collegial communication and feedback in both directions is absolutely necessary between anesthetist and surgeon. Criticism of communication difficulties comes from both sides.

#### *3.1.3 Surgical assistant*

The role of the surgical assistant is held by different members of the team. On the one hand, resident physicians assist in operations as part of their surgical training, on the other hand, this role can be assumed by registered nurse first assistants. The surgical assistant receives clear and unambiguous instructions from the surgeon. The participation of the surgical assistant must not be limited to a mere passive presence at the operating table. It is an active responsible assignment with constant communication with the surgeon leading the operation.

#### *3.1.4 Nurse anesthetist*

The nurse anesthetist is an advanced practice registered nurse. She supports the anesthetist before, during and after surgery. The nurse anesthetist receives clear and unambiguous instructions from the anesthetist. Constant communication and feedback with the anesthetist is absolutely necessary.

#### *3.1.5 Surgical technologist*

Surgical technologists are trained in numerous types of operations. They are able to assume the next steps in the operational procedure in order to provide the surgeon with the necessary instruments without delay. This helps the surgeon to focus adequately on surgery. The surgical technologists are registered nurses or other medical staff with an appropriate education. They receive clear and unambiguous instructions from the surgeon. Constant communication and feedback with the surgeon is absolutely necessary.

#### *3.1.6 Circulating nurse*

Circulating nurses take care of the procurement of instruments and surgical accessories. The circulating nurse receives from the surgical technologist or from the surgeon directly. Constant communication and feedback with the surgical technologist is absolutely necessary.

#### **3.2 The surgical ward team**

The surgical ward team consists of at least one surgeon and one nurse. The team is led by a surgical consultant or a surgical registrar [33]. The surgical registrar must have the guaranteed possibility to consult the chief surgeon for pending questions. This team conducts the daily ward round of the patients in the surgical ward and takes care of the resulting ward work. The surgical ward round is a complex process [33]. Sometimes it lasts several hours until all parameters in every patient case are assessed completely [33]. It is advantageous if the individual members of the surgical ward team do not change too often, e.g. for at least a week, as this will interrupt the continuity of the individual patient cases. Wound care, dressing changes and wraps must always be made by both the surgeon and the nurse. Otherwise mandatory hygienic rules and sterility cannot be adhered to. Once again, constant collegial communication and feedback in both directions between surgeon and nurse is absolutely necessary for the team.

#### **3.3 The emergency surgical team**

During normal course of action in the emergency room, the emergency surgical team consists of a physician, who is a surgeon or an emergency physician with a background surgical consultant, and a registered emergency nurse. When treating polytraumatized patients, the general or trauma surgeon is the trauma leader. The shock room supply follows ATLS guidelines [34]. Since the polytraumatized patient is in life-threatening condition, the surgeon's leadership role becomes even more important than in surgical team constellations in other areas. Having the decisionmaking power, the surgeon bears the greatest responsibility for the patient's outcome. The surgeon depends on a competent and reliable team to achieve the common goal. However, teamwork is a key component to the success of the emergency surgery team.

#### **4. Characteristics of team members**

The characteristics of the team members describe necessary abilities, which are a prerequisite for the proper functioning of the team. A sufficient level of professional and technical competence and preparation is a matter of course. However, nontechnical skills are just as important for teamwork.

Open communication and effective coordination skills are required to avoid conflicts, confusion and overstepping boundaries or to resolve existing conflicts healthy [35]. Collaboration willingness is required to complete tasks on time and to share the workload fairly. Furthermore, a high level of interdependency is required to maintain trust, reliability and risk taking. Mutual performance monitoring describes the ability to understand the intentions, roles, and responsibilities of other team members [36]. In this way members can closely monitor performance of others for the purpose of common goal [37]. Backup behavior describes the ability to look after the needs of other team members and to ensure balance during times of increased workload [36]. Adaptability describes the ability of team members to adapt their work to feedback from other team members in order to achieve the common goal [38]. This characteristic requires flexibility. Every team member must be able to adequately response to changing conditions [36]. Team orientation describes the ability to prioritize team goals over individual goals and to respect different opinions [37, 39, 40].

The motivation of the team members has to be present and preserved. Clear and attainable goals must be set. Satisfactory education and career opportunities must be promoted for residents and other team members. Further requirements are the willingness to balanced member contributions, mutual support, effort, and cohesion [41]. The personality type of the team members is a characteristic that cannot be trained. It can only be adjusted to a certain extent. During the hiring of the team member, care must be taken to ensure that they complement and enrich the team and that their specific personality type suits the team. Unsuitable personality type constellation in the team has to be corrected by cancelation or rotations of team members. Here, a proven method of measuring teamwork in people wanting to join a team can help out. The knowledge, skills, and abilities teamwork test (KSA) was introduced in 1994 by Stevens [42]. In a 35-point test it assesses 14 individual KSA requirements for teamwork. The KSA focuses on team-oriented situations, which makes it suitable for evaluating teamwork and team-specific behavior, determining the level of teamwork and finding ways to improve communication.

#### **5. Team processes in the surgical department**

Team processes are recurring and ongoing short-term courses that occur in the team. The following specific teamwork processes are grouped into three categories: transition processes, action processes and interpersonal processes [43, 44]. Consciously going through these processes by the team leads to a general improvement in performance by improving collaboration, coordination, and communication of the team members [45]. Action processes occur when the team takes tangible steps to achieve their goals. The progress toward the goals is monitored by responsible team members. Transition processes take place between periods of action. During the transition process, the team assesses its overall performance. The team members give feedback to each other and try to improve the upcoming action process. The interpersonal process is an ongoing process in which team members have to communicate all their positive and/or negative opinions about other team members or about the team's performance.

#### **6. Team developmental model**

The team developmental model proposes to separate the development of a team in four stages over a longer period of time: forming, storming, norming, and performing [46]. There are different levels of teamwork in each stage. The forming stage is characterized by mistrust, lack of risk-taking, approach and avoidance attempts of the new team members. There is an internal conflict between members who seek their place among themselves. This stage has a low level of teamwork performance. The storming stage is the stage of deeper conflicts. There is competition for power and authority between team members. This stage has a varying level of teamwork performance, which is predictive for the future of the team. The norming stage is characterized by rising levels of interdependence, team spirit and reliability. This stage has a high level of teamwork performance. The performing stage is the last stage of team development. It is characterized by a satisfactory environment in which the team is able to accomplish its tasks most effectively and successfully. This stage has the highest level of teamwork performance.

#### **7. Measuring and training of teamwork**

Each team must be regularly assessed for their nontechnical skills. The causes of good and bad team results must be identified in the characteristics of the team members. Feedback must be given to all team members. The identified weaknesses or strengths in the characteristics of the team members can thus be corrected or promoted. To implement this task, tools had to be developed that allow nontechnical skills of a team to be measured. Numerous such measurement tools have so far been developed for teams in general and have been improved over time. With the increasing awareness that teamwork is fundamental to the outcome of surgical patients [47], progress has also been made in measurement of nontechnical surgical team skills over the past decade. However, experience shows that in practice surgical teams are insufficiently and inconsistently measured [47]. The possibility of training teamwork with serious improvement of the team performance is questionable. While some authors recommend regular team training [14, 48], a systematic review of literature from 2011 with 1036 identified relevant abstracts and 14 articles (four randomized studies and 10 nonrandomized studies) analyzed in detail came to the conclusion that evidence for the technical or clinical benefits of teamwork training in medicine is

#### *Teamwork in a Surgical Department DOI: http://dx.doi.org/10.5772/intechopen.93698*

insufficient [49]. Another systematic review of literature from 2018 stated that there is insufficient evidence to support the hypothesis that teamwork training interventions improve patient outcomes [19]. One could conclude from this that the personality type of the team members plays a very important role, as this is the main characteristic that can hardly be changed or trained. Candidates wishing to join the team must therefore be carefully screened for their suitability with the rest of the team.

#### **7.1 Measuring tools for the surgical team**

Current literature shows that teamwork disruptions, communication errors, cultural and hierarchical barriers lead to safety deficiencies in the operating rooms [50–53]. Furthermore, a systematic review of the literature from 2012 with 28 included studies showed a strong correlation between teamwork failure and technical errors during surgery [54]. A control instrument was required. Several tools have been developed to evaluate teamwork in operating theaters based on direct observation or video analysis [50, 55–63]. In a current systematic review of 2121 searched references and 14 studies included, two assessment tools were identified to measure effectively the nontechnical skills of the surgical team in the operating theater: The Observational Teamwork Assessment for Surgery (OTAS) and Operating Theater Team Non-Technical Skills Assessment Tool (NOTECHS) [47]. The criticism of both tools is that they rely on the questionable assumption that the team performance equals the sum of performances of the team members [47]. The Observational Teamwork Assessment for Surgery was introduced in 2009 by Sevdalis [55] and validated in 2010 by Hull [56]. OTAS consists of 15 items with a 7-point scale and assesses teamwork-related task checklists and teamwork-related behaviors [55]. The validity and reliability of the NOTECHS tool was demonstrated in live operating theater environments in 2009 by Mishra [57]. The tool was restructured and improved in 2014 by Robertson [57]. The new NOTECHS II tool offers a higher level of precision and a higher measuring sensitivity [58]. Another systematic review of iterature from 2015 with 25 studies included concluded that the Nontechnical Skills for Surgeons (NOTSS) assessment was the tool with the highest level of validity, reliability, and acceptability [64]. The NOTSS assesses situation awareness, decision-making, communication, teamwork, and leadership in a 4-point numeric scale system [65, 66]. A systematic review of literature from 2013 indicated that safety checklists are beneficial for teamwork and communication in the operating theater [67]. This may be one mechanism through which patient outcomes are improved [67]. The results of another systematic review and metaanalysis from 2014 with 19 included studies found that surgical safety checklists improve teamwork and communication, reduce morbidity and mortality [68].

#### **7.2 Measuring tools for the surgical ward team**

Teamwork in the surgical ward is as important as in the operating theater. In an assessment of patient risks associated with poor communication in surgical care the following problems were detected: communication during the surgical ward round is often limited between patient and physician, with nurses making little contribution [69]. Nurses sometimes have important additional information about patients. Unlike physicians, they monitor patients' daily activities. Therefore, only surgical ward rounds with an integrated assessment by different professional groups, including nurses, allow a complete collection of the important and necessary patient information [69]. Up to two thirds of the deadly events in hospitals are due to surgical care [25, 26]. Communication errors have been identified as the main cause of these adverse events [24, 27]. A study on surgical treatment errors due to

communication breakdown showed that their occurrence is equally distributed across the continuum of care, before, during and after surgery [51]. Despite this knowledge about the distribution of adverse events, there is sparse literature on the measurement of teamwork quality in the surgical ward. Filling this large gap in science will show at which points in the surgical ward improvements in teamwork are necessary. In 2019, Krishnamohan introduced a surgical ward round checklist to monitor documentation [33]. It is claimed to improve communication between team members in the surgical ward team [33]. In 2014, Hull introduced a combined assessment toolkit for technical and nontechnical team skills in surgical ward care [70]. It consists of a novel clinical checklist for ward care (Clinical Skills Assessment for Ward Care); a novel team assessment scale for ward rounds (Teamwork Skills Assessment for Ward Care); and a revised version of a physician-patient interaction scale (Physician-Patient Interaction Global Rating Scale) [70]. It provides a systematic assessment of the quality and safety of surgical care and can be used to check and train residents' skills and performance.

#### **7.3 Measuring tools for the emergency surgical team**

The surgical team in the emergency room is often exposed to critical situations. Managing patients in a life-threatening condition is probably the greatest responsibility of medical staff. These teams often consist of interdisciplinary medical staff which is exposed to the challenge to work simultaneously on the treatment of critically ill patients [71]. Wrong decisions quickly lead to fatal consequences. For this reason, in addition to necessary knowledge and experience, strict leadership of the team is required. Only then can clear and quick decisions be made and unambiguous instructions given to the team. Leadership skills are highlighted in advanced life support training and have shown beneficial results in simulated and clinical resuscitation scenarios [72]. A study of 106 adult resuscitation team events with three or more team members over a 10-month period found a need for leadership training [73]. Emergency teams must develop their leadership skills through training and reflective debriefing [73]. Nevertheless, teamwork is indispensable again. A promising way to improve quality in emergency teams is to use nontechnical skills that aim to address human factors by improving leadership, communication, and decision-making [72]. Assessments to evaluate the nontechnical skills of the team are essential to reduce medical errors and improve team performance [71]. In a systematic review of literature from 2016 10 assessment tools for nontechnical skills of hospital action teams were identified [71]. Unfortunately, the validity of these assessment tools to measure the nontechnical performance is limited [71]. A feasible, valid, and reliable measuring tool is the Team Emergency Assessment Measure (TEAM) [73].

#### **8. Benefits and disadvantages of teamwork**

Despite the numerous studies that have found advantages in the use of nontechnical skills in surgery, possible disadvantages are still being discussed [74, 75]. Over-focusing on teamwork can prevent teams from peaking. On the one hand, this can affect the whole team or, more often, individual team members who, like the faster animals in a moving herd, wait for the slower ones. In this way more competitive and talented team members can be disadvantaged in favor of the team and their development can be slowed down. One can certainly imagine that the desire and pursuit of professional self-actualization and even showing off is more strongly expressed among surgeons than among other groups of physicians. Forced

#### *Teamwork in a Surgical Department DOI: http://dx.doi.org/10.5772/intechopen.93698*

commitment to teamwork might reduce the autonomy and individualism of some team members. In other cases, the workload is unevenly distributed, with some team members doing more work and others less. Therefore, the aim of the team leader and of all team members must be to avoid such unfair events. All of these events are possible reasons for conflict in the team. The resulting conflicts prevent the team from achieving the common goal. These potential problems in the team should be considered. A team needs to create conditions for healthy team competition. This can help keep team members motivated, outperform the team average and not suppress individual talents. Again, taking into account the professional development of individual team members must not impair the team cooperation, as it is known that team cooperation is more often associated with very successful and effective teams [76, 77].

Still, the distinct advantages in teamwork in the surgical department must be emphasized. A combined problem-solving effort of the team has surely more potential than an individual [78]. Another advantage of teamwork is building relationships. The pursuit of a common goal leads to greater cohesion, which improves the team's performance [43, 78]. Distinct individual qualities of a team member can also be advantageous in case that the knowledge and skills are offered to improve other team members.

#### **9. Leadership and teamwork**

Team leadership describes the ability to coordinate team activities, to distribute tasks fairly, to evaluate performance, to provide feedback and in this way to enhance the team performance [37, 39]. Leadership is a process where the leading team member sets the direction for one or more team members and helps them improve their performance [79]. Positive leadership skills lead to better satisfaction of the medical staff, higher motivation of team members, increased staff retention, and improved performance [80–83]. Beneficial team leadership leads to increased patient satisfaction and reduced adverse events [84–86].

There are different styles of leadership [87], whereby the dominant role of the leader is more or less pronounced. The style of leadership indicates the level of authority of the team leader. Under strict leadership there is less freedom and leeway for subordinate team members. Strict leadership is based on a pronounced hierarchy in the team, led by an authoritarian leader with subordinate followers. On the other hand, servant leadership is a style in leadership where leaders serve their followers [88–90]. Servant leaders try to build a stable organization, bring out the best performance and serve the team [91]. A detailed comparison of lean and servant leadership is given in a systematic review of literature of 29 articles [92]. A systematic review of literature with 18 articles included found that leadership styles were strongly correlated with quality in care, both for the patients and medical staff [93]. Finally, leadership and teamwork must not be seen as contradicting characteristics of teams in the surgical department. Strict leadership does not automatically exclude the need for a functioning team. Every style of leadership and even strict leadership depends on the team members and on their differently led team.

#### **10. Conclusion**

Teamwork is essential in surgery. A surgeon alone cannot adequately fulfill his daily tasks, neither in the operating theater nor in the surgical ward nor in the emergency department (**Table 1**). The teamwork, that is, nontechnical skills,


#### **Table 1.**

*Summary table of important information.*

#### *Teamwork in a Surgical Department DOI: http://dx.doi.org/10.5772/intechopen.93698*

of teams in the surgical department has an obvious impact on patient outcome. The privilege and burden of decision-making is primarily focused on the surgeon. The performance of the team members depends on the behavior, knowledge, and interpersonal and leadership skills of the surgeon as a team leader. Every team leader depends on his team members. Leadership and teamwork must not be seen as contradicting characteristics of the teams in the surgical department. Both are necessary for the surgical department to function. Each team must be regularly assessed for their nontechnical skills. The causes of good and bad team results must be identified in the characteristics of the team members. Feedback must be given to all team members. The identified weaknesses or strengths in the characteristics of the team members can thus be corrected or promoted. To implement this task, tools had to be developed that allow nontechnical skills of a team to be measured. Two assessment tools are recommended to measure the nontechnical skills of the surgical team in the operating theater: The Observational Teamwork Assessment for Surgery (OTAS) and Operating Theater Team Non-Technical Skills Assessment Tool (NOTECHS). There is a reliable combined assessment tool to measure technical and nontechnical team skills in the surgical ward team. It consists of a novel clinical checklist for ward care (Clinical Skills Assessment for Ward Care); a novel team assessment scale for wards rounds (Teamwork Skills Assessment for Ward Care); and a revised version of a physician-patient interaction scale (Physician-Patient Interaction Global Rating Scale). The Team Emergency Assessment Measure (TEAM) can be used as a measuring tool for emergency surgical teams. Current literature shows that teamwork training interventions do not improve patient outcomes significantly. The personality type of the team members seems to play a very important role, as this is the main characteristic that can hardly be changed or trained. Candidates wishing to join the team must therefore be carefully screened for their suitability with the rest of the team. This is where the Teamwork Test (KSA) of knowledge, skills, and abilities can be helpful as a proven method of measuring teamwork in people who want to join a team. Frequent changes to the members of the core surgical team should be avoided, since the surgical team is a very well-coordinated and professional team. Despite the numerous studies that have found advantages in the use of nontechnical skills in surgery, possible disadvantages are still being discussed. Over-focusing on teamwork can prevent team members from peaking. More competitive and talented team members might be disadvantaged in favor of the team and their development can be slowed down. Forced commitment to teamwork might reduce the autonomy and individualism of some team members. A team needs to create conditions for healthy team competition. This can help keep team members motivated, outperform the team average and not suppress individual talents. Still, the distinct advantages in teamwork in the surgical department must be emphasized. A combined problem-solving effort of the team has surely more potential than an individual. The pursuit of a common goal leads to greater cohesion, which improves the team's performance. Distinct individual qualities of a team member can also be advantageous in case that the knowledge and skills are offered to improve other team members. Once again, teamwork is essential in surgery.

*Teamwork in Healthcare*

#### **Author details**

Nikolai Ramadanov Center for Emergency Medicine, University Hospital of Jena, Jena, Germany

\*Address all correspondence to: nikolai.ramadanov@gmail.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 9**

## Outbreak Management and COVID-19 Pandemic

*Vasfiye Bayram Değer*

#### **Abstract**

Humanity has battled with various epidemics, pandemics and natural disasters throughout history since it began to live in communities, still continuing to do so. In the past, it was very difficult to overcome many of these phenomena both at global and regional level, and even many people were killed. However, during the plagues, countries attempted to develop a number of strategies, tactics and methods within the scope of combating the epidemic. At this point, these struggles, measures and actions have facilitated prevention and spread of outbreaks, and sometimes they have not been sufficiently efficacious. On the other hand, struggles with epidemics, pandemics and natural disasters, which deeply affect all segments of the society in terms of social, cultural and economic aspects as well as mental and physical health, have been inherited to the present day, becoming a vast accumulation of practices to be re-applied in possible disasters humanity will face. The main point lies in the fact that here is that the struggles fought in traditional societies and modern societies have different characteristics. Especially in those traditional societies where medicine and technology are underdeveloped, the struggles carried out within uncertain constraints have caused pandemics and epidemics to last longer. The modern society we live in today, on the other hand, is on the verge of several risks and threats unlike traditional societies. When we consider the modern society within the risk society approaches, the present risks should also be thoroughly discussed. In this context, epidemics, which are a type of natural disaster, and the methods of combating them should be investigated within the framework of risk and crisis management due to the risks in modern society.

**Keywords:** outbreak management, risk management process, outbreak

#### **1. Introduction**

Considering the history of outbreaks as a biological phenomenon, it is obvious that they are as old as human history. The most fundamental aspect of this interpretation lies in the acceptance that microorganisms that cause diseases are also much older than human history. The microorganisms, which are the main source of outbreaks that cause the mass casualties, have not been recognized for a long time because they are too small to be discovered. However, it is possible to evaluate the lifestyles in traditional societies as one of the involving factors in the lack of knowledge about the diseases [1]. Since the risk of contracting any epidemic disease was low in traditional society periods when there was no sedentary life and people relied their lives on hunting and gathering, it was nearly impossible to know about these diseases. On the other hand, it was not possible for the outbreak to be lasting for a

long time because the persistence of the disease among people required the need for a large human population. However, with the subsequent transition to sedentary life, many contributing factors have also emerged, causing the diseases to spread easily. Consequently, awareness about outbreaks has increased and the names and systematic of outbreaks in history have started to be discussed [2].

The outbreaks are classified and termed according to their scientific structure and characteristics, spreading areas and the size of population they affect. At this point, an outbreak is divided into three categories as endemic, epidemic and pandemic. In ancient Greek, the word "en" means inside and the word "demos" means people. Derived from the combination of these two words, "endemics" is the term used to describe a disease that has always existed in a given population and can survive in a given population without external influence. The word "epidemic" is derived from the combination of the ancient Greek words "epi" meaning on or over and "demos" meaning people. In order for a disease to be defined as an epidemics, it must be prevalent in a certain human population within a certain period of time and have a pervasive effect more than expected compared to previous experiences. Finally, the term pandemic is derived from the ancient Greek word "pan" meaning all and "demos" meaning people. Unlike endemics and epidemics, pandemics refers to the type of disease that spreads over a continent or even the entire world [3].

The typical course of the disease in a pandemic with a global impact is explained as follows: The infection spreads to healthy people in a short time. It is acute and severe in its course. Those who contract the infection either die or recover completely in a short time. Finally, the survivors can develop long-term or lifelong immunity to the infection. Indicating a typical cycle of an infectious outbreak, the above steps have caused numerous casualties throughout history and left indelible marks in the areas they affected. These infections emerged as epidemics, some of which lasted for a short time or a long time, but each time caused many deaths, and humanity tried to take measures against and overcome them. On the other hand, the outbreaks have led to momentous economic, administrative, social and political changes in societies other than casualties [4]. Given the effects of past and recent epidemics on individuals and society, it is seen that epidemics are not only biological phenomena that threaten the public health but also diseases that trigger changes and transformations in all areas of life [5].

The outbreaks whose prevalence and recognition increased as humanity started to live in large settlements with crowded groups caused millions of people to suffer and lose their lives throughout history. Regarding epidemics, Diamond stated that the disease has an exclusive cycle in itself [6]. According to Diamond, epidemics are defined as the type of disease during which the sick people infect the people around them rather than individual chronic cases and the majority of the population contracts the disease in a very short time. In addition, another major characteristics of epidemics is that they progress acutely and ultimately result in death or recovery in a short time [6]. Due to their inherent characteristics, epidemics have culminated in great political, social, economic, cultural and psychological devastation in the societies where they emerged. The literature review shows that approximately three major plagues, seven cholera outbreaks and more than 10 influenza pandemics have occurred since ancient times, affecting the entire social order. Epidemic outbreaks of smallpox, yellow fever and malaria have had almost as devastating effects as the pandemics aforementioned [7].

When the diseases that broke out in the past are examined, as stated above, people and their established systems were affected in terms of politics, socioeconomic life, and mental health. The epidemics have exerted great impacts that even changed the course of battles and led to changes in power and order. When the battles in history are examined, it is seen that the epidemics changed the outcome

#### *Outbreak Management and COVID-19 Pandemic DOI: http://dx.doi.org/10.5772/intechopen.96335*

of many wars, caused the collapse of empires, and even states used these epidemics as a martial strategy [6]. As a matter of fact, the Peleponnesian wars are one of the most popular examples showing that epidemic diseases affect the results of wars [8]. Thucydides [9] explained the severity of the disease that plagued the Peloponnesian Wars and changed the course of the war in favor of the Athenians with the following words: "The disease was so severe that no one knew what would happen, and respect for everything divine and venerable was lost." As a matter of fact, even Pericles, the honourable statesman of the Athenians, died during the war due to the epidemic. Besides affecting the results of the wars, epidemics also affected the military organization and the urban planning and castle architecture [10]. In the Roman Empire, for example, the duty of the military medical troop is commissioned not only to treat the soldiers wounded in wars, but also prevent the spread of epidemics. However, it is estimated that epidemics caused significant problems in economic and commercial life, increased the cost of goods and services, social confusion and chaos caused by mass migration. In addition, the death rates caused by the epidemics experienced in the past were quite high compared to those by others. The major reasons for can be listed as inability to make an early diagnosis of the disease and determine the source as well as lack of means to prevent the transmission routes, and lastly primitivity of technology [5].

When the epidemics in history are examined, one of the epidemics that claims mass deaths other than the bubonic plague and cholera and continues to do so even today is the influenza epidemic. It is the most common acute and febrile respiratory disease in its broadest meaning [1]. The disease, also called as influenza in medicine, is caused by A, B and C type viruses. Its course can be mild and uncertain, and in some cases, complications that cause death may occur. The worst complication is pneumonia caused by the infection affecting the lungs. It is known that the influenza is an infectious disease whch have caused more than 10 pandemics most of which originated from China since ancient times. Unlike diseases such as plague, cholera, smallpox, measles or malaria, the influenza is not a viral disease that causes death or deformities in the human body in a short time. The most prominant characteristics of influenza is that the virus causing the infection can be mutated continuously and the treatment of the disease can vary in parallel with its changed state. Therefore, it may take long time to provide treatment against the influenza caused by viruses not recognized by the body [1].

The first known influenza epidemic in history struck Italy and France in 1173. The epidemic in 1580 can be considered as the first one in history. It occurred in Asia and spread to Africa, Europe and the U.S. Later, another epidemic that started in Russia between 1729–1733 pervaded the whole Europe. Then, in 1781, another influenza pandemic, started in China and spread throughout Europe and the U.S. Moreover, with the development of transportation and communication networks, influenza epidemics have become more and more prevalent. As a matter of fact, three more pandemics occurred between 1830–1831, in 1883 and 1889–1890. The most remarkable of these pandemics broke out in Russia between 1889–1890, then spread to Europe and was called as the Russian Flu [11]. By 1918, another epidemic called Swine Flu occurred in three waves, again causing the deaths of millions of people. During the epidemic encountered in this period, it was found that more than four million people died in the U.S. alone [1]. In the subsequent periods, three more influenza pandemics originated from China and spread to different continents. During the Asian Flu in 1957 and the Hong Kong Flu pandemics in 1968–1970, more than one million people died worldwide. These pandemics were followed by SARS (Severe Acute Respiratory Syndrome) in 2003, Swine Flu in 2009–2010, MERS (Middle East Respiratory Syndrome) in 2015 and lastly 2020 COVID-19 Pandemic caused by Coronavirus. When the vast epidemics and

pandemics in the history are examined, it is obvious that the plague, cholera and influenza outbreaks generally emerge as pandemics. On the other hand, those epidemics and endemics that were effective in the region where they originated have reached dimensions that could threaten human health and have caused mass deaths. The most common of these diseases include smallpox, measles, mumps, typhoid, typhus, HIV/AIDS, malaria, fever and EBOLA [5].

By definition, the concept of risk management does not necessarily mean preventing the risk completely, but rather refers to approaching the problems systematically and carefully as well as preventing unnecessary losses through careful management of the risks that are decided to take [12].

The important points in risk management involve recognizing the risk clearly enough, diagnosing it correctly, seeking ways to eliminate the risk, and transferring the risk by minimizing it. In this context, in order to overcome the Covid-19 pandemic process with the least damage, the precautions must be absolutely examined in view of risk management. In addition, crisis management, which will maximize the success of risk management, should not be undermined. Therefore, the definition of crisis crisis refers to a difficult moment or a certain period of depression in the life of a person, an organization or a society. In this respect, when the crisis is evaluated, its uncertainty includes the possibility of harm and risk within itself [13]. Hence, considering the relationship between risk management and crisis management, it is necessary to state that the risk precedes the crisis and so does the risk management. However, it is also apparent that there is a relational cycle between risk management and crisis management processes in terms of epidemic management. If more risk factors identified in the epidemic management process are reduced and the probabilities are predicted better, then they can be used more often in determining future projections along with more precautions taken to reduce risks and develop appropriate policies, which ultimately contributes to more effective crisis management from the moment the crises occur [4].

In this context, successful implementation of the activities conducted to battle against the epidemic around the world and in Turkey, it is imperative that the course of the epidemic be evaluated in terms of risk and crisis management to achieve lasting and effective results. However, taking the historical background and past experiences into account while planning risk and crisis management will be one of the most crucial strategies.

In general, the concept of risk means something that includes uncertainties in itself. The risk exists if statistics of probable distributions can be calculated for the outcomes of any given situation while uncertainty exists if there is no common attitude towards such a situation. Due to uncertain characteristics of risk, failure to make statistical inferences about a subject, and the uncertainty of repeatable risk situations even if they are made, cause a lack of foresight in terms of decision-making and planning. Therefore, it is necessary to state that any uncertainty is one of the important points to be evaluated within the scope of risk management. In classical risk analysis approaches, it is stated that decisionmakers should evaluate the situation with a holistic perspective, taking the uncertainty into the scope of the analysis according to possible future results [14]. In order to determine the risk factors in risk analysis, a pre-risk scanning system should be established at first. The activities carried out in the screening system also require an effective crisis management since the goal in risk management is not to eliminate the risk, but to overcome the crisis by minimizing the damage in the event of a possible crisis [15]. Hence, it is necessary to activate the process of crisis management in determining the ways to be followed in risk analysis. As a matter of fact, the steps in the scanning system that are determined in analyzing the risks in risk analysis approaches are defined in relation to the crisis and

#### *Outbreak Management and COVID-19 Pandemic DOI: http://dx.doi.org/10.5772/intechopen.96335*

crisis management. According to Özer [16]; the steps determined in the scanning system that makes risk analysis possible are presented below;

**Problem Management:** The solution of the existing problem is evaluated as a type of problem that will affect those at risk. In this step, the negative effects of the problem are tried to be reduced. In this respect, the problems must be classified into short and long term effective categories. Since some problems may trigger crises in the long or short term, crisis screening should also be done for them.

**Risk Evaluation:** In this step, weaknesses that may cause a crisis are determined by defining risk factors. Therefore, a number of measures must be taken to eliminate weaknesses before possible crisis situations are identified.

**Relations with Groups at Risk:** In risk situations, the groups that will be most affected by the threats of this risk must be determined and contacted. Communication with these groups will be most effective and useful in times of crisis.

By raising awareness before the crisis, the panic situations that will occur during the crisis and the new risks and crises to be created by these situations will be prevented. The risk screening system formed by determining the steps above will render the risk determination process more concrete and planned. In the implementation of the risk screening system, a successful risk management process must be performed by following the steps of defining, measuring, judging and evaluating the risk and finally analysing it. In the risk management process, it is targeted at the basic identification, control and recording of the threats and opportunities, minimizing the risks, maximizing the gains, preventing and reducing the losses, optimizing the gains, managing the crisis effectively and finally reaching at the maximum management capacity [16]. If we schematically express the risk management process under general headings in line with the steps listed above, the following steps will appear.

In line with the steps given in **Figure 1** regarding the risk management process, in case of an infectious outbreak, the current risk situation must fit be identified. Elimination of the uncertainty about the existence of the risk situation is a priority in order to determine the next steps to be followed. When making risk evaluation after the situation is identified, the harming potential (impact) of the disease, the

rate of exposure to the agent in the society and the susceptibility of the society must be taken into account. However, a number of questions arise in the following: Who are the population or groups at risk? What is the level of risk evaluation (local, regional, national etc.)? Who are the people who will carry out the risk evaluation phase? and What is the time frame specified in the risk evaluation?. Seeking reasonable answers to these well-defined questions during the epidemic will enable the risk evaluation phase to be carried out more systematically [17].

Risk control and precautionary analysis following the risk evaluation phase are of vital importance for risk management since the tools and precise strategies that reduce, inhibit or eliminate the risk are determined at this step [18]. At this point, it is necessary to identify a number of methods in line with the data obtained from the epidemics in the past. However, the formation of a team of experts in the field considering the essence of the decisions to be taken is important in determining the strategy and tactics to be practised. Otherwise, that will bring about new risk situations. Another point to be mentioned about this step is to ensure that all segments of the society are aware of the determined methods and strategies through means of modern information technologies. In this process, the mental health of the society must be thoroughly monitored while the existing bad conditions should be improved as much as possible and the hopeful message that no individual in the society is alone and this challenging process will be overcome together should be communicated. These steps requiring an effective use of mass media must also be managed accurately and in a controlled manner.

The tools and methods that ensure risk control are identified in the third step by considering all uncertain, probable and certain situations, and the necessary decisions are taken to move to the next step [19]. These decisions are taken by the administrators who are in appropriate positions and the process of making controlled decisions is initiated by analyzing all costs and benefits [16].

In the fourth step of implementing the decisions taken, the strategies determined and developed by using time and resources are started to be practised. In order to achieve that, a good communication between decision-makers and the risk group must be established beforehand. In the previous stages, it is necessary to convey the decisions taken to those in the risk group properly, to express the expected attitudes from the risk group and to ensure the maximum participation of everyone in the risk group since this step will ensure elimination of the threats, reduction of the effects of the threats or minimization of the number of people affected by the threats. Therefore, the actions to be performed require a high level of coordination and harmony [5].

After the successful implementation of the decisions, the next action is to monitor thecourse of the event. In the process of monitoring the event, problems must be identified and eliminated if possible while the people in the risk group should be encouraged to abide by the decisions and the control efficiency of the process must be ensured for the continuity of the process [18]. Then, the same process must be repeated by making a risk evaluation for new situations that occur after the decisions made [18].

In order to go through a successful risk management process, the aforementioned five steps must be fulfilled in accordance with the requirements. In addition, individuals or groups that play an active role in the risk management process should pay attention to some factors including "avoiding unnecessary risk, taking risk decisions at the appropriate level, accepting risk when the benefits are superior to the costs" [19].

While evaluating epidemics in terms of risk, crisis, risk and crisis management, it can be said that the risk during such outbreaks is generally a combination of the possibility of an infectious disease to trigger an epidemic and its impact size [17].

#### *Outbreak Management and COVID-19 Pandemic DOI: http://dx.doi.org/10.5772/intechopen.96335*

On the other hand, a crisis refers to an unpredictable, unexpected and unusual situation that occurs abruptly [20]. From this point of view, it should be stated that epidemics that cannot be identifed by the health community also create a crisis situation. In addition, the risk may also vary depending on the conditions of the country/region, political landscape, perceived risk and interest of the media and society. On the other hand, crisis situations are also shaped by the perceptions of the masses. The extent of the crisis is affected by the life experiences of the society where it emerges in view of the perception of the threat it created. Therefore, probabilities such as the emergence of crises, their impact, and the groups they will affect should be taken into serious consideration when making a risk evaluation. The main purpose of risk evaluation within the scope of combating unknown/unidentified epidemics is to initiate emergency interventions, constrict the epidemic with a specific treatment and non-pharmaceutical public health measures specifically for the disease that is not eliminated by a vaccine when the disease is first encountered, and mitigate its impact. In this context, performing a risk analysis/evaluation refers to a process that is started by identifying the event and continues until it is taken under control [17]. Therefore, the steps of the risk scanning system in the aforementioned risk analysis approach should be carried out systematically in the risk management process. In addition, risk assessment carried out with the screening steps within the scope of risk analysis should be carried out with an interdisciplinary approach by experts in the field and with the participation of the society in the process. On the other hand, the crisis and crisis management issues should not be ignored while performing risk analysis and evaluation. Identification of threatening issues should also be considered in the context of crisis management since there is a high probability of crises to occur in situations where risks exist [5].

The questions to be answered in order to determine the crisis possibilities in risk management and to terminate the process successfully care as follows [13]:


Strategic methods and tactics determined in line with the answers given to these questions should be applied in relation to risk and crisis management.

One of the issues strongly emphasized in evaluating risks and crises in terms of outbreaks is sharing the results of the risk analysis, in other words, proper communication of the identified risk. The risk must be interpreted and shared with the parties at every stage of the evaluation. Communicating or sharing the risk with

#### *Teamwork in Healthcare*

appropriate language will not only help the public to prepare for the measures to be taken and increase participation, but also guide the preparation of protocols for laboratory-based test development, diagnosis, monitoring and treatment [4].

Risk, crisis management and evaluation processes are defined as a combined process of three-components in which up-to-date information is collected, evaluated and recorded on a continuous and regular basis to manage an acute public health issue [5]. It is possible to categorize these components into three gorups: threat, exposure and contextual evaluation. In the threat evaluation of an epidemic, answers to the following questions are sought;


Secondly, answers to the following questions are sought in the exposure evaluation:


Finally, answers to the following questions are sought in the contextual evaluation;


In the event of an epidemic, the answers sought to the questions listed above and the answers given to these questions will make it possible to make a successful risk and crisis management evaluation about the disease. Another important issue

*Outbreak Management and COVID-19 Pandemic DOI: http://dx.doi.org/10.5772/intechopen.96335*

at this point is to be able to adapt past experiences to today's conditions by learning from past experiences and knowledge, whether or not the disease that caused the epidemic has the same characteristics as in the previous period. As a matter of fact, making these adaptations is one of the main factors that will enable us to carry out risk and crisis management effectively [5].

The COVID-19 outbreak that started in Wuhan, China; On March 11, 2020, more than 118,000 cases in 114 countries reached 4291 deaths and were approved by the World Health Organization (WHO) as a pandemic [21]. Since WHO proclamation of COVID-19 as a pandemic, the global spread rate has increased and the spread in the society persists in many countries. Updated number of cases and an interactive map highlighting confirmed cases worldwide are available on the websites of the World Health Organization and the European Center for Disease Prevention and Control [22].

Infection is mainly transmitted through droplets. It is generally reported that the incubation period is between 2–14 days and the average incubation period is 4.8 days. The contagious period of COVID-19 is not exactly known. It is thought that it starts a couple of days before symptomatic period and ends up with fading of symptoms [23]. The whole society is vulnerable to COVID-19. Healthcare professionals are the most risky occupational group in terms of encountering the infectious agent. Men, people over the age of 50, those with comorbidities (hypertension, cardicac disease, diabetes mellitus, malignancy, COPD, renal failure, etc.), seasonal agricultural workers and those living in nursing and rehabilitation centres, schools, barracks, detention houses and immigration camps are among vulnerable groups in terms of COVID-19. The clinical indicators of infection range from non-mild symptoms to severe pneumonia with organic functional damage. Common symptoms include fever, cough, dyspnoea and myalgia. Symptoms such as sore throat, chest pain, hemoptysis, conjunctival congestion, nausea and vomiting, headache, runny nose, painful muscles and joints, extreme weakness, loss of smell and taste, and diarrhea can also be seen [24]. The first COVID-19 diagnosis in Turkey was made on March 11, 2020, and some precautionary actions were taken to prevent the spread of the disease and to treat patients. In line with the epidemic plan, a multi-sectoral approach has been applied and preventive measures have been put into practice that address the society as a whole. During this process, pandemic action decisions started to be implemented in Family Health Units. The administrational decisions register that is approved by every physician working at the Family Healthcare Centre included the measures to be taken during the pandemic process and the changes to be made in FHC's operation in written form [24]. There is no vaccine or medicine yet to protect against COVID-19. The best way to prevent the infection is to avoid exposure to the virüs [25].

#### **2. Global overview**

In China, efforts to prevent spread of COVID-19 have been used the basic principles that include identifying and isolating infectious sources and cutting off transmission routes. As of January 31, 2020, about 12,000 cases were confirmed and 18,000 cases were suspected in China. Studies have reported that the spread of COVID-19 is relatively rapid and reached to many other countries after its outbreak in China. On January 31, 2020, 213 cases of deaths were reported worldwide. As of the same date, confirmed cases have been reported in the following 19 countries outside China: Australia (n = 9), Canada (n = 3), Cambodia (n = 1), France (n = 6),

Finland (n = 1), Germany (n = 5), India (n = 1), Italy (n = 2), Japan (n = 14), Nepal (n = 1), Malaysia (n = 8), the Philippines (n = 1), Republic of Korea (n = 11), Singapore (n = 13), Sri Lanka (n = 1), Thailand (n = 14), United States of America (n = 6), United Arab Emirates (n = 4) and Vietnam (n = 5) [26, 27].

The disease gradually spread all over the world and the epicenter of the pandemic subsequently shifted from Wuhan in China to Europe and the USA. The infection has a very dynamic structure spreading rapidly. The number of confirmed cases varies due to differences in epidemiological surveillance and diagnostic capacities across countries. Since a reliable treatment method has not yet been devised for this type of virus, controlling the rate of spread requires effective planning of healthcare infrastructure and services. Therefore, the estimation of the total confirmed cases and possible new cases in the future is vital for directing the demand to the healthcare system and managing the pandemic [28].

Italy is the first country in Europe to be seriously challenged by a large number of deaths from COVID-19, followed by Spain, France, Germany and the United Kingdom. European countries have taken measures such as flight restrictions, closing down borders, cafes and restaurants, and suspending education to prevent the spread of the disease. The UK and the Netherlands took a ethically different and ominous approach targeting at herd immunity. However, even these two countries eventually had to resort to some measures and restrictions [29]. In the USA, the first COVID-19 case was reported in Washington State on January 15, 2020 [30]. On January 20, state and local health departments in the United States initiated monitoring of all people thought to have had close contact with people infected with COVID-19. The purpose of these efforts is to ensure rapid evaluation and care of patients, limit further transmission and better understand underlying risk factors. A number of measures such as active symptom monitoring consisting of daily phone calls, texting or face-to-face conversations about fever or other symptoms during the 14 days following the last known exposure to a COVID-19 confirmed person, were conducted by local health organizations. In addition, specific guidelines for health services (infection control and prevention, laboratory testing, environmental cleaning, worker safety and international travel etc.) including patient management have been developed and published online. These guides are updated as we learn more. US public health authorities still continue to study on clarification of virus incubation period and duration with implications for quarantine time and other mitigation measures, the relative importance of various modes of transmission (understanding these modes of transmission has major implications for infection control and prevention, including the use of personal protective equipment, determination of the severity and fatality rate of COVD-19 in the US health system, as well as more detailed description of the infection spectrum and risk factors, identification of the role of asymptomatic infection in ongoing transmission; and to assist in the development of vaccines and therapeutic interventions and finally evaluating the immunological response to infection. As of June 27, 2020, the total number of diagnosed cases worldwide reached 9.9 million. The number of people who lost their lives was nearly 500,000. The United States was the country with the highest number of cases (n = 2.5 million), followed by Brazil (n = 1,280,000), Russia (n = 627,000) and India (n = 510,000) respectively. The highest number in Europe was seen in the UK with 310,000 cases. Other countries in Europe with a high number of cases were Spain (n = 295,000), Italy (n = 240,000) and Germany (n = 195,000) respectively. Considering the number of casulties, the United States ranked as the first country with 127,000 deaths. Other countries with a high number of deaths are Brazil (n = 56,000), United Kingdom (n = 43,000), Italy (n = 34,000) and France (n = 29,000) respectively [24, 31].

#### **3. Overview of Turkey**

The first detected cases of Covid-19 were announced on 11 March 2020 by the Ministry of Health in Turkey and the first death case due to the virus took place on 15 March, 2020. The Ministry of Health also announced that coronavirus cases were confirmed all over Turkey on 1 April, 2020. As of June 27, 2020 the number of people infected with the coronavirus in Turkey was 190,000 while the number of those who lost their lives due to virus was about 5,000. On this date, Turkey outnumbered China where the first cases were seen and ranked 12th after Germany while ranking as 17th among 185 countries in view of death cases [24].

#### **4. COVID-19 outbrak management in Turkey**

The Ministry of Health established an Operational Center on January 10, 2020 against possible risks after the COVID-19 outbreak started in China, and urgently formed the Scientific Committee, which plays a critical role in outbreak management. COVID-19 outbreak management is carried out under the coordination of the Ministry of Health and in cooperation with the sectors within the framework of the "Pandemic Influenza National Preparation Plan", taking into account the recommendations of the Scientific Advisory Board. The impact of the COVID-19 measures taken by central institutions and organizations is increased by the cityspecific evaluations made by the "Provincial Pandemic Committees". During the outbreak period, required measures are taken and implemented for the infection chain specific to COVID-19 within the scope of public health management. These measures can be classified as source-oriented measures (detection and notification of infected persons, isolation and treatment of the patient, filiation, screening studies, examination and follow-up of contacts, quarantine practices, health education), measures for the route of transmission (social distance, hand hygiene, respiratory hygiene, surface cleaning, disinfection, frequent ventilation of indoor environments, improvement of indoor air quality, use of appropriate personal protective equipment and health education in line with the risks when necessary, and measures for the host (health education, adequate and balanced nutrition, sufficient and regular sleep, physical exercise, cessation of smoking, etc.), reducing the possibility of exposure to the agent (limiting collective activities in the streets, flexible working/working from home, reducing contact time, shortening the shifts and organizing rest intervals, etc.) and early diagnosis and treatment of cases [32].

Community-level measures have also been initiated while finding and monitoring the cases and their contacts. When starting or ending a measure against the community, factors such as costs, social problems and "precautionary burnout" in the society are taken into account, ensuring that they will not cause an increase in cases again. Different communication strategies are used effectively to ensure social participation since the compliance of the society with the measures is an important factor in outbreak control. Compliance with different measures is monitored by qualitative and quantitative methods, and new measures are taken against decreased compliance and burnout over time. The size of the measures may differ according to the risk level and local measures may be required by surveillance data. In addition to the "Provincial Pandemic Plan", "number of new cases, incidence and cumulative incidence rate, number of cases and distribution of incidence by district, age group, gender, vulnerable groups etc., number of cases healing daily, and mortality rates" are used in order to evaluate the COVID-19 outbreak at the provincial level [24].

#### *Teamwork in Healthcare*

An effective surveillance system should be implemented in order to make evidence-based decisions in outbreak management at national and provincial/ district level. Coordination between central and provincial organizations should be carried out at the highest level in outbreak control and prevention procedures by sharing data analysis and evaluations at the provincial/district level with the teams involved in the data collection process [24].

#### **5. Primary COVID-19 outbreak management in Turkey.**

In the light of this information, the most critical measure to be taken during the pandemic process is usage of personal protective equipment (PPE) by the whole society, especially healthcare workers. In order to prevent the coexistence of healthy people and possible COVID-19 cases and transmission routes at the first contact places of the health system, WHO's screening and triage recommendations for COVID-19 should be followed [33]. For this reason, Family Health Unit (FHU) employees were made to wear PPE (mask, gloves, visor or goggles, aprons) and every patient admitted was obliged to wear a mask. A triage unit has been created at the entrance of FHU. By measuring the fever of each patient and questioning his/ her history (fever, cough, breathing difficulty, contact and travel history), possible COVID-19 cases were tried to be diagnosed by the assistant health personnel working here (nurse, midwife, paramedics). Suspected cases were evaluated by taking them to the isolation unit at the entrance of the FHU and thus the possible contamination risk was reduced. Patients deemed at risk were referred to a higher level health institution by contacting the Provincial Health Directorate. The patients who were not deemed to be at risk were admitted in a certain order in accordance with social distance rules and the size of the FHU waiting rooms. Hand disinfectants were available in FHU entrances and exit and waiting rooms. Procedures for FHU hygiene were restructured in accordance with the directives of the Ministry of Health [33].

In Family Health Units where primary health care services are provided, preventive health services are most frequently resorted for medical procedures such as having an examination, prescribing medication, getting an injection, dressing and various health reports. People can access all these services by applying to their registered family physician, patients were primarily directed to family health centers by the Ministry of Health in order to reduce crowding that may occur in secondary and tertiary healthcare providers during the pandemic process, and some regulations were remade for FHU applications [33].

Treatments and preventive health services are provided together in primary health care institutions. Preventive health services include primary, secondary and tertiary prevention [33]. Primary prevention involves the procedures performed to prevent or eliminate the cause of any health problem before it emerges in the individual or society. Secondary prevention includes the measures taken to identify a health problem in a person or community at an earlier stage. In this way, treatment becomes easier, thereby its spread is prevented and its impact is decreased in the long term [34]. Considering how simple but effective measures such as quitting smoking and avoiding obesity can prevent many diseases and save lives, the importance of especially primary preventive health services can be understood better. During the COVID-19 pandemic, primary and secondary prevention methods have been effectively used. The precautions taken to avoid contact with the virus and the early diagnosis and isolation of the contacts from the environment played a leading role in attenuating the impact of COVID-19 pandemic. Many health policies have been created to prevent this contact. In our country, in order to control the epidemic, to identify the first source, and to monitor and isolate the contacts, filiation was enforced

#### *Outbreak Management and COVID-19 Pandemic DOI: http://dx.doi.org/10.5772/intechopen.96335*

under the leadership of Provincial Health Directorates/Community Health Centers in accordance with the rules determined by the Ministry of Health. During the pandemic process, family physicians also took an active role in the filiation. Persons at risk were monitored by the family physicians and/or family health workers in line with the criteria set by the Ministry of Health. A person with confirmed or suspected COVID-19 and others who had close contact without taking protective measures against droplets were quarantined for 14 days after their last contact. Those whose tests were negative were quarantined for 14 days. Those whose tests were positive were quarantined for 14 days after 4 days without symptoms. Those who completed military service were quarantined for 14 days after they returned home. Those who were abroad and returned home were quarantined for 14 days. All these people were questioned by phone especially in terms of fever and respiratory symptoms, and informed about the quarantine conditions and closely monitored [33].

As a result, the COVID-19 pandemic has deeply affected our lives in our country as well as all over the world and showed that we need to rearrange our life norms. It is inevitable that such kind of epidemics will recur in the globalizing world. Therefore, social awareness and protective measures are essential. İn the Covid-19 outbreak everyone should be vigilant until the last case is healed, and precautions taken in family health centers, which are the front line of health services, should continue to be implemented. Preventive health services should be constantly supported, and risky/possible cases should be monitored and filiation should be continued [33].

The COVID-19 pandemic had severe health and economic consequences both in the world and in our country. An effective treatment and vaccine for the infection has not yet been found. The best intervention that could be done to reduce the contagiousness of the disease is to maintain social distance, comply with hygiene rules and wear a mask. Community immunity is another way to control pandemics. In short, it is a way of protecting individuals indirectly from an epidemic to develop immunity in the majority of the population. When it is desired to ensure community immunity by reducing protective measures, the number of cases and deaths will be increased. On the other hand, when it is desired to maintain strict protective measures until the vaccine is produced, it will take time to be widely implemented in the world. Political decision-makers should work in coordination with academia, relevant governmental institutions and non-governmental organizations in order to evaluate the psychological, sociological and economic effects of maintaining all the measures in the society and to make the best decision within the possible benefit/ loss relationship.

An outbreak management, as stated by İnandı and et al. [16], should be addressed as follows. Considering the differences in dynamics and intervention methods, the outbreak can be examined in five phases:

**Initial Phase:** During this period, sporadic and importing cases emerge. Cases are localized at first and transmission is slow. Then clusters of cases begin to appear.

**Peak Phase:** It is the period when there is widespread human-to-human transmission in the community and the outbreak curve begins to rise. In this period, the reproduction number-defined as R0 (the average number of new patients that a patient can infect the disease in a fully susceptible society) is greater than 1 and the number of patients in the community gradually grows. If the contagiousness of the agent is high, the number of sick people may increase in a very short time and constrain the capacity of health systems. During the outbreak, as some people get sick, the susceptible population will decrease. R0 changes and this new reproduction number is called as the effective reproduction number - Re [35]. During the peak period, the concept of "the number of cases increasing exponentially" is also an important concept. If no precautions are taken, the number of people affected

in the epidemic increases rapidly and exponentially, as each sick patient infects the disease to new people. In this phase, the number of days to double the cases is short.

**Plateau Phase:** The peak is followed by the plateau phase, in which the rate of increase in cases decreases. During this period, the number of patients detected daily is high while there is no significant increase compared to the previous days. The outbreak curve forms a near-straight line. The Re value is about 1.

**Bottom Phase:** There is a continuous decrease in the number of new cases. Although Re is below 1, it is still close to 1 and the control of the disease has not been fully achieved yet.

**Control Phase:** It is the phase where the number of new patients is substantially reduced and a flat course is seen because the outbreak is under control or people in the community have recovered to a large extent. At this stage, Re value is below 1 and gradually decreases. If the disease inherits immunity, the longer the time in the epidemic increases, the less susceptible people are. The presence of the vaccine and its administration to susceptible people are important in controlling the epidemic. Person-to-person transmission can be avoided by reducing the number of susceptible people through vaccination (community immunity), but this is unlikely for COVID-19 since there is currently no effective vaccine available.

#### **6. Indicators that can be used for decision-makers to evaluate risks and intervention according to the stages of the outbreaks**

As in the chain of infection in all infectious diseases, the agent in COVID-19 (source) arises as a result of the interaction between the transmission route and the host. Breaking this chain through various interventions will provide the opportunity to control the epidemic at first and then interrupt it. These interventions range from efforts that focus on limiting the disease in a specific region (suppression) to reducing the social effects of the epidemic (impact reduction), and this variability also reveals the differences in crisis management strategies of the countries [36]. In this period when there is no progress in vaccination and treatment, it is aimed to minimize the "impact" that will arise by evaluating the interventions aimed at lessening social exposure together with the risk. Case-specific decision matrices are used in scoring this impact and risk evaluations are made by crossing the risk elements and the availability of intervention tools. An example of this type of risk scoring has been used by the World Health Organization to evaluate sporting events and religious activities in terms of COVID risk [17].

İnandı (2020) and hıs frıends the risk factors and intervention opportunities specific to the upward and downward stages of the epidemic prepared by reviewing the guidelines and recommendations of the Ministry of Health, national and international organizations are grouped below [17]. Here, the risks and intervention tools that decision makers should consider in their own provinces are pointed out. It is possible to duplicate the indicators presented in this table. To do this, the "question generator" approach described in the risk assessment section of the article can be used. When appropriate questions are asked according to the phase of the outbreak, relevant indicators can be created as shown in the table. For example, the following questions can be asked to determine the indicators for populational characteristics:


*Outbreak Management and COVID-19 Pandemic DOI: http://dx.doi.org/10.5772/intechopen.96335*

Intervention possibilities according to the phases of the outbreak are also listed below. Accordingly, for example, if it is concluded that the risk has been evaluated during the bottom phase and the risk is reduced, appropriate interventions can be selected and implemented gradually in health services at community and individual level.

#### **7. Examination of risk factors and intervention opportunities according to different phases of the outbreak**

#### **7.1 Peak/Plateau**

### *7.1.1 Risk factors*


#### *7.1.2 Morbidity and Mortality Criteria*


#### **7.2 Intervention Opportunities/Capacity**


#### *7.2.1 Individual Precautions Regarding Disease Control*


#### *Teamwork in Healthcare*

#### *7.2.2 Social Precautions Regarding Disease Control*


#### *7.2.3 Bottom Phase*


#### *7.2.4 Morbidity and Mortality Criteria*


#### *7.2.5 Planning shifting to routine health services at all levels including primary health care*


#### *7.2.6 Individual Precautions Regarding Disease Control*


#### *7.2.7 Social Precautions Regarding Disease Control*


#### *7.2.8 Governance*


The outbreak process we are experiencing has shown that pre-epidemic sociodemographic characteristics, social infrastructure, health system capability and

democracy culture, as well as combating strategies, make the struggle stronger or weaker [17]. These features function as a parameter in the risk evaluation guidelines of WHO and ECDC [37, 38]. The size of the outbreak and the change in the number of cases is shaped according to the characteristics of the agent and the route of transmission, as well as the characteristics of the society exposed to the agent and the adequacy of combatting opportunities, varying with the temporal characteristics (season, religious holidays, tourism) and geographical regions (urban–rural, metropolitan). In the battle against the virus, the status of resources at the country/ local level (infrastructure, manpower, research and development etc.), preparedness, mobilizing capabilities, cooperation-coordination and participatory decisionmaking mechanisms in the organizational culture have gained importance [17]. In the battle against the Covid-19 virus, which has emerged with a new agent with many unknown findings, there is a need for those approaches that examine the risks with a global, national and local perspective on the basis of science and implement protective and preventive interventions in this direction.

For those countries such as Turkey having many cities with different geographical and climatic structure, populational characteristics and socio-economic conditions, there is an urgent need to be met in the risk evaluation and intervention at the provincial level. Even the regions where the risk will differ within the same province can be examined in this context. The provinces are authorized for additional measures to be taken by provincial pandemic boards, taking into account their own special circumstances [17]. In risk evaluation to be carried out at the provincial level, differences in age, socioeconomic and cultural characteristics, disadvantaged groups, collective living institutions, seasonal risks in the province should be addressed seperately, and the framework of the intervention should be transformed into a gradual mitigation by examining these risks.

Equally important, or perhaps more important thing is whether information about the outbreak is accessible. "Experts" cannot be expected to make an accurate risk evaluation without basic data and essential information. Information is one of the most important pillars of decision-making processes of both individuals and social structures. It plays an important role in perceiving a risk and developing an attitude and behavior towards a subject. Accurate and shared information also contributes to the creation of a trustful atmosphere in the society. Decision processes based on scientific data and evidence are more successful in achieving desired results on a subject. Evidence-based decision making focuses on obtaining the best (optimum) result on a subject [39].

Another important issue in outbreak management is associated with ensuring community engagement [40, 41]. International health guidelines emphasize the importance of community engagement. Combining views and insights from different segments of society is of paramount importance in enhancing the well-being. That's why healthcare professionals work with the community to plan, research, deliver and evaluate healthcare services. In the coronavirus pandemic, community engagement has been crucial in many collective responses, from compliance with the stay-at-home call to steps that countries need to take to alleviate restrictions, and help people who need support in the community through volunteering services [38]. The community wants to participate in the process [42]. This was evident during the pandemic process. Therefore, effective mechanisms should be established to include all segments of the society in outbreak management processes. Optimal results in an outbreak, a situation in which cases and deaths are minimized, fundamental rights and freedoms are protected, economic development and social life can be sustained, can only be achieved with an approach that provides transparency, evidence-based decisions, effective risk communication and community engagement [17].

*Outbreak Management and COVID-19 Pandemic DOI: http://dx.doi.org/10.5772/intechopen.96335*

#### **Author details**

Vasfiye Bayram Değer Faculty of Health Sciences, Mardin Artuklu University, Mardin, Turkey

\*Address all correspondence to: vasfiyedeg@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[20] Sezgin F. "Kriz Yönetimi", Gazi Üniversitesi Sosyal Bilimler Dergisi. 2003; 4(8): 181-195.

[21] Porzio G, Cortellini A, Bruera E, Verna L, Ravoni G, Peris F et al. Home Care for Cancer Patients During

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COVID-19 Pandemic: The Double Triage Protocol. 9-11 J Pain Symptom Manage. 2020 Jul; 60(1): e5-e7. doi: 10.1016/j.jpainsymman.2020.03.021.

[22] İşsever H, İşsever T, Öztan G. Epidemiology of COVID-19. Sağlık Bilimlerinde İleri Araştırmalar Dergisi. 2020; 3(1): 2-13. DOI: 10.26650/ JARHS2020-S1-0001.

[23] Zheng S, Fan J, Yu F, Feng B, Lou B, Zou Q, et al. Viral load dynamics and disease severity in patients infected with SARS-CoV-2 in Zhejiang province, China, January-March 2020. BMJ; 369. doi: 10.1136/bmj.m1443.

[24] Şengül E, Ünal E. COVID-19 Salgınında Halk Sağlığı Yönetimi. Med Res Rep. 2020; 3(Supp 1): 162-171.

[25] WH0.Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: interim guidance, 2020. World Health Organization, 2020.

[26] Adhikari SP, Meng S, Wu Y-J, Mao Y-P, Ye R-X, Wang Q-Z, et al. Epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (COVID-19) during the early outbreak period: a scoping review. Infectious Diseases Of Poverty. 2020; 9(1): 1-12.

[27] WHO. Novel Coronavirus (2019-nCoV) Situation Report–11. (2020). https://www.who.int/docs/ default-source/coronaviruse/situationreports/20200131-sitrep-11-ncov. pdf?sfvrsn=de7c0f7\_4. Access date: 21 Jan 2020.

[28] Ceylan Z. Estimation of COVID-19 prevalence in Italy, Spain, and France. Sci Total Environ.2020; 729: 138817. doi:10.1016/j.scitotenv.2020.138817

[29] Mavragani A. Tracking COVID-19 in Europe: Infodemiology Approach. JMIR Public Health Surveill. 2020;

6(2): e18941. Published 2020 Apr 20. doi:10.2196/18941

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[31] Worldometer. Covid-19 Coronavirus Pandemic. https://www.worldometers. info/coronavirus/. (Acces Date: 27 Dec 2020).

[32] T.C. Sağlık Bakanlığı COVİD-19 Rehberi. https://covid19bilgi.saglik.gov. tr/tr/covid- 19-rehberi.html / (Erişim Tarihi: 27.06.2020).

[33] Samancı VM. Birinci Basamak Sağlık Hizmetleri ve Pandemi Süreci. Konuralp Tıp Dergisi. 2020; 12(S1): 391-393.

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[35] Wikipedia, "Basic reproduction number-Wikipedia." https:// en.wikipedia.org/wiki/Basic\_ reproduction\_number (Acces Date: 27.05.2020).

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[37] WHO. World Health Organization, Rapid Risk Assessment of Acute Public Health Events. 2012.

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[42] Villadiego L. "Spaniards find beauty in helping each other amid COVID-19 crisis | Europe | Al Jazeera." https:// www.aljazeera.com/indepth/features/ spaniards-find-beauty- helping-covid-19-crisis-200319105933362.html (Acces Date: 27.05.2020).

#### **Chapter 10**

## Epidemiology of Obesity in Children and Adolescents

*Giulio Nittari, Stefania Scuri, Getu Gamo Sagaro, Fabio Petrelli and Iolanda Grappasonni*

#### **Abstract**

The childhood overweight and obesity epidemic has become a global emergency in public health and a crucial challenge of the twenty-first century. Nowadays, childhood and adolescent obesity represent a significant public health problem both in developing and developed countries. Globally, above 340 million children and adolescents aged 5–19 years were overweight or obese in 2016. Childhood obesity is a critical burden because it can be associated with a higher possibility of obesity, premature death, and disability in adults, as well as early markers of cardiovascular disease. In Europe, childhood obesity remains a significant health challenge and is distributed disparately across and between countries and population groups. In 2019, over 398,000 children aged 6–9 years were severely obese in Europe. Particularly, Southern European countries such as Greece, Italy, Malta, San Marino, and Spain had one in five children obese in 2018. In Europe, different initiatives and actions have been launched in recent years to fight childhood obesity. However, the progress on combating obesity in children has been slow and inconsistent across the region. In this chapter, we have discussed the prevalence of obesity in children and existing policies to combat childhood obesity in the World Health Organization (WHO) European Region.

**Keywords:** obesity, overweight, childhood, adolescents, prevalence, epidemiology, policies, prevention

#### **1. Introduction**

Obesity in children is the most serious public health problem globally [1], as children are more likely to become obese adults in their future lives. Currently, childhood obesity represents a significant public health challenge in both developed and developing countries by increasing the burden of noncommunicable diseases (NCDs) [2]. Recent estimates suggest that over 38 million children younger than 5 years of age were overweight or obese in 2019 [3]. Over 340 million children and adolescents aged 5–19 years were overweight or obese in 2016 [3]. The prevention of diabetes mellitus and obesity in adults and children was one of the goals set by the World Health Assembly in 2013 [4]. The rapid increase worldwide in obesity is also analyzed in association with the economic causes because some differences were observed between high- and low-income settings. In high-income settings, the higher prevalence of obesity is observed in disadvantaged and marginalized communities. In contrast, in low- and middle-income settings, the prevalence of obesity is higher in groups with higher socioeconomic status. This trend can be explained by socioeconomic inequalities, because in the high-income countries, commonly, the socioeconomic disparities improve the consumption by the poor people of inexpensive, energy-dense foods and beverages.

Furthermore, the increment of obesity prevalence by 23–33% was recorded for children in low-education, low-income, and higher-unemployment households. The family with low-income demonstrates a lower awareness that their children are overweight and then face a host of barriers to improving the diet, the activity behaviors, and the general health status [5]. Many economic consequences for public health strategies are related to the epidemic trend of childhood obesity.

The problem of childhood obesity has become a global public health concern, and the fight for its prevention is a commitment that involves all institutions. The prevention of obesity requires the implementation of surveys to monitor its evolution over time, the knowledge of its determinants, and the research and implementation of interventions, necessarily in a multisectoral and multidisciplinary context, as well as a continuous evaluation process. These actions are necessary for the implementation of evidence-based interventions, which must be supported by appropriate nutritional policies. Overweight and obesity at a young age are associated with various health or economic consequences, therefore it is important to analyze the causes and risk factors and identify the best prevention and treatment strategies. On the prevention of childhood obesity, the promotion of teamwork and the dissemination of information related to childhood obesity is one of the vital strategies to fight against childhood and adolescent obesity. Therefore, teamwork in health care is a crucial strategy for promoting public health and preventing childhood chronic diseases such as childhood obesity.

In Europe, childhood obesity remains a significant health challenge and is distributed disparately across and between countries and population groups [6]. Approximately, 398, 000 children aged 6–9 years were severely obese in Europe in 2019 [7]. Obesity in children is associated with immediate adverse consequences such as psychological problems [8] and lower educational attainment [9]. Also, it is associated with negative health effects later in life or adulthood, such as type 2 diabetes mellitus, hypertension, obstructive sleep apnea, dyslipidemia, and other noncommunicable diseases [10]. Childhood obesity is the outcome of an interaction between a complex series of factors related to environmental, genetic, and ecological effects [10]. Due to the speedily increasing prevalence of childhood obesity in Europe, various initiatives and actions have been launched in recent years in response to this alarming trend. As a result, the WHO European Childhood Obesity Surveillance Initiative has measured the trends in childhood obesity for over a decade [11]. It provides data to inform policy and practice to respond to the problem of childhood obesity [11, 12]. Also, the EU developed an action plan to tackle childhood obesity (EU Action Plan on Childhood Obesity 2014–2020) on February 24, 2014 [13]. However, the progress on combating obesity in children has been slow and inconsistent across the region. For instance, the latest data have shown that southern European countries such as Greece, Italy, Malta, Cyprus, San Marino, and Spain have the highest rate of childhood obesity (nearly one in five children are obese) [14]. On the other hand, Denmark, France, Ireland, and Norway are among countries with the lowest rates of obesity in children in either sex [14]. Hence, childhood obesity is still a so-called time bomb [15] for future demands for health services

*Epidemiology of Obesity in Children and Adolescents DOI: http://dx.doi.org/10.5772/intechopen.93604*

and could jeopardize the progress toward achieving the Sustainable Development Goals (SDGs) [16].

The present chapter is aimed at (1) illustrating the prevalence of obesity in children and adolescents aged 5—19 years by the WHO European Region and (2) analyzing the effectiveness of the prevention strategies adopted in EU countries to combat childhood obesity from a social and legal point of view and pointing out the best strategies to reduce the prevalence of obesity in children and adolescents.

#### **2. Epidemiology**

#### **2.1 Prevalence**

Data on the prevalence of obesity in children and adolescents aged 5—19 years in the WHO European Region were taken from the Global Health Observatory (GHO) data [17]. By geographic area, the highest crude prevalence of childhood obesity was observed in Mediterranean countries in 2016, ranging from 7.6% to 13.8% for either sex. In particular, Greece, Malta, Italy, Cyprus, Andorra, Turkey, and Israel among the Mediterranean countries had the highest prevalence of childhood and adolescent obesity in 2016 (**Table 1**). In 1980, Oriental European countries had a prevalence of less than 2%, ranging from 0.3 to 1.9%. However, in 2016, it changed completely, and the prevalence was more than 4%, ranging from 4.2 to 11.1% (**Table 1**). The prevalence in all northern European countries, except Iceland, increased by over 100% between 1980 and 2016, but in Iceland, it increased by 94% in the same period (5.1% in 1980 and 9.9% in 2016). In 2016, among the Western European countries, the United Kingdom (UK) and Germany had the highest childhood obesity. In contrast, Armenia, Azerbaijan, and the Republic of Moldova among Eastern European countries with relatively low prevalence levels (**Table 1**). The prevalence distribution in Oriental Europe countries showed relatively small when compared to the other areas in Europe in 2016. However, EU member states (Bulgaria, Czechia, Hungary, Lithuania, Poland, Slovakia) among Oriental countries had higher prevalence levels (**Table 1**).

#### **2.2 Trends**

Obesity in children aged 5–19 years in almost all European regions have increased rapidly from 1980 to 2016. Mainly EU member states have shown increasing trends in the prevalence of obesity in children and adolescents during the study period. Notably, Greece and Croatia have shown secular trends in the prevalence of childhood obesity among EU countries in the Mediterranean Region (**Figure 1**). Besides, the prevalence in the United Kingdom tripled for either sex from 1980 to 2016, ranging from 3.4 to 10.2%, respectively (**Table 1**). Similarly, in France and Spain, the prevalence almost tripled from 1980 to 2016: for example, in France, it ranged from 3% in 1980 to 8.1% in 2016 and in Spain, passing from 3.8% in 1980 to 10.8% in 2016 (**Table 1**). In Slovakia, the prevalence of obesity in children has increased from 0.6% in 1980 to 8.1% in 2016 (**Table 1**). On the other hand, in Cyprus, Lithuania, Portugal, and the Netherlands, the prevalence has increased more than five times over 36 years in each country (**Table 1**). In contrast, in Italy, Malta, and Belgium, the magnitude of childhood obesity has doubled from 1980 to 2016. As shown in **Table 1**, in Poland, the prevalence has increased from 1% in 1980 to 9.1% in 2016, while in Bulgaria, it grew by more than eight times in the same



#### *Epidemiology of Obesity in Children and Adolescents DOI: http://dx.doi.org/10.5772/intechopen.93604*


### **Table 1.**

*Prevalence (%) of obesity in children aged 5–19 years by the WHO European region from 1980 to 2016.*

*Epidemiology of Obesity in Children and Adolescents DOI: http://dx.doi.org/10.5772/intechopen.93604*

#### **Figure 1.**

*Trends in the prevalence of obesity in children and adolescents aged between 5 and 19 years in the Mediterranean region EU countries from 1980 to 2016.*

#### **Figure 2.**

*Trends in the prevalence of obesity in children and adolescents aged between 5 and 19 years in the northern EU countries from 1980 to 2016.*

period (1.3% in 1980 and 10.8% in 2016). In Ireland, the prevalence of obesity in children and adolescents has steadily increased over 36 years (1.5% in 1980 and 9.8% in 2016) (**Figure 2**). Mainly the prevalence level increased from 1.5 and 1.4%, respectively, for girls and boys in 1980 to 9.1 and 10.4% for girls and boys in 2016 (**Table 1**). Furthermore, the Oriental EU member states except for Lithuania all have shown consistently increased trends in the prevalence over 16 years (from 2000 to 2016) (**Figure 3**). Trends in the prevalence of obesity in children and adolescents aged 5–19 years have been presented in EU countries by geographic areas (**Figures 1**–**4**).

#### **Figure 3.**

*Trends in the prevalence of obesity in children and adolescents aged between 5 and 19 years in the oriental EU countries from 1980 to 2016.*

#### **Figure 4.**

*Trends in the prevalence of obesity in children and adolescents aged between 5 and 19 years in the occidental EU countries from 1980 to 2016.*

#### **3. Policies**

The alarming proportions reached by childhood obesity in many countries pose an urgent and serious challenge, also concerning the most serious consequences of obesity on health. Obesity can produce effects immediately on a child's health, educational performance, and quality of life, or chronic illnesses in adults, which are very likely to remain obese. The policy to tack childhood obesity is slow and inconsistent and then to review and resolve this gap, in 2014, the Commission on Ending Childhood obesity has been established. Moreover, the "Strengthening Nutrition Action of Food and Agriculture Organization of the United Nations and World Health Organization-United Nations decade of Action on Nutrition 2016-2025,"

#### *Epidemiology of Obesity in Children and Adolescents DOI: http://dx.doi.org/10.5772/intechopen.93604*

describes that in the same year (2014). The Second International Conference on Nutrition (ICN2) listed obesity and overweight among the malnutrition forms. It focused the attention of 164 member States of FAO and WHO, about the need to change the choices of the food systems for better diets and a healthier planet. The unhealthy diets, maternal and child malnutrition, are considered as the current top risk factors for one-quarter of global deaths.

Furthermore, the number of people of all ages who are affected by diet-related noncommunicable diseases (NCDs) has increased. The documents produced by ICN2 make up the roadmap for the governments of the world to eradicate hunger and prevent all forms of malnutrition such as undernutrition, micronutrient deficiency, overweight, and obesity. One year later, has been adopted the 2030 Agenda for Sustainable Development ("2023 Agenda") and its Sustainable Development Goals (SDGs) at the United Nations (UN) General Assembly. In 2015, the United Nations mentioned the prevention and control of noncommunicable diseases as a top priority in the Sustainable Development Goals, and obesity listed as a risk factor for noncommunicable diseases [18]. The Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013–2020 assess policy options for member states per their legislation for the selection and for undertaking actions from among the policy options about the monitoring, the disease registries, and the surveillance of NCDs.

Regarding the surveillance, the WHO indicates the surveillance of the key risk for the NCDs considering behavioral and metabolic risk factors as for example the use of alcohol, the physical inactivity, tobacco use, unhealthy diet, overweight, and obesity, raised blood pressure, raised blood glucose, and hyperlipidemia, and determinants of risk exposure such as marketing of food, tobacco, and alcohol [19]. Moreover, to accelerate the actions on nutrition, the UN General Assembly, in 2016, proposed that the period from 2016 to 2020 should be a UN Decade of Action on Nutrition (Nutrition Decade), providing a clearly defined, time-bound, and cohesive framework for all countries and stakeholders to increase nutrition investments and implement policies and programs to improve food security and nutrition, reach the six global nutrition targets 2025, and the diet-related global noncommunicable disease (NCD) targets. Modifying possible risk factors as the reduction of an unhealthy diet is one of the "best buys" for the prevention and control of noncommunicable diseases (NCDs) proposed by the World Health Organization [20].

All reports proposed by the international organization of public health proposed a no single intervention to resolve childhood obesity and overweight but analyses and interventions about the environmental context and three critical periods in the life-course. The first is the preconception and pregnancy, infancy and early childhood, and finally, older childhood and adolescence. Therefore, the prevention and the treatment of obesity require a whole-of-government approach in which the policies of all sectors are across the same target, which the health, the eradication of harmful health impacts, and thus improve population health and health equity. The Commission on Ending Childhood Obesity collected and an organic package of recommendations to address childhood obesity and achieve strategic objectives. As a result, the first object is tacking the obesogenic environment because the major negative elements are the unhealthy diet and physical activity of children. The second goal is the reduction of the risk to develop the obesity development factors able to change the biology and behavior of children before birth and through infancy. The last is the treatment and cure of children or young people with notified obesity. Consequently, the areas identified by the commission to define the preventive actions are the promotion of healthy foods intake, physical activity, the cure preconception, and pregnancy care, the early childhood diet, and physical activity, the health, nutrition, and physical activity for school-age children and finally the weight management. The first recommendation concerns the promotion of healthy food intake

and the reduction of sugar-sweetened beverages by children and adolescents. Among the actions promoted are listed the development and diffusion of appropriate and context-specific nutrition guidelines for adults and children, the implementation of a tax on sugar-sweetened beverages, and the marketing of foods and nonalcoholic beverages to children. Besides, the description of the nutrient-profiles to identify unhealthy foods and beverages associated with a standardized global nutrient labeling system. The Codex Alimentarius Commission proposes a standardized system of food labeling for all packaged foods and beverages, which can support the nutrition and health education [21]. In association with the correct labeling system could be improved, also, the public education of both adults and children about nutrition literacy and the interpretation of front-of-pack. This recommendation is included in the recommendation 14 of United Nations decade of Action on Nutrition 2016–2025, concerning saturated fat, sugars, salt, and trans-fat reduction has been focused on the promotion of a healthy diet to stop the consumption and sale of highly processed foods, growing fastest in lower-middle-income countries. The actions to prevent and control NCDs include the reduction of salt intake, and the setting of target levels for the amount of salt, reformulating food products. Furthermore, the action plan has been indicated the elimination of industrial trans-fats and the reduction of sugar consumption through taxation on sugar-sweetened beverages. The availability, and consequently, the high consumption of these products, is the principal cause of health problems such as obesity and other diet related NCDs. The reduction of sedentary behaviors in children and adolescents, focusing on physical activity programs, is the second recommendation and includes the definition of advice to children, adolescents, parents, caregivers, teachers, and health professionals on healthy body size, physical activity, sleep behaviors and appropriate use of screen-based entertainment. The same recommendation promotes the improvement, during the recreational time, for all children (including the children with disabilities), of physical activity favoring adequate facilities at school or in public areas. Recent epidemiologic data show a decline from the age of school about physical activity. About 81% of adolescents have insufficient physical activity lower than 60 minutes each day. Obesity is more linked with physical activity because it creates a vicious cycle, which increases body fat levels and decreases physical activity. The recommendation about the prevention of childhood overweight and obesity regarding all guidelines promoted introduces the protection of the diet in women during pregnancy, the improvement of child nutrition status and growth, and finally, the promotion of physical activity to address sedentary lifestyle from the early stages of life. The best keys to these recommendations are breastfeeding promotion and protection because they have a crucial role in the reduction of childhood obesity risk. Indeed, the diagnosis and management of hyperglycemia and gestational hypertension, the monitoring of gestational weight gain, the correct diet, and lifestyles during pregnancy are key preventive factors against childhood overweight and obesity. To ensure healthy child development, policies should provide advice not only on healthy eating but also on appropriate sleep time, sedentary or screen time, physical activity, or active play for the age group of 2–5 years. The school is also a fundamental environment to promote the correct lifestyles, especially about the diet. Two aspects can be improved at school, the promotion of standardized meals, in accordance with guidelines, without unhealthy foods with sugar, sweetened beverages or energy-dense, nutrient-poor foods etc. but characterized by the introduction of fresh fruits, vegetables, and safe drinking water. The secondary aspect is the improvement of knowledge's on children about health education within the core curriculum of schools and practical experiences of food preparation available to children, their parents, and caregivers.

Finally, the six recommendations of the commission are the correct weight management in children and young people suffering from obesity and overweight,

#### *Epidemiology of Obesity in Children and Adolescents DOI: http://dx.doi.org/10.5772/intechopen.93604*

developing multicomponent services concerning physical activity, nutrition, and psychological support. These supports are delivered by professional and treated teams, as part of Universal health coverage. The responsibilities of these actions are divided by different structures at different levels. The first is the WHO and concerns the institutionalization of each measure across all technical areas of WHO, and regional and country offices. Furthermore, it provides the consultation and technical support for action at global, regional, and national levels, with international agencies, and the governments of each Member States. Each Member States are supported by International organizations, and define political commitment against childhood obesity, coordinate all sectors and institutions engaged for policies about nutrition, food, agriculture, sport and recreation, urban planning etc. Collect and record all data on BMI-for-age of children and define the national targets for childhood obesity. The other structures are represented by nongovernmental organizations (NGOs), the private sector, the philanthropic foundations, and academic institutions [22].

In Europe, the EU Action Plan on Childhood Obesity 2014–2020 translates the international guidelines with the purpose of demonstrating the shared of EU Member States to addressing childhood obesity; set out priority areas for action and a possible toolbox of measures for consideration and finally propose ways of collectively keeping track of progress. The EU Action Plan considers the presence of three types of stakeholders which are: the 28 EU Member States, the European Commission, and international organizations such as the WHO and finally civil society (e.g., nongovernmental organizations (NGOs), industry, research institutes, and associations). The national, regional, and local level was represented by the specific authorities. Each area defined in the EU action plan is in agreement with the areas proposed by the Global Action Plan, and to evaluate the efficacy of the intervention for each region were defined as specific indicators. Regarding the area for action 1: Support a healthy start in life the first operational objective is, for example, increase the prevalence of children that are breastfed, the indicator is the % of children breastfed and the final target the achievement of 20% in 2020 of children with adequate periods of exclusive breastfeeding according to national recommendations. The area of action 2 is about the promotion of healthier environments, especially at schools and preschools, and the main priority is the establishment of children's health as a priority at schools, and for example, the first operational objective is to "provide the healthy option and increase daily consumption of fresh fruit and vegetables, healthy food and water intake in schools (with a targeted focus on schools in underprivileged districts)." The action is the development of preschool and school meals with fruits, vegetables, and drinking milk following the existing EU guidelines. The indicators are, for example, the number of member states implementing frameworks on preschool and school meals, and the target to achieve in 2020 is 90% of the member states participating in the program. The other areas are the improvement of healthy options regarding the availability of healthy food choices to children and the target of restriction related to vending machines. Area number 4 has the goal to limit the exposure of children to advertisements for food/drinks high in fat, sugars, and salt. The improvement of family knowledge and information's on the daily food and health choices of children of action number 5. The last two areas of action are number 6 to encourage physical activity, and number 7 is related to the monitoring and evaluation of children's nutritional status and behaviors. At this moment, the assessment of the effectiveness of the Action Plan that can be analyzed is referred to in 2018, because the final assessment will be defined at the end of 2020. The initial results compare the activities improved before 2014 with the activities promoted with the EU Action Plan in each action area [23]. The results show an improvement of actions relatively the guidance around the pregnancy, the policies on vending machines, energy drinks, and reformulation of food and especially the concentration of salt.

#### **4. Prevention strategies adopted by European states**

Despite the important engagement of the European countries in reversing the progress of obesity, the incidence of overweight subjects remains alarming, particularly if considering the young population. Childhood weight gain has, in fact, a severe impact on health and psychosocial outcomes, deeply affecting individual and family's quality of life. Research shows that overweight children are more likely if compared to normal weight ones, to become obese adults and so to develop chronic conditions. The recent increment of hours dedicated to "screen time" and the associated damaging effects on eating habits, together with little safe spaces to be active in, are essential factors influencing the level of physical activity and health among young. Also, cheaper and larger-portioned fast food, as well as the massive consumption of high-sugar products, must be taken into consideration. In 2014, in EU, the 7% of yearly national health budgets were spent on diseases correlated to obesity, and investigations showed how policies addressed to children obesity control would repay on investment of 6–10%.

For these reasons, in 2007, after analyzing the report by the WHO European Childhood Obesity Surveillance Initiative (COSI), the European Commission adopted the White Paper on a Strategy for Europe on Nutrition, Overweight and Obesityrelated Health issues, composed of six major goals: better-informed subjects, physical activity, and healthier options promotion, supporting low socioeconomic groups and developing evidence and monitoring systems to support the program. The High-Level Group on Nutrition and Physical Activity and the EU Platform for Action on Diet, Physical Activity, and Health are the main instruments set up for implementation of the strategy. The first one enables governments to share health and economic analysis and enhances contact between governments and the EU platform for action on a diet, physical activity, and health. It also works on some priorities such as reducing children's exposure to marketing of foods high in fat, salt and sugars, physical activity, labeling, and public procurement of food, reducing health inequalities. The EU Platform is a forum for European level organizations, including Food business and consumer organizations, scientific associations, and NGOs. The high-level group can also be asked by the commission to prepare the groundwork for relevant prevention and promotion initiatives agreed by the steering group on promotion and prevention.

In 2013 the strategy went through an external evaluation to test its efficiency: the results were positive. However, they suggested a greater commitment to promoting physical activity. Besides, an Action Plan on Childhood Obesity addressed to a Europe-wide context was redacted, to lower young overweight by 2020. One of its main goals is to support a healthy start in life, encouraging breastfeeding and promoting the adoption of a healthy lifestyle both during the early stage of life and preconception period. Developing healthier school environments is the sequel, providing wholesome meals, with the proper nutritional intake, and also allowing adequate time to consume it. Making the healthy option more available in addition, both in schools and in the working environment, would encourage good eating behavior to be part of the routine. The fourth point is about making families informed in order to empower parents in planning a correct meal plan and schedule regular active leisure activities, which is also linked to the significant focus on the promotion of the physical activity. Last, the increase in monitoring and research, would, in the end, test the nutritional quality of food, health status, and habits of children, together with the collection of systematic data.

The main actors of the plan are 28 EU Member States, the European Commission, and a variety of civil society stakeholders such as NGOs, industry and agricultural sectors, University and research institutes. Another project, the Joint Action on Nutrition and Physical Activity (JANPA), was proposed as a contribution to the EU action plan on childhood obesity 2014–2020, focusing on specific

*Epidemiology of Obesity in Children and Adolescents DOI: http://dx.doi.org/10.5772/intechopen.93604*

outcomes that can effectively contribute to nutritional and physical activity policies during childhood. It has the following objectives: economic evaluation of the cost of overweight and obesity in children with the aim to encourage public actions, promoting healthy nutrition and physical activity to pregnant women and families with young children, promoting healthier environments in schools and preschools, efforts at a local or at a national level regarding nutrition and physical activities, promoting healthy eating and drinking practices, and improving the information addressed to the consumer at the national level [13]. At the national level, many policies and programs have been adopted in recent years in Europe, aiming to prevent child obesity and improve its treatment and management.

#### **4.1 Italy**

Data from the Childhood Obesity Surveillance Initiative (2015–17) show that Italy is ranked first in Europe for child obesity, with 21% of children obese or overweight: taking into account this evidence, Italy has turned its attention not only to monitoring, but also to the population approach, using media, brochures, and education in schools and health-care facilities. These actions are part of the Italian Health Plan on Prevention. One of the objectives of this program is to reduce the preventable and avoidable burden of morbidity, mortality, and disability of noncommunicable diseases. Another initiative adopted in Italy is the program named "OKKIO all Salute," launched in 2007 as a part of the COSI initiative, to monitor children's weight, eating behaviors, physical activity habits, and their related risk factors among children of 6–10 years. From 2008, around 45.000 families took part in this project. Italy is also part of the international program HBSC (Health Behavior in School-aged Children), showing commitment to understanding factors influencing children's eating behaviors [24].

#### **4.2 Malta**

The increasing prevalence of overweight and obesity, especially among children, is a significant public health problem in Malta, as it has been estimated that 40% of school-aged children are overweight or obese. Different actions have been put in place to tackle this problem since the Maltese Presidency of the Council of the EU selected childhood obesity as one of its priority areas during its European Presidency in the first half of 2017. Considering the fact that children spend much time in school, particular attention was put to the school environment. In 2016, the government of Malta enacted the "Healthy Lifestyle Promotion and Care of Non-Communicable Diseases Act," which aimed to promote physical activity and balanced diets to achieve healthy lifestyles and reduce the noncommunicable diseases in all age groups. An intersectoral Advisory Council was set up, and one of its major initiatives was outlining a legislative tool for schools: there was a clear need for improving the school environment to help the whole school community to adopt healthier dietary patterns and lifestyle. The consumption of healthy foods and restrictions on products high in salt, sugar, and fats were encouraged, following nutritional criteria based on the WHO nutrient profiling model and carrying random inspections by specifically trained health practitioners.

In August 2018, the Maltese government issued subsidiary legislation to regulate the food being sold and provided by schools, implement programs for healthy eating, ban advertising or sponsorship of unhealthy foods, and ensure the provision of drinking water in schools. One of the divergences identified across EU states was in planning food procurement tenders for schools that promoted healthy eating and to allow their smooth implementation. It has been important to set clear specifications, with support from the Joint Research Centre and experts [24].

#### **4.3 Poland**

In Poland, a 2016 Regulation by the Minister of Health addressed groups of food intended for sale to children and adolescents in the education system. Besides, the School Program Strategy 2017/18–2022/23 has, as one of its goals, the promotion of a healthy, balanced diet among children and parents. In particular, it aims to change the eating habits of children by increasing the share of fruit and vegetables and the intake of milk. In Poland, the food industry is one of the most influential lobby groups, with well-organized representation and significant financial resources. Poland is also one of the participating countries in the Choices Program, an initiative introduced in the Netherlands in 2006 in response to WHO's call for the food industry to take an active voluntary role in tackling obesity. To reduce the consumption of salt, there has been an important consumer awareness initiative through media, schools, and health-care facilities, as well as 16% of salt reduction in bread by 2012. Concerning physical activity, it is mandatory in primary and secondary schools, and it is included in general teaching training [25].

#### **4.4 United Kingdom (UK)**

In some countries, reducing childhood obesity is a task shared by the Ministry of Health with the Ministry of Finance (responsible for taxes on food high in saturated fat and sugary soft drinks), the Ministry of Education (for school curricula, healthy nutrition education, and physical activity), and the Ministry of Agriculture and Food Industry (for free school fruit and vegetable schemes and sustainable healthy food supplies) [24]. This is the case of England, opposed to the approach of the Republic of Moldova, where a lack of multisectoral collaboration has been found. The UK Childhood Obesity Plan introduces for the first time a soft drink industry levy and the revenue will be invested in programs to reduce obesity and encourage physical activity, in addition to substantial restrictions for sailing and promoting high sugars and fat drinks or snacks, after the introduction of a tax on sugary drinks was announced in March 2016 and came into force in April 2018.

In some countries, television (TV), radio, and Internet services are regulated with some set standards for advertising to protect children from the overconsumption of unhealthy foods, and this is the case of England, where, the National Office of Communications since 2006, does not allow TV advertisements for such foods to be shown during or close to children TV programs. They also launched a sugar reduction program intending to remove sugar from the food's children frequently eat, paying attention that it is followed by a calorie restriction and not by compensation with extra fats. Also, supporting agricultural innovation by bringing together food business and researchers is part of the project. Support is also given to disadvantaged families, with the distribution of 60 million worth of vouchers that can be exchanged for fresh fruit and vegetables or vitamins. Of course, also physical activity is considered, and it is included in each day at school for at least 30 minutes. It should also be taken into consideration the GREAT commitment of the UK Government in enabling health professionals to support families' diet, as well as training them to face eating behaviors changes and promoting wellbeing [26].

#### **4.5 Moldova**

Concerning Moldova, concrete actions to face childhood obesity were only undertaken in 2012. The National Health Policy (2007–2021) was the first policy document that addressed obesity as a priority, involving the society and *Epidemiology of Obesity in Children and Adolescents DOI: http://dx.doi.org/10.5772/intechopen.93604*

government, but it was in 2014 when the Moldovan government endorsed the first National Food and Nutrition Program for 2014–2020 and the Action Plan for 2014–2016, with the specific objective to halt the rise of obesity prevalence among children and adults. The 31 July 2007, the Ministry of Health Decision forbids the marketing of energy-dense food with high-fat content and reduced nutritional value in institutions for children. In 2009, new laws prohibited marketing pressure on children to consume healthy drinks. After the Food Law was amended, selling and distribution of unhealthy food within 100 m by schools were banned. The Republic of Moldova became part of COSI from 2013 and participated in the third and fourth rounds of this initiative. Further in 2014, the government adopted the first National Food and Nutrition Programmed for 2014–2020 (NFNP) and its Action Plan with the aim of zero increase in obesity prevalence, employing compulsory nutritional labeling, limitations on advertising, together with the elimination of trans-fats and reduction of sugar and salt [24].

#### **4.6 France**

EPODE, or Ensemble, Prévenons L'Obésité Des Enfants (Together, Let us Prevent Childhood Obesity) was established in January 2004, based on the guidelines from the National Health Program recommendations. This program was developed based on the effectiveness observed from the Fleurbaix-Laventie Ville Santé Study, which started in 1992 and continuing, which showed a decrease in childhood obesity rate after the nutritional and physical activity initiatives were implemented in the two towns. The project is supported by the French Ministry of Health, in collaboration with more than five other Ministry, the French National Academy of Medicine, together with some partners like Nestle and Ferrero, financing half of the costs of the program. EPODE now extends to nearly 1.8 million inhabitants in 167 French cities, 20 cities in Spain, and eight cities in Belgium. The project aims to reduce BMI in overweight or obese children promoting physical activity and a healthy diet through three major steps: (1) informing community and families about the obesity problem, using meetings and brochures; (2) Training participants (teachers and professionals); (3) starting the action in schools, distributing educational materials, improving school catering, and hosting food workshop [27].

#### **4.7 Germany**

Understanding the importance of obesity as a health issue, and recognizing the worrying increase of overweight adolescences, a range of federal policies were established in Germany to face the issue since, public health services in Germany have played a great role in putting obesity on the political agenda, and they focused on dealing with obesity from child and adolescent health services perspective. The Robert Koch Institute has launched the German Health Interview and Examination Survey for Children and Adolescents (KiGGS-Study), with a baseline study in 2003–2006 and a follow-up study in 2014–2017. The results of the second study were published in March 2018. They pointed to a strong social gradient, with the prevalence of overweight reaching 27.0% and 24.2% in girls and boys respectively, aged 3–17 years with low socioeconomic status compared to 6.5% in girls and 8.9% in boys with high socioeconomic status.

Some of the other vital initiatives in response to the Survey are the National Cycling Plan 2020, which promotes cycling, walking, and the use of public transport and the two programs of the Federal Centre for Health Education (FCHE): Gut Drauf (Feeling Well), which aims to improve the health of children and adolescents

aged 12–18 years, and Tutmirgut (Good For Me), aimed at children aged 5-11 years. In 2007, there were 708 programs for overweight or obese children and adolescents in Germany, reaching approximately 44,000 persons [24]. In Germany, policies are implementing a salt reduction in bread and many consumer awareness initiatives regarding a healthy lifestyle, promoted in schools, and via media and Internet [28].

#### **4.8 Denmark**

The Danish National Action Plan against Obesity was written to improve awareness in the Danish population and generally reduce high BMI. Children and adolescents are one of their main targets. Concerning nutrition, the aim concerning children's diet is to reduce the number of subjects who consume more energy from fat and sugar and, at the same time, pay attention to the correct fiber intake. Also, life outside the home was provided with healthy food, and parents were supported in taking proper diet choices. Of course, also physical activity is considered, and new guidelines were established, increasing the hours to it dedicated to schools and strengthening the competences of teachers. Suitable playground and outdoor areas were provided, as well as car-free areas near schools and safe foot and cycle paths [29].

#### **5. Conclusion**

Handling childhood obesity is undoubtedly challenging despite the substantial progress made concerning healthy nutrition, early life, and increased physical activity. It has also been essential to restrict advertising on TV actively. Still, it should also be taken into consideration to control video games, mobile phones, tablets, and social media since, nowadays, there is no more efficient way to address kids than getting in touch with them through the Internet. Monitoring childhood obesity is, for sure, more rewarding if compared to adults but, initially, for the complexity of relating to young subjects, it can be very onerous.

Consequently and taking into account the role played by multinational food industries in supporting French policies should be considered to further involve in obesity control plans, food, and sports industries. Doing so will make it possible to boost the research resources and, at the same time, allow the markets' sectors, that would possibly be affected by the latest policies and guidelines, to adapt their selling to the new consumer type. It should also be mentioned that some European countries are still not facing the childhood obesity problem, primarily due to inadequate resources and a lack of interface between the health institutions and industries.

In Malta, for example, the requirement of precise definitions for food procurement that tenders on how to set a healthy meal plan in schools was given by the Advisory Council with the support from the EU Joint Research Centre, a proper example of a strategy controlling balance and micronutrient intake of at least one meal per day of all school kids. This strategy, together with the Healthy Weight for Life strategy for 2012–2020 and the Food and Nutrition Policy and Action Plan for Malta 2015–2020, makes Malta one of the most committed European countries in the battle against childhood obesity. The Maltese case is one of the first to be taken into consideration when evaluating the situation**.**

#### **Conflict of interest**

The authors declare no conflict of interest.

*Epidemiology of Obesity in Children and Adolescents DOI: http://dx.doi.org/10.5772/intechopen.93604*

### **Author details**

Giulio Nittari1 \*, Stefania Scuri<sup>2</sup> , Getu Gamo Sagaro1 , Fabio Petrelli<sup>2</sup> and Iolanda Grappasonni<sup>2</sup>

1 Telemedicine and Telepharmacy Centre, University of Camerino, Italy

2 School of Pharmacy, University of Camerino, Italy

\*Address all correspondence to: giulio.nittari@unicam.it

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

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[4] World Health Organization. Resolutions and Decisions, Sixty-Sixth World Health Assembly. WHA66/2013/ REC/1. Geneva [Online]. 2013. Available from: https://apps.who.int/ gb/ebwha/pdf\_files/WHA66-REC1/ WHA66\_2013\_REC1\_complete.pdf

[5] Rogers R et al. The relationship between childhood obesity, low socioeconomic status, and race/ ethnicity: Lessons from Massachusetts. Childhood Obesity. 2015;**11**(6):691-695. DOI: 10.1089/chi.2015.0029

[6] Nittari G, Scuri S, Petrelli F, Pirillo I, Di Luca NM, Grappasonni I. Fighting obesity in children from European world health organization member states. Epidemiological data, medical-social aspects, and prevention programs. La Clinica Terapeutica. 2019;**170**(3):E223-E230. DOI: 10.7417/ CT.2019.2137

[7] World Health Organization. COSI: Severe Obesity among Children Aged 6-9 Years [Online]. 2019. Available from: http://www.euro.who.int/\_\_data/assets/ pdf\_file/0019/400654/COSI-Severe-Obesity-FS-ENG-LowRes.pdf?ua=1

[8] Spinelli A et al. Prevalence of severe obesity among primary school children in 21 European countries. Obesity Facts. 2019;**12**(2):244-258. DOI: 10.1159/000500436

[9] Cohen AK, Rai M, Rehkopf DH, Abrams B. Educational attainment and obesity: A systematic review. Obesity Reviews. 2013;**14**(12):989-1005. DOI: 10.1111/obr.12062

[10] Kumar S, Kelly AS. Review of childhood obesity: From epidemiology, etiology, and comorbidities to clinical assessment and treatment. Mayo Clinic Proceedings. 2017;**92**(2):251-265. DOI: 10.1016/j.mayocp.2016.09.017

[11] World Health Organization. WHO European Childhood Obesity Surveillance Initiative (COSI). Copenhagen, Denmark: World Health Organization Regional Office for Europe; 2020. [Accessed: 14 September 2020]. Available from: https://www. euro.who.int/en/health-topics/disease prevention/nutrition/activities/ who-european-childhood-obesitysurveillance-initiative-cosi

[12] WHO. WHO European childhood obesity surveillance initiative: Overweight and obesity among 6-9-year-old children. Report of the third round of data collection 2012-2013 (2018); 2018

[13] European Commission. EU Action Plan on Childhood Obesity 2014-2020. European Journal of Commission. 2014;(July):68. DOI: 10.2785/36105

[14] WHO. Latest Data Shows Southern European Countries Have Highest Rate of Childhood Obesity. 2018

[15] Lobstein T et al. Child and adolescent obesity: Part of a bigger picture. Lancet. 2015;**385**(9986):2510- 2520. DOI: 10.1016/ S0140-6736(14)61746-3

[16] World Health Organization. Mapping the health system response to childhood obesity in the WHO European Region An overview and

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country perspectives. Copenhagen, Denmark: WHO Regional Office for Europe; 2019. [Accessed: 14 September 2020]. Available from: http://www.euro. who.int/pubrequest

[17] WHO. Global Health Observatory, World Health Organization. Available from: https://www.who.int/data/gho [Accessed: 16 July 2020]

[18] World Health Organization||Food and Agriculture Organization of the United Nations. In: Strengthening nutrition action: A resource guide for countries based on the policy recommendations of the Second International Conference on Nutrition (ICN2). Geneva, Switzerland: World Health Organization; 2018. Available from: https://apps.who.int/iris/ handle/10665/274739

[19] World Health Organization. WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020. Geneva, Switzerland: World Health Organization. [Accessed: 14 September 2020]. Available from: https://www.who. int/nmh/events/ncd\_action\_plan/en/

[20] World Health Organization. Tackling NCDs: "best Buys" and Other Recommended Interventions for the Prevention and Control of Noncommunicable Diseases. Geneva, Switzerland; World Health Organization: 2017. Available from: https://apps.who.int/iris/ handle/10665/259232

[21] Joint FAO/WHO evaluation of the work of the Codex Alimentarius Commission. 2003

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[26] Childhood Obesity: Applying All Our Health–GOV.UK. 2020. Available from: https://www.gov.uk/government/ publications/childhood-obesityapplying-all-our-health/childhoodobesity-applying-all-our-health [Accessed: 18 July 2020]

[27] EPODE Tackles Childhood Obesity in France | CYP Now. 2019. Available from: https://www.cypnow.co.uk/ best-practice/article/epode-tackleschildhood-obesity-in-france [Accessed: 18 July 2020]

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[29] National Board of Health. Center for Health Promotion and Prevention National Action Plan against Obesity [Online]. 2003. Available from: https:// www.sst.dk/~/media/681E3288F0A14C2 EAA71ED9C4866D01F.ashx

#### **Chapter 11**

## Unmet Supportive Care Needs of General Cancer

*Ezaddin Kamal Mahmod and Saadia Ahmed Khuder*

#### **Abstract**

Purpose Aside from their oncology condition, cancer patients often experience many ancillary problems, including negative physical symptoms, social isolation, spiritual suffering, and often psychological distress. Supportive care services can be defined as services designed to help patients, their families, and caregivers with their experiences during the diagnosis, treatment, follow-up, and palliative stages of the cancer journey. In an extensive review of the literature, we identified no previous studies that have investigated the SCNs of cancer patients in Iraq or any other Middle Eastern countries. Therefore, this study aims to determine the SCNs of cancer patients in Iraq. Methods The present cross-sectional study and data was conducted in Rezgary teaching and Nankaly Oncology Hospital in the Kurdistan Federal Region of Iraq. A total of 300 eligible cancer patients were invited to participate in the study from February to August, 2018. Eligibility criteria included: 18 years or above; having a definite diagnosis of any type of cancer; physically or mentally able to participate in the study; and being aware of exact diagnosis for at least three months. Results In 15 items of the SCNs, more than 60% of the participants reported that their needs were unmet. Most frequently, unmet needs were related to health system and information, physical and daily living, psychological, and patient care and support domains, and most met needs were related to physical and daily activity domains. Conclusions Kurdish cancer patients had many unmet needs and there is a need for establishing additional supportive care services and educational programs to increase quality of life in Kurdistan Region- Iraq.

**Keywords:** unmet, cancer patient, supportive care needs, Kurdistan region

#### **1. Introduction**

Cancer is the second leading cause of death worldwide, with an estimated global health burden of 193.6 million disability-adjusted life years. This presents a particular challenge for developing nations, which face additional challenges in delivering complex cancer treatments [1]. As a result, the diagnosis of cancer may be experienced as a stressful event that negatively impacts many aspects of patients' lives [2].

After the Iraqi regime change in 2003, rapid changes occurred in the lifestyles of Kurdish people that affected patterns and rates of cancer trends in Kurdistan. Additionally, the population suffers from the cumulative impacts of three vicious wars in Iraq, including targeted genocide against the Kurds and the use of chemical weapons, creating long-term environmental pollution and increasing cancer incidence, aside from their immediate casualties, with especially high rates of

hematological malignancies. Tentative published data evidences the increasing cancer prevalence in Kurdistan, [3–6] but related phenomena and care needs have not been explored in detail. This study presents new and more accurate data on the patterns of cancers in Kurdistan and the care needs of cancer patients.

Aside from their oncological condition, spiritual suffering, social isolation, and negative physical and psychological symptoms are among many other problems that cancer patients may experience [7, 8]. Due to this, a variety of supportive care services is needed and has to be reinforced [2, 9]. Such services can be directed to support patients, their families, and caregivers during different stages of the cancer journey, such as at the initial post-diagnosis phase, the duration of treatment and follow-up, and even end of life care [6]. Currently, offering supportive care services is regarded to be of equal importance to the diagnosis and treatment of cancer itself, and it involves more holistic healthcare provision compared to the biomedical approach that dominates mainstream oncology treatment [10]. The first step in planning any supportive care services for cancer patients is identifying their supportive care needs (SCNs) [1, 11, 12].

While several studies have investigated the SCNs of cancer patients worldwide, most were conducted in Western countries [11, 13–20]. Few studies have investigated the SCNs of cancer patients in non-Western settings, but pioneering research indicates that cancer patients in the latter have many unmet supportive needs, albeit there are numerous methodological issues and diverse findings between studies in Western and non-Western countries [21–25].

Unmet needs are defined as "the requirement for some desirable, necessary or useful action to be taken or some resource to be provided in order for the person to attain optimal well-being" [26, 27]. A systematic review by Harrison et al. [28] concluded that unmet needs were frequently reported in relation to activities of daily living, psychological and psychosocial issues, the need for information, and physical concerns. Similar findings were reported by Fiszer et al. [29].

SCNs are a "culture-dependent" notion. Thus, cultural issues must be taken into consideration when developing an effective supportive care program [23]. After an extensive literature review, no previous studies found to investigate the SCNs of cancer patients in Iraq or in any other Middle Eastern countries. Hence, this study aimed to determine the SCNs of cancer patients in Iraq.

#### **2. Materials and methods**

This study was conducted in Rezgary Teaching Hospital and Nankaly Oncology Hospital in the Kurdistan Federal Region of Iraq. Both hospitals are educational centers affiliated with Hawler Medical University, a referral center for sub-special cancer treatment.

A total of 300 eligible cancer patients were invited to participate in the study from February to August, 2018. Participant eligibility criteria included being aged 18 years or above; having a definite diagnosis of any type of cancer; being physically or mentally able to participate in the study; and being aware of exact diagnosis for at least three months.

Participants completed a questionnaire comprising two parts. Participants' basic socio-demographic and disease-related characteristics were assessed in the first part. In addition, information regarding medical treatments was obtained from the participants' health records. The second part consisted of an SCNs Survey (SCNS), used to examine the SCNs of cancer patients; it is derived from previous studies [30]. The SCNS comprises 48 items addressing five domains of needs:

*Unmet Supportive Care Needs of General Cancer DOI: http://dx.doi.org/10.5772/intechopen.96063*


Each item was based on a five-point Likert scale (1 = not applicable or no need, 2 = satisfied, 3 = low need, 4 = moderate need, 5 = high need). To determine the SCN score, the five-point Likert scale was dichotomized to unmet need (for moderate need or high need) or no need (for not applicable, satisfied, or low need). Previous researches have used this scoring system widely [23, 24].

The English version of the SCN SF48 was translated into Kurdish by two independent English-Kurdish translators. Eight academic staff at Hawler Medical University (HMU) College of Nursing reviewed the questionnaire to ensure face and content validity. Based on their comments, minor amendments were made. The internal reliability coefficients (Cronbach's alpha values) of the translated questionnaire were substantial (greater than 0.90) when piloted with 25 cancer patients.

The participants were recruited from inpatient wards of both studied hospitals. Participants were provided with information about the study and the questionnaire to fill in. If participants were incapable to complete the questionnaire due to literacy problems, the researchers assisted them to complete it with a short interview.

Many cancer patients in Iraq may not know the exact diagnosis of their disease, and only limited information is disclosed to them, as highlighted in previous research. Consequently, an important clinical concern in this study was to determine participants' own awareness of their diagnosis of cancer [3–6]. In order to identify this and prevent unwanted revelations, this information was obtained from the patients' caregivers and/or healthcare professionals and then checked with the patients through a short private interview. This procedure was approved by the Regional Ethics Committee at HMU College of Nursing. All participants were informed of the study aims and objectives, and informed consent was obtained. Participants were told that participation was entirely voluntary, and their decision would not affect their care or statutory rights. They were also assured of data anonymity and their right to withdraw from the study at any time.

Data analysis was performed using SPSS version 22 (SPSS Inc., Chicago, Illinois). Analyzing the demographic characteristics, cancer-related information, and unmet and met SCNs of participants was undertaken using descriptive statistics (frequency, percentage, mean, and standard deviation).

#### **3. Results**

Participants' demographic and cancer-related features are reported in **Table 1**. Most of the participants were female (66.7%), married (84.7%), educated at primary level (19.7%), employed as independent workers (65.7%), and living in urban areas (54.7%). More than half of them were aged above 48 years old. The particular cancer


**Table 1.**

*Participant demographic and disease-related characteristics.*

#### *Unmet Supportive Care Needs of General Cancer DOI: http://dx.doi.org/10.5772/intechopen.96063*

diagnosis, treatment received, and the taking of treatment were noted; over 40% of the 120 patients participating in this study had been diagnosed with breast cancer, and their treatment was primarily chemotherapy and/or radiation therapy. Most of them attended treatment and were receiving chemotherapy.

The data analysis shows that in 13 items of SCNS, more than 65% of the participants reported that their SCNs were not satisfied (**Table 2**). This demonstrates that the participants have many unmet SCNs. In terms of domain, 6 of these 13 items concerned H&I; 3 were Psycho; 2 were in NS; and 1 each was in P&D and the P&S domains. In H&I, three 3 of the most unmet needs were "Being given information (written, diagrams, drawings) about aspects of managing your illness and side-effects at home," "Being informed about your test results as soon as feasible," and "Being adequately informed about the benefits and side-effects of treatments before you choose to have them." These results highlight that the patients have many unmet needs, especially in the information domain. Within the Psycho domain, the 3 most unmet needs were for "Concerns about the worries of those close to you," "Anxiety," and "Concerns about the ability of those close to you to cope with caring for you." This means that the patients were distressed about the outcomes of the disease or worried about the changes in the routines of their disease and their families. The most frequent unmet needs were "Concerns about your financial situation" and "Concerns about getting to and from the hospital," which were related to the non-specific domain. In the P&S domain, only one item was reported as highly unsatisfactory by more than 83% of participants, which was "Lack of energy and tiredness."

Participants' mean scores in the SCNS domains are illustrated in **Table 3**. In four domains (Psycho, H&I, P&D, and P&S), the participants gained scores of more than 10, which indicates that most of the participants had many unmet needs. However, only the sexuality domain had a score of less than 10. The most unmet needs were for the domains of H&I (36.42), P&D (35.56), Psycho (28.4), P&S (14.27), sexuality (7.76) and non-specific (6.07).


#### **Table 2.**

*Top 15 unmet SCNs of cancer patients.*


#### **Table 3.**

*The score of participants in each domain on SCNs survey.*


#### **Table 4.**

*Top 10 most frequently met needs of participants.*

The 10 most frequently met needs of participants are reported in **Table 4**. More than 70% of the participants reported that they have no needs in these items. As shown in this table, in terms of the studied domains, 4 of the commonly met needs related to aspects of physical and daily activity; and 3 each related to the H&I domain. Interestingly, 4 of these items are related to P&D (3 items) and H&I mean no need to help in physically and patients have equal rights to being treatment and follow-up.

#### **4. Discussion**

To our knowledge, this is the first study that has investigated the SCNs of cancer patients in the Kurdistan Federal Region, and indeed Iraq in general. The results demonstrate that Kurdish cancer patients have many unmet SCNs, especially in the domains of health system, information, P&D. Most of the participants reported unmet SCNs in 13 items of SCNs.

In an extensive review of the literature, it was found that some studies reported that cancer patients have low needs; [11, 19] but most studies highlight that cancer patients in both non-Western [17–21] and Western countries [9, 14, 31] have many SCNs. None of the analyzed studies reported such high levels of needs as reported by the participants of our study.

#### *Unmet Supportive Care Needs of General Cancer DOI: http://dx.doi.org/10.5772/intechopen.96063*

The results of our study demonstrate that 6 out of 15 most frequently unmet SCNs of cancer patients are related to the H&I domain. This finding is to some degree different with previous studies conducted in Western countries, which reported the H&I domain to be the second or third domain in which cancer patients' needs are unmet [6, 9, 13, 32–36]. Conversely, the findings of other studies conducted in Southwest Asia indicated that H&I domain needs are among the most frequent unmet SCNs of cancer patients [17, 20, 21, 34]. Likewise, a comparative study revealed that Hong Kong breast cancer patients ranked H&I needs as the most frequent unmet SCNs, while German women consider needs from P&D and Psycho needs to be the most frequently unmet supportive care they experienced [19]. Therefore, this finding supports that SCNs are a culture-dependent issue [19]. Additionally, survivors' needs are dynamic and might change over time. A shift in perceived cancer survivors' needs from informational needs to Psycho needs has been found by researchers, partly attributable to improvements in information delivery over the years [37]. Further research is required to ascertain whether the predominance of H&I needs in the Kurdistan region can be justified by reasons like changing expectations for information provision due to ease of access to internetbased information, or an institutional deficit instigated by other possible reasons, such as lacking clinical resources or insufficient staff education. No additional evidence could be established on the prevalence of cancer patients' informational needs, and whether these needs have changed over time or been influenced by contemporary changes in information seeking practices.

The results of our study also indicated that Psycho needs are the second category of unmet SCNs of Kurdish cancer patients, after H&I needs. This finding is consistent with the results of other studies in non-Western countries [17, 20, 21, 37]. It should be noted that Kurdish cancer patients are often unaware of the prognosis of their diseases, and consider cancer to be a conventional, curable disease. Consequently, it can be inferred that the nondisclosure of cancer prognosis for most Kurdish cancer patients may explain the unusually low level of Psycho SCNs found among Kurdish cancer patients.

The results of this study have important clinical implications, particularly in demonstrating that cancer patients in the Kurdistan Region of Iraq have many SCNs in different domains. Few established supportive care programs are available for patients with cancer in Iraq, and our findings underline that there is an urgent need for such programs to be established. Most unmet SCNs cancer patients in Iraq are from the perspective of the domains of H&I and P&D. Thus, educating cancer patients and meeting their H&I and Psycho needs should be considered as a fundamental part of supportive care programs.

There are limitations to our study. This study was conducted in two oncology centers in the Kurdistan Region of Iraq; even though the setting comprises the main referral center for a large province in northern of Iraq, it does not include all areas of Iraq. The findings related to non-specific SCNs ought to be interpreted with caution, considering the taboo associated with sexual issues in Iraq and Kurdish culture. Further studies are necessary that investigate the SCNs of different cultures in the Middle East. Using other data collection methods, including private interviews, may increase the validity of results in the sexual domain of SCNs.

#### **5. Conclusion**

This study highlights that Kurdish cancer patients have many unmet needs in all domains of SCNs. These findings indicate that programs and services to address the SCNs are urgently needed. Future research in Iraq should shed light on the

#### *Teamwork in Healthcare*

particular SCNs of patients in cultural contexts, to help tailor more comprehensive and holistic care, particularly for cancer patients, in order to improve the quality of healthcare services provided.

### **Ethical considerations**

The research project was approved by the Ethics Committee of Hawler Medical University, College of Nursing (Project No. 3, approval date: 2016/03/16).

### **Author details**

Ezaddin Kamal Mahmod\* and Saadia Ahmed Khuder Hawler Medical University, College of Nursing and Midwifery, Erbil City, Kurdistan Region, Iraq

\*Address all correspondence to: ezaddinbotany@yahoo.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Unmet Supportive Care Needs of General Cancer DOI: http://dx.doi.org/10.5772/intechopen.96063*

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*Unmet Supportive Care Needs of General Cancer DOI: http://dx.doi.org/10.5772/intechopen.96063*

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### *Edited by Michael S. Firstenberg and Stanislaw P. Stawicki*

One of the most important advances in the delivery of healthcare has been recognition of the need for developing highly functioning multi-disciplinary teams. Such teams, when structured in a cohesive fashion, can function more effectively and efficiently than the sum of their parts. The benefits of teamwork extend from the delivery of care to a single patient to the overall structure and function of entire care delivery systems. Recognizing the value of collaborative approaches for improving all aspects of healthcare delivery and having champions, leaders, structure, function, goals, and accountability are paramount to success, regardless of how defined. Another important pillar of teamwork is excellent communication with clearly defined information flows and cross-verification mechanisms. This book outlines how to work together for shared goals in a complex, diverse, and constantly evolving health care system.

Published in London, UK © 2021 IntechOpen © Tomwang112 / iStock

Teamwork in Healthcare

Teamwork in Healthcare

*Edited by Michael S. Firstenberg and Stanislaw P. Stawicki*