Study eligibility

Any study published in English from 01 January 2000 to 01 June 2020 that has 1) performed a situation analysis to assess the environment for pandemic management, or 2) examined macro-level contextual determinants influencing pandemic management of one or more of the following pandemics: Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), COVID-19, Influenza A (H1N1), Ebola virus disease, and Zika virus disease, were considered in this review, in any country(ies) setting(s). The PICO (Population, Intervention, Comparison and Outcomes) [14] and SPIDER (Sample, Phenomenon of interest, Design, Evaluation, Research type) inclusion and exclusion criteria were applied at the review stages [15]. Studies focussing solely on other infectious diseases (eg, tuberculosis, malaria, HIV/AIDS, cholera, dengue), non-communicable conditions (eg, obesity, diabetes, Alzheimer disease, substance misuse), or local outbreaks (eg, a Methicillin-resistant Staphylococcus aureus outbreak in one hospital) were excluded.

Search strategy and information sources

The methods used in this review are in line with the PRISMA extension for scoping reviews (PRISMA-ScR) guidelines [16]. The protocol is available from the authors upon request. The PRISMA-ScR checklist was completed to guide study selection and data extraction. We restricted the search period from January 2000 onwards to capture major pandemics. We limited the language to English. We searched PubMed, Ovid MEDLINE, Ovid EMBASE, Global Health, Health Management, and the Cochrane Library databases. Searches included both controlled vocabulary (pre-defined subheadings) (eg, Pandemics) and text words (eg, strategic analysis). The search strings used are provided in Appendix S1 of the Online Supplementary Document .

Study selection

The title and abstract of the studies yielded from the database and reference list search were randomly assigned into two groups. Three researchers (NZ, RA, HK) participated in the title and abstract screening and in each group, by rotation, one pair independently reviewed each title and abstract and the third researcher resolved the disagreements in decisions (Group 1 - RA, Group 2 - HK). Two researchers (NZ, HK) independently reviewed the full-text articles which passed the title and abstract screening. All discrepancies were discussed and re-examined by the third reviewer (RA) until agreement was reached.

Assessment of study quality and risks of bias

We excluded those studies where a full article was not available (eg, conference proceedings, meeting minutes). We excluded studies that did not include the sections in the preferred reporting items set out in the PRISMA-ScR checklist [16].

Formal quality appraisal of the included individual studies was not performed, as this would be beyond the aim of this scoping review, which was to map key concepts, types of evidence, and gaps in research [17,18]. Evaluation of intervention and policy effectiveness is not the aim of the current review [19,20].

Data extraction and analysis

Three researchers (NZ, HK, RA) carried out data extraction, with cross-validation for 50% of the studies using a standardised data extraction table (Microsoft Excel, Microsoft Inc, Seattle, WA, USA). We anticipated descriptive results given the qualitative nature of the studies. Key study characteristics, methods of data collection, situational analyses frameworks employed, and which of the PESTELI domains had been examined (E), findings reported on (F) and recommendations made (R) were extracted ( Table 2 ). Factors influencing pandemic management into facilitators and inhibitors against the 7 domains were synthesised ( Table 3-6 Table 4 Table 5 Table 6).

Ethics approval

This study did not require ethics approval as is a literature review.

Included studies

A total of 176 studies were identified from the primary electronic databases. Two further studies were identified through a search of reference lists. After removal of duplicates and studies in diseases not of interest, a total of 144 records remained for screening. 45 studies were eligible for full text review and 26 studies were excluded with reasons, yielding 19 studies that met the inclusion criteria. Figure 1 summarizes the flow of literature search and screening.

Figure 1.  Study flowchart.

Study characteristics

Of the included studies, 6 were single country analyses [21- 23,25,26,31], and 13 were regional level multi-country studies [24,27-30,32-39]. Fourteen studies had a single disease focus, with 3 studies on COVID-19 [21- 23], 4 studies on Ebola virus disease [24-27], and 7 studies on Influenza A [ 28-34]. Five studies evaluated responses to one or more of COVID-19, SARS, MERS, Influenza A (H1N1), Ebola virus disease, and Zika virus disease pandemics [35-39].

No study included in this review explicitly set out to employ the PESTELI framework, but 3 studies employed alternative frameworks, including the SWOT (Strengths, Weaknesses, Opportunities, and Threat) framework [21], the PIP (Pandemic Influenza Preparedness) framework [28], and the SYSRA (Systemic Rapid Assessment) framework [30]. The other 16 studies examined macro-level determinants affecting the response and ability to manage the pandemic, including workforce mobilisation and deployment; adherence of vaccination and antiviral therapy; public knowledge, awareness, and perception; and compliance of non-pharmaceutical interventions. All studies were published after pandemic emergence. The timeline of the pandemics against the publication of the included studies ( Figure 2 ), shows a notable gap for SARS and Zika.

Figure 2.  Pandemic and study publication timeline.

Most of the studies employed one method of data collection: 9 reviews of the published academic literature [26,32- 36,38-40] and 2 [23,31] used primary data through population survey surveys.

Four studies [21,25, 28,30] used primary data via interviews or panel discussion with experts and stakeholders as well as secondary data collected through review of literature or other textual sources.

Ten studies were results of work by researchers from a single country [21-23,26 ,29,32-34,36,39]. Nine studies were outcomes of international collaborations, where all corresponding authors of these international study groups were from high income countries bar 1 [24,25 ,27,28,30,31,35,37,38]. Two studies involved co-operation between research institutes and international agencies (ie, WHO and UN) [25, 28]. Two studies had co-authors from national and local health authorities [21,25 ]. One study bridged research institutes, national and local health authorities, and the private sector [37].

Analysis using the PESTELI framework

Though the PESTELI framework was not utilised, one study reported findings in each of the domains [ 28]. Most studies (16) included analysis of the sociological domain. Notable gaps are evident in the legislative (14 studies), ecological (12 studies) and economic (11 studies) domain. While the political domain features in 11 studies [21,24-28,30,35-37,39] only five of these make recommendations in this domain.

Political facilitators influencing the response included demonstration of political commitment [21,24,26], and strength in governance and stewardship [30]. Inhibitors within the political domain emanated from lack of coordination between central and local governments and inadequate preparedness plans (21,36); discord about which experts and institutes should lead [25] and the extent of inclusivity of stakeholders [35].

Under economic factors, international aid and external funds were a facilitator (28,29) but over reliance on external funding was also reported as a barrier [30 ]. Level of health system financing was an inhibitor [24 ,30] and facilitator depending on country context, particularly in regards to sustained community health worker investment and enhanced support during pandemics in the case of Ebola in Uganda and Sierra Leone [35 ].

Sociological facilitators were high media coverage and maintaining public attention [27]; professional training of staff in health care and social care organisations [35]; and social support to citizens in isolation [36]. Conversely, the most frequently reported sociological inhibitors include lack of public knowledge and public health education in infectious disease prevention [23,26 ,30,31]; stigma and discrimination against infected patients and health care professionals involved in direct patient care [25,26, 33,39]; cultural, traditional, and/or religious practices that may over-ride guidance and health protection messages [ 24,28,39]. Perceived low risk of infection threat and the low value of infection preventive measures [32,34], and, diametrically opposite, anxiety and fear [26,29], also hindered progress. Lack of trust and confidence in authorities and abilities of the health care system to cope affected health-seeking behaviours [26,33]. Recommendations were proposed in 9 studies to address these sociological inhibitors, and some repeated from the first of these studies in 2014 to the latest in 2020. Recommendations include transparent communication between government and citizens to share information that is up-to-date, easy to interpret, and relevant to contexts (eg, tailored information for vulnerable groups) [23,25,26,29,31,33,35-37].

Among the 7 studies, which included ecological analysis, 6 also analysed sociological factors [24,28,30,35,37,39]. The findings suggested that the drastic change in human lifestyle exerted an impact on ecological and environmental profiles, which then influenced human behaviour further. For instance, globalisation (S) and deforestation and climate change (E); dietary habits (S) and livestock production (E); population age distribution (S) and epidemiology profile (E); and international travel (S) and infection transmission (E). High vaccination coverage was the only ecological facilitator reported in 3 studies [28,30, 35]. Ecological inhibitors were centred around human behaviour; contact/proximity with wild animals; transmission of zoonotic diseases through livestock production, and high levels of international travel [24,28,37,38].

Among the 11 studies which assessed factors in the technological domain [21,22,25 ,26,28,30,35-39], existing information technologies did facilitate progress [22,30], but delayed deployment and limited utilisation of such technologies remained an inhibitor resulting in weak surveillance capacity [21,22 ,25,28,35,36,39]. In terms of the wider industry, internet coverage was cited as a facilitator [22] and inhibitor when coverage was low [37]. Industry inhibitors were an inadequate supply of personal protective equipment (PPE) and other medical resources [24 ,25,27,35,36]; and medical staff shortages [24,25 ,28,30]. As expected, the interdependence between the technological and industry domains is highlighted. Technologies reliant on uninterrupted power and network coverage are obvious examples, but also more basic equipment and supply-and-distribution chains rely on the existing wider industry or the ability to quickly scale up and deploy emergency provisions. Recommendations, including, for example, accelerated mobilisation of research and development (R&D) through incentives, were proposed to mitigate inhibitors in both technological and industry domains to enhance preparedness for future pandemics [22], but the timescales for this varied.

Overall, as noted above, the legislative domain was a gap in analyses and also was not explicitly assessed in the otherwise comprehensive assessment using the SYSRA framework of the Influenza A pandemic [30]. Five studies reported legislative facilitators [21,24,26,28,37] including travel bans and border closures [21,24,26]. The absence of legal frameworks for declaring an emergency and taking actions was cited as an inhibitor in the Eastern Mediterranean region [28].