Background
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school communities’ understanding of, and participation in the closures;
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interactions between the school community and health officials; and
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the beliefs and values which underpinned community responses.
Methods
Recruitment and study procedure
Study participants
Data analysis
Value | Description |
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Accountability
| There should be mechanisms in place to ensure that ethical decision-making is sustained throughout the crisis |
Inclusiveness
| Decisions should be made explicitly with stakeholder views in mind and there should be opportunities for stakeholders to be engaged in the decision-making process. For example, decision-making related to staff deployment should include the input of affected staff. |
Openness &Transparency
| Decisions should be publicly defensible. This means that the process by which decisions were made must be open to scrutiny and the basis upon which decisions are made should be publicly accessible to affected stakeholders. For example, there should be a communication plan developed in advance to ensure that information can be effectively disseminated to affected stakeholders and that stakeholders know where to go for needed information. |
Reasonableness
| Decisions should be based on reasons (i.e., evidence, principles, values) that stakeholders can agree are relevant to meeting health needs in a pandemic influenza crisis and they should be made by people who are credible and accountable. For example, decision-makers should provide a rationale for prioritising particular groups for antiviral medication and for limiting access to elective surgeries and other services |
Responsiveness
| There should be opportunities to revisit and revise decisions as new information emerges throughout the crisis as well as mechanisms to address disputes and complaints. For example, if elective surgeries are cancelled or postponed, there should a formal mechanism for stakeholders to voice any concerns they may have with the decision. |
Results
Schools’ responses to closure
Interactions between schools and public health officials
Personal responses during the closures
Making meaning of school closures in a pandemic: ethical processes and values for schools, parents, students and policy makers
Ethical processes | Ethical decision-making or decisions should be… | Evidence of ethical processes in study | Examples - positive | Examples - negative |
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Accountability, openness and transparency | sustained throughout the crisis and publicly defensible – processes should be open to scrutiny and reasons for decisions publicly accessible | Mixed – strong processes in some schools but not in others | “That Monday morning we had signs on all the gates to say that the school was closed to year 10 students. We had staff monitoring all the gates to make sure if a year 10 student didn’t get the message that we would send them home. Actually we didn’t have a single student turn up…, but I think having the SMS messaging system was absolutely critical. The feedback we got afterward was that instant contact with parents through SMS, through emails, through phone calls, …it was really critical”. [Principal, school 5l] | “It was clear that we were to stay home. It wasn’t clear whether people could visit us. It wasn’t clear whether our family could leave. So the people we lived with…That wasn’t clear but it was very clear that we had to stay home for the week.” [Teacher, school 3] |
“If they want them home and in quarantine from potential contact, then it really should be stated that that's what they want. Some people are just going to ignore it anyway, no matter what you do, but for people who do actually read and take notice of these things, it makes it easier to make a more informed decision like yes, I can see the point of this, I will keep them home, not let their friends come around, not take them to sport or out shopping with me sort of thing” [Parent, school 4] | ||||
Inclusiveness | made with stakeholder views in mind and stakeholders should be engaged in the decision-making process | Inclusive approaches in some schools but not in all (leading to confusion in message transmission) | . . . we were aware that through Facebook, things were going out absolutely everywhere. So we thought, we can’t stop that, what we can do is educate the [students] so that what they are sending out is informed, we ran through our student leadership groups, we ran seminars . . . to say . . . if you’re going to be talking about this, this is what you should be talking about . . . if you’re going to be talking to your mates or talking to . . . mates of mates, which happens with Twitter and Facebook or whatever, this is what you should be saying.{Principal, school 5] | “.......it became a directive that you must close those classes. … Generally the school knew that that wasn't going to stop it because everyone in the school we believed had some contact with someone else who actually knew that child, so it was either all school closure or non school closure.” [Principal, school 4] |
Reasonableness | based on reasons (evidence, principles, values) and made by people who are credible and accountable | In general, perceived lack of clear rationales for closures | “It was clear, like just stop I guess interaction with one another and just stop the spread so that was really clear and that’s why I guess I definitely stayed home for a while…It wasn’t clear why we would meet altogether in the gym if that was the case so… Like there was some irony I guess in meeting altogether…” [Teacher, school 3] | |
“The official line was we refer to the government website … and a lot of the information on there was quite ambiguous..... And it was really putting the onus back onto the individual to make a judgement, as was the case with me. That’s why I made the judgement that well I don’t have any symptoms, I haven’t taught that boy directly, I haven’t come in contact with that boy directly, therefore it’s highly unlikely that I would be irresponsible by going interstate. So, I did, and I was fine”. [Teacher, school 4] | ||||
“and the real confusion lies in that the kids were told that they shouldn’t go out and they should stay fairly contained but be at home with family. But the family could all go out and they couldn’t see the logic in it…” [Teacher, school 3] | ||||
Responsiveness | revisited and revised as new information emerges | Mixed – while policy changes responded to the changing situation, some members of school communities interpreted the policy shifts as inconsistent and not responsive to local circumstances | “I think the biggest issue with school closures…was it wasn’t consistent. They changed the rules and then even after we excluded people, the initial exclusion was for a week but then we changed the rules and told them to come back after two days. So I think that you have to be consistent and there’ll still be phases. I can understand phase one, phase two, phase three or whatever phases they need because once it’s reached a certain point you realise that isn’t working and it’s probably more disruptive than it’s doing any good”. [Teacher, school 2] |
Ethical values: | Decision-makers must strive to: | Evidence of ethical values in study | Examples - positive | Examples - negative |
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Values which were strongly in evidence
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Duty to provide care | – work collaboratively with stakeholders to establish practice guidelines | Strong: All groups took duty to care seriously; schools had a broader definition of duty of care. | [Do you think that closing the school was an appropriate response…] | |
At that time, yes I do. Yes. Because I think that, again, if it had spread – [but] I mean, I teach a Year 12 class and we simply cannot afford the time to be mucking around and just staying away, et cetera… [Teacher, school 3] | ||||
– develop fair and accountable processes to resolve disputes | ||||
“Well, I guess when we knew that it wasn’t even as strong as the normal flu or whatever so that seemed kind of stupid but then there was the other argument which was; what if it turns into something really bad”. [Student, school 2] | ||||
Protection of the public from harm | – weight the medical and moral imperative for compliance | Strong – good awareness of need to protect public from harm | “… I really thought some of the rules were totally ridiculous but I didn’t want to put others at risk … I did take the dog for a walk but I made sure I went on a route where I wasn’t going to come in contact with anyone because I can’t sit still for 24 hours…But I think it was more – like I wouldn’t have visited my brother because I didn’t want to put his kids at risk.” [Teacher, school 2] | |
– ensure public are aware of medical and moral reasons for public health measures | ||||
– ensure public are aware of benefits of compliance and consequences of non-compliance | ||||
– establish mechanisms to review decisions as public health situation changes | ||||
[So thinking about the fact that you stayed home for that whole week and sort of stuck to the regulations I guess, what sort of promoted you to do that? Why did you stick to the rules?] | ||||
“Um.... There wasn’t really any point for me going out anyway, you know. I’d rather stay home, just stick to what rules were set then…yeah, ‘cause if I did have the infection I didn’t want to spread it any more.” [Student, School 4] | ||||
Stewardship | – consider benefits to the public good and the fair distribution of benefits and burdens | Strong- serious efforts to minimise harm and use the pandemic for good ends | “Before I left to go home that day I scanned in all of my lesson plans and all the resources for my Year 12 classes, which I was most anxious about. And so I emailed those to all of my students, and I was in phone contact, I was on email, and I set them enough work to make sure they didn’t lose any time or we didn’t fall behind in our course......I didn’t mind doing that. … And with my Year 10s, I didn’t set them as much work, and I was available through email and I gave them my home phone number”. [Teacher, school 1] | |
Values for which evidence was mixed
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Solidarity | – ensure good, open, honest communication | Mixed: Solidarity between PH officials and schools in some situations, but not all. | “Look, Communicable Diseases were fantastic. They were probably in the same spot we were....”. [Principal, school 3l] | “Effectively the only thing we really got told was to … try not to go to public places etc . . . a few of us [were] going out to dinner on Saturday night, so we cancelled that, then found out [a school leader] went to the football that Friday night. [The school leader] said that some information had come through later that we didn't have to be as isolated. That wasn’t conveyed to staff in any way, shape or form, which I thought was pretty disgusting. . .” [Teacher, school 3] |
– open collaboration in a spirit of common purpose between institutions | “I would say as the events unfolded that the communication … from the school was outstanding and from the Health Department who were here and giving information to the kids and to parents. There were daily phone calls to find out whether [our son] had shown any symptoms and when we were at work and he was at home on his own those phone calls were still there.” [Parent, school 1] | |||
– share public health information | ||||
– coordinate delivery of health care and deployment of human and material resources | Lack of solidarity undermined School closures | |||
Privacy | – disclose only private information relevant to achieve legitimate and necessary goals of public health | Mixed: good awareness of privacy issues but sometimes practices undermined this | “So, you know, we sort of, we really wanted to stress to the media that this is a human story It was about the dignity of the child that’s ill, and the dignity of all people that [have] swine flu…” [Principal, school 5] | “Oh, there was nothing subtle about it. Everyone knew that if you were the three students . . . that got the pink one [form], that meant it was really bad, and if you were the 27 kids that got the orange colour, then that meant it was really good . . . They are very attuned - the kids know . . . they pick it up straight away. . so they knew straight away…..yeah, the pink one - oh my god, I’m going to die. It was like, oh my god, that’s it; and then the bursting into tears stuff.... Because no one really knew”. [Teacher, school 4] |
– release private information only if there is no less intrusive means to protect the public. | ||||
– provide public education to correct misperceptions about disease transmission | ||||
Equity | – preserve as much equity as possible between interests of those with influenza and others | Mixed: awareness of equity issues but sometimes practices undermined this | Some of the wording from the Department is very hard for families to understand. They would read something like a release and they would ring up and ask what does that mean? We would have to explain that means this. Why doesn’t it say that? It does but [not] someone whose third or fourth language is English. [Principal, school 3] | “Totally confused about the home isolation. We tried to clarify that through the web and realised how many families and parents don’t have [access to] the web”. [Principal, school 3] |
– ensure procedural fairness in decision-making | ||||
“… the Year 12s … they obviously blamed the Year 10s for bringing it in and … then they all started hating us… The [student]who had it … had to have a couple of days off when [they were] better because [they] just couldn’t handle people…sneering at [them]…” [Student, School 1] | ||||
Individual liberty | – ensure restriction to individual liberty are proportional to harm, necessary and relevant to protecting public good, employ least restrictive means and are applied without discrimination | Mixed: range of views about whether restrictions on liberty were justified | They said there was a real concern. They were really concerned about it. Therefore you must take it with some seriousness. [School librarian, school 1] | “..He [stayed home] pretty well but I think he went down and had a hair cut at the local hairdressers and a couple of other things. I don’t think he mixed with many other students. But he went off and did his violin lesson as he normally does....As far as I was concerned, if he was symptom free, the risk of him transferring it was no greater than anyone else in the community.” [Parent, school 2] |
Values for which there was little evidence or contrary evidence:
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Proportionality | – use least restrictive or coercive measures to limit individual liberties or entitlements | Lacking: Most members of school communities thought the response was not proportional to the danger | “. . it would be the wrong thing to say it was a sop to the policy, but that’s what it turned out to be, because in reality we had one student who had minimal contact with a small number of students, and we shut the whole place down as a result of that.” [Principal, school 1] | |
– use more coercive measures only when less restrictive measures have failed to meet public health goals | ||||
Reciprocity | – ease burdens of stakeholders responding to public health measures | Lacking: little to no awareness of impact on individuals; stigmatisation | “… I did ring up a girlfriend and asked her to do some shopping she dropped things on the front verandah, knocked on the door, and went. [sigh] so it was a bit of a lonely time for me. When you’re on your own, to be totally isolated with no one. With no contact with anyone, except the telephone.” [School librarian, school 1] | |
Key value
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Trust | – take steps to build trust with stakeholders before a crisis | Mixed: not strongly apparent in all schools, but where displayed school closures worked well | ....it was difficult when I didn’t quite understand it, but then, we trusted fully with the Department of Health. They inspired a lot of confidence. I think they were fantastic with this. [Principal, school 5] | “. . . you don’t know how much PR was involved versus actual medical necessity . . when any government agency is making a decision…they need to be seen to be handling it in a controlled way . . . for fear of being criticised in the media for it.” [Teacher, school 2] |
– ensure decision-making processes are ethical and transparent to affected stakeholders | ||||
“Someone got positive for swine flu in my grade. Everyone was a bit nervous but a lady came along and she told us it was alright and stuff. But yeah, the principal was saying, just everyone keep calm. [Student, school 3] |