Design a National Plan for Response to earthquake in the Health System: Study Protocol Abstract Background: For various reasons, including the inadequacy of management processes at supporting the national and regional levels, there is still a lack of national standards or programs to respond to earthquake hazards in the health system. Thus, the objective of the study was to address developing a specific response model which to consider effective planning to all sections of the health system. Method: This is a mixed (quantitative-qualitative) method based on four phases. In the first phase, a comprehensive review will be conducted. The second phase is a qualitative study in which the study population is including all managers and indivi (Preprint)

Abstract

Earthquake due to the severity of financial and human losses, it is one of the most catastrophic events compared to other disasters (1, 2). Also, 80% of earthquake casualties in the world are related to 6 countries, including Iran and in the last 3 decades, Asia has had one third of the world's natural disasters and in the meantime, Iran after China, India, Bangladesh, has the most damage caused by natural disasters (3). In the last hundred years, more than a thousand devastating earthquakes have occurred in seventy countries and out of every 153 devastating earthquakes that occurred in the world, 5/17% was related to Iran that this figure was even more than in Chain and Japan (4). These impacts indicate the lack of an effective and coherent response program. What is certain is that the social and human consequence of the earthquake are not limited to the affected areas but also may have some lasting consequences and mediated and impacts it will be found even decades later (5). Some of the consequences of earthquake include: Increased physical problems, social disruption, damage to social networks, decreased social tendencies, homelessness and insecurity, psychological and individual impacts, (increased stress, conflicts, decreased sense of usefulness, severe reduction of needs, lack of daily activities, physical and environmental impacts,(lack of access to health and medical services, pollution of water and soil resources, destruction of housing and economic impacts of livelihood (6, 7). The consequences of the earthquake seem to depend on the performance of three groups of policymakers, experts and executors. Therefore, if these three groups act in harmony and do their duties properly and in accordance with the scientific criteria the consequences of earthquakes will be greatly reduced; otherwise, the earthquake in Iran is damaging and catastrophic (8). The experience of other countries in this way is similar. After studying the effectiveness of the responses, three important questions were asked. Due to the vulnerability of the region to such events, the main reason for the failure of planners in forecasting and what was the preparation for the big earthquakes? How can a more effective set of programs reduce earthquake mortality? What better medical and health interventions can be provided for the injured and displaced? Therefore, to have a proper response in the correct response to earthquakes and other natural disasters, health system policymakers inevitably need to learn the knowledge of planning and management according to global standards disaster response and institutionalization are part of the national health system. Internationally, the Sendai framework for disaster risk reduction was developed during 2030-2015. The goal of its operational priority is to reduce the risk of natural disasters in 2015 approved by the United Nations General Assembly. It seems that despite the existence of the Sendai framework at the international level, currently in Iran, there is no theoretical approach and a coherent and well-known model in the field of hazard response. Despite the efforts made to develop a response plan in Iran many parts of the needs in the response process have been neglected (9, 10). In addition, the program in Iran is designed and published based on the common needs of all hazards and because the earthquake is considered a priority hazard in the country and impacts the health, well-being and welfare of society and has special features, in order to reduce plan can be annex to the national disaster response plan, so that operational units in different parts of the country can use the national model and pay attention to geographical requirements to address all the needs that this annex can impose on health.

The practical objectives of this research are as follows: The practical objectives of this research are as follows 1(Ability to use the program for different health departments in response to an earthquake 2 (developing the platform to enable timely, rapid, and comprehensive action in response to health-related needs in earthquakes, and 3) laying the groundwork for the development of local, regional programs though guidelines.

Study design This study is mixed method (qualitative and quantitative) consisting of four phases, each of which is an introduction to the implementation of the next phase (Additional file 1.). Phase 1: Identify the components of the response program to hazards (Comprehensive reviews) Aim: The first phase includes a comprehensive review to extracting and identifying the components of studies related to health response plan in which to prioritize earthquake studies to achieve a theoretical framework (This phase was completed in 2020). Study population: Studies, documents, books, reports and programs and frameworks designed and published in field of hazards management including PubMed, Springer, ProQuest, Science Direct, Scopus, Cochrane, Google Scholar as well as Persian databases such as SID, Iranmedex as well as websites of organizations such as United Nations, WHO, Fema, Ocha, Jica, Nidm, Word Bank, and crisis management organizations in selected countries involved in the field of humanitarian assistance. Keywords are included National plan, Response, Earthquake, Earthquake response system, health. Research sample: Documents, books, reports, frameworks and national and international programs, etc., which designed dealing with disasters focused on earthquake response in Persian and English. Inclusion criteria: Includes studies, documents and information resources that are related to the response plan and have been developed at the national level and are related to the activities of the disaster response phase. Research environment: The best practice and support for the development of research was included libraries, universities, internet and national intranet. Data collection tool: Data Extraction Form will be used to collect data, which includes fifteen specific functions and includes the dimensions of the disaster response program. Data collection method: Using search various strategies and keywords have been collected relevant information sources in both of English and Persian languages. For this purpose, electronic studies, articles and researches, reports and programs in recent years about national and local programs in response to earthquakes or the consequences of earthquakes on health in different countries are reviewed. New keywords and phrases may also be added during the study based tracking professors’ views. Data Analysis Strategy: The method is content analysis. At this stage, the researcher has attempted to identify the different dimensions of the earthquake risk response plan in the country and abroad so that he can use them in the next steps in compiling the national plan. Phase 2: Identifying experiences and reviewing health documentation in response to earthquakes (Qualitative study) Aim: This phase will be to focus on two goals, first identifying experiences and then viewing health documents in response to earthquake separately, but simultaneously will be done (This phase was completed in early 2021). Study population: Population included all employees who working in response-related activities in the sub-units of the Ministry of Health and Medical Universities, also, the documents including reports, lessons learned, books and manuscripts that have been extracted from the activities of health care units related to the Ministry of Health and Medical Education and the subdivisions of Medical Universities at the provincial level. Sampling: This phase began with goal-based sampling and it gradually continued as snowball sampling to saturate the data. Samples of participants selected among all managers and experts in charge of operational units in the departments of treatment, health and pre-hospital, food and medicine in the provinces affected by the earthquake. Also, documents related to the actions of different parts of the health system of the Ministry of Health and Medical Universities in response to hazard were considered by researchers. Inclusion criteria: Employee selected who working in the universities of medical sciences with the priority of Tehran, Kerman, Kermanshah, Bushehr, Isfahan and they had participated in operational activities related to the health system response to the earthquake and willingness to cooperate and participate in research and retelling their experiences to the researcher. Exclusion criteria: Individuals who are unwilling to respond to questions during the interview and withdrawal it. Ethical considerations: The present study was approved by the Ethics Committee of the Isfahan University of Medical Sciences (Code: IR.MUI.RESEARCH.REC.1399.758 & registration code: 399933). Data Collection tools: Interview guideline form and research fiches were used to collect data (Additional file 2.) Data collection method: The data collection method was semi-structured interviews. Data analyzing method: Framework analysis is used to refining the data into six stages of analysis, familiarization, identification of a thematic framework or indexing or coding basis, charting, and finally planning and interpretation (11, 12). MAXQDA 18 software was used to import, encode and analyze the data. Qualitative content analysis method was used to analyze the documents extracted from reports and archives(12). Data validation (in the supplementary interview section): To ensure trustworthiness of a research study was used the five Lincoln and Guba & Lincoln criteria (Credibility, Dependability, Conformability, Transferability, Authenticity) (13, 14). Phase 3: Development of dimensions of the national plan to response of the Iranian health system to the earthquake Aim: In the third phase, researchers compared and merged the results of the first and second phases. Output and expected results of this stage will be the initial plan of response to earthquake hazards. Therefore, the basic items and elements of the plan are extracted and summarized using the opinions of the research team and professors of the Department of Disaster in Health and Emergencies at Isfahan University of Medical Sciences, and the initial plan is designed. After their agreement, the initial plan of responding to the earthquake will be developed based on the following steps: Step 1: Coordination with the research team and panel of experts (professors and experts) Step 2: Understand the situation and describe the findings Step 3: To determine the goals of the program Step 4: develop the initial plan and to prepare components and maintenance it. It is worth noting that this program is prepared based on the method used in the book of the National Program for Response of the Health System in Accidents and Disasters and the basis of the program is based on the provision of specialized functions. In fact, specialized functions can have one or more specialized functions. However, the use of this method is also common in other organizations such as Fema (15). Data collection tool: The tools of this stage were data extraction form including options for the names of the persons’ participant at the interview and their opinions. A voice recorder was also used. Phase 4: Validation of the initial plan of the National Health System of Iran in response to earthquake (Delphi method) Aim: The fourth phase also includes a qualitative-quantitative study using the Delphi method. The purpose of this stage is to validate the initial pattern of the national health system program in response to earthquake. Study population: All operational sections of the national disaster management system which has been introduced in framework of the health system response. Samples: The sampling method is purposeful. Samples included 12-20 members of the Disaster Operations Center (DOC) that have been notifiedd in the Health System Disaster Management System. These positions included treatment, health, food and medicine, development, pre-hospital, etc. Inclusion criteria: Inclusion criteria were had enough experience, being involved in the process of responding to one of the events related to natural and man-made disasters during the period of their responsibility. If access to any of the sites is not possible due to limited access, the researcher will invite the relevant people at the provincial level involved in various events and earthquakes. Inclusion criteria were that person had to have some experience involving in the process of responding to one of the events related to natural and man-made disasters during the period in the fulfillment of their professional duties. Exclusion criteria: Person who have the above conditions did not have the opportunity to conduct an interview or cancel their participation during the interview. Research environment: The Ministry of Health and Medical Education and the selected Universities of Medical Sciences of Iran (Universities of medical sciences of Kerman, Kermanshah, Bushehr and East Azarbaijan) Data collection tool: Structured questionnaire will be prepared based on the Likert scale. Dimensions and components required in the national earthquake response plan in the health system are included in this questionnaire. Method of data collection: Since our goal in this stage was to find feedback on a special issue, namely the structure of the national response plan, we collect feedback in in two rounds, a questionnaire using Emails were sent to team members twice to reach a consensus of up to 75%, and follow-up was done to receive responses. In each stage, the answers received by the analyst and the researcher entered the next stage, and in all stages of data collection was done the importance of the factors in the form of Likert scale. Data analysis: To analyze the results of Delphi rounds, descriptive statistics and SPSS software will be used. If there is no consensus among members, the third step will be done. The expected results in this stage are the validation of all components of the initial pattern of and the determination of additional requirements and capacities related to the national program.

This study is a perfect sample of the consequences of an earthquake in the health sector. However, the development of such programs has a long history in Iran and other countries, but most of these programs have an approach to all hazards and address the common needs of the disasters they have been discuss. Also, in most of the previous programs, the basis of the community after the emergence of hazards and accordingly, depending on the type of country, different categories of functions are expressed based on this function of the task description is also stated. Findings of the results of the present study show that most of the activities of the health system in response to earthquake in Iran, like other previous findings (6, 16-21), it arises from immediate needs when they occur. But in present study, in fact, the occurrence of direct and indirect impacts of earthquakes is well known and experiences of effective earthquake response from the opinion of operational teams participating in health care relief operations, may add valuable annex to the programs of health policymakers and allow experts to consider new aspects of earthquake health impacts.

According to the results of the present study, the earthquake response plan is divided into two general categories, initial and special that the initial response includes a number of functions such as evaluation, co-ordination, organization, resource mobilization, command and management of operations, implementation of response plan, evacuation, security and safety, information management and communication that each one includes subsets when responding to an earthquake. For example, rapid needs assessment refers to a set of epidemiological, scientific, and anthropological tools that provides accurate and population-based information to decision makers in a simple format that can be used to make quick and cost-effective decisions in the event of an earthquake. Also, special services include four dimensions,1) emergency service specialized functions in the field of search and rescue, trauma care, emergency treatment services, emergency medical actions, 2) continuation of routine services with specialized endemic disease care function, continuation of chronic patient care, continuity of mental health services, continuity of preventive health services, 3) public health services with specialized functions such as health and improvement and health care of different groups, vaccination and disease management, and 4) support services and resource supply chain that are responsible for support and logistics in resource supply equipment and facilities related to the implementation of the earthquake response program and gift management and are volunteers that each one in line with its specialized functions and they are activated according to the needs created in the earthquake. The results of the present study are the necessity of having a time line of specialized response functions based on co-ordinates and shows the needs created in the earthquake, which is included in the final formulation of the national earthquake response plan.

The present study was approved by the Ethics Committee of the Isfahan University of Medical Sciences (Code: IR.MUI.RESEARCH.REC.1399.758 & registration code: 399933) at 1 March 2021