Community-based education: An effective policy for earthquake preparedness in Iran: Empirical study

Abstract

BACKGROUND:

As natural or man-made shocks, disasters are sudden events that require emergency and fundamental measures. The need to be prepared for disasters has become clearer than ever worldwide. This study aimed to investigate the effect of earthquake preparedness training using the face-to-face or cascade method in rural households living in Juybar County (Iran) in 2018.

METHODS AND MATERIAL:

Following an experimental design with a pretest and posttest, the study was performed on married women aged 10–49 living in Kurdkolay village of Juybar county (n = 372). Participants were randomly categorized into two groups of training (n = 95) and face-to-face cascade method (n = 95). Data were collected using the Disaster Preparedness Assessment Index, comprising demographic and education sections. Data were collected using the disaster preparedness assessment index and analyzed using SPSS version 24.

RESULTS:

The findings indicated improved preparedness in all five dimensions in both groups. There was a significant difference between the study groups immediately and one week after the intervention (P < 0.05); i.e. a higher impact for the face-to-face cascade method. Meanwhile, both groups presented a similar level of preparedness 90 days after receiving the intervention (P > 0.05).

CONCLUSIONS:

The face-to-face cascade method was more effective in the short term, while no difference was found in the long term. Crisis managers and policymakers should choose their preferred method based on available facilities, human resources, and context to increase preparedness against earthquakes. Mothers play a vital role in educating and nurturing their children. It is suggested to conduct educational programs at the community level using the most appropriate methods that are chosen based on the best evidence.

Introduction

As natural or man-made shocks, disasters are sudden events that require emergency and fundamental measures.[1,2] The need to be prepared for disasters has become clearer than ever worldwide. Education on health during disasters not only is linked with declined mortality and morbidity but also results in improved health of societies and decreased healthcare costs.[3,4] Iran is among the top 10 disaster-prone countries[5], so of 40 natural disasters in the world, 31 have so far happened in the country.[6] Iran is now the fourth Asian country prone to natural disasters, behind India, Bangladesh, and China.[7] Among various disasters, earthquake is the leading cause of mortalities.[8,9] Iran is ranked as the first country regarding earthquake-related deaths among earthquake-prone countries, as the World Disaster Organization reported.[10]

Based on available evidence, the country experienced nearly ten earthquakes with a magnitude of >5 and one with a magnitude of >6 every year during the last century. On average, major earthquakes, greater than magnitude seven, happen every ten years, which claim thousands of lives and cause substantial damage. For instance, based on the analysis of earthquakes in the past century in the country, nearly 21 earthquakes greater than five Richter have been recorded, leading to the loss of at least 600,000 lives in total. Hence, special attention should be paid to promoting specialized knowledge on earthquakes (e.g. on structural (It is vague), geotechnical engineering, and disaster management) along with public awareness and preparedness. In this regard, particularly after the Manjil-Rudbar earthquake (June 1990), government agencies and Iranian Non-Governmental Organizations paid special attention to community education and earthquake training.[11]

Preparedness plays a major role in the disaster management cycle. It refers to activities that empower governments, organizations, and communities to respond quickly and effectively to adverse situations caused by a disaster. People are the most important and largest stakeholder in disaster preparedness.[12,13,14]

People’s neglect and insufficient awareness are the main reasons for earthquakes’ high fatality.[15] Education of local communities has a major impact on preventing negative consequences of disasters,[16] with the traditional lecture method as the most common type of education. Its major advantage is reaching a large number of people.[17,18,19] Face-to-face education is a well-established method of education in health systems because it is an effective behavior change technique, mainly due to paving the way for in-depth discussions among participants. Meanwhile, it has limitations, including its time-consuming nature and not being applicable to large groups.[20] Historically, rural areas of Iran are particularly vulnerable to disasters due to their close contact with the natural environment and low resilience. Earthquakes in Juybar, Qazvin, Ahar and Varzagan, Salmas, and Ardabil are examples of this historical trend.[21,22,23]

Although Iran is an earthquake-prone area, few comprehensive interventions are provided to increase communities’ awareness and preparedness. Previous studies showed that Iranians do not have a high and acceptable level of knowledge about earthquake-related solutions, preparedness, and post-earthquake measures. The lack of awareness in a country located in an earthquake-prone area is highly thought-provoking and indicates the need for effective education.[24,25,26,27,28,29] Meanwhile, the participation of different people in various courses of health education in disasters can bring positive results, including declining mortality and disability, improved health, and declining government costs.[5] Education and culture building are the most important elements that aim to improve the knowledge and awareness of local communities exposed to the risk of hazards. Training and empowerment of people concerning disasters and unexpected events are effective measures in directing health development, and realization of their importance definitely depends on accurate and targeted identification of needs, compilation of relevant content, planning, and continuous holding of training courses.[6] As Iran lies in the seismic belt and several major earthquakes have occurred in the country, this study aimed to investigate the effect of face-to-face group and face-to-face cascade education on the preparedness of the rural community of Kurdkolay in Jouybar county against earthquakes in five dimensions of nonstructural factors, emergency bag, communication, emergency exit plan, and first aid.

Materials and Methods

Study design and setting

Following an experimental with pretest and posttest design, this study aimed to compare the effect of face-to-face cascade and group education on preparedness against earthquakes.

Study participants and sampling

The sample size was estimated as 275 women aged 10–49 years old. The total number of eligible women aged 10–49 years old was 372. Noteworthy, the possible dropout of the subjects was also considered when estimating the final sample size. Written informed consent was obtained from all participants before entering the study and after a comprehensive introduction to the study protocol. Participation in this survey was voluntary, and no incentive was offered to participants. For this purpose, the health house of the village asked all eligible women to participate in this study. Apart from prior criteria, the inclusion criterion was no history of participation in similar programs during the past six months. Those who did not participate in classes and partially filled out questionnaires were excluded.

Participants were randomly divided into two groups of control and intervention. The former received in-person training using a nurse’s lectures, practical training, and question and answer. Noteworthy, they were divided into two groups with 45 and 50 subjects due to their large number. The latter received in-person individual training using the cascade face-to-face technique by six eligible volunteer women who were selected based on the criteria of social acceptability, being literate, and willingness to participate. A licensed nurse trained all volunteers in a Behvarz training center to be prepared for peer training. In total, two training sessions were held. The first session contained scientific education and concepts, the importance of the topic and strategies to minimize damages during various stages of the earthquake, examples of successful strategies, emergency bags, communication, and emergency exit conditions. The second session was about first aid training, including initial splinting and bleeding management and preparing a safe home map. Trained volunteers provided a similar training package to all participants. An in-person, face-to-face cascade training method was used for those in the intervention group. All subjects participated in the pretest. In addition, they participated in posttests seven and 90 days after providing the intervention.

Data collection tool and technique

Data were collected using the Disaster Preparedness Assessment Index, comprising demographic and education sections. Its validity was evaluated by obtaining comments from 11 experts. Also, its reliability was evaluated using the test–retest method (0.98), which yielded desirable outputs. The education section contains 15 items with yes and no answers. Each yes has a score of one, while a no indicates a score of zero. The score range of the questionnaire was between zero and 15. The highest and lowest scores were 15 and zero, respectively.

All participants filled out this questionnaire four times; i.e. before, immediately after, seven days after, and 90 days after the intervention. Data analysis was administered using descriptive and inferences statistics, independent t-test, and Chi-square by SPSS version 24. Statistical significance was considered when the P value >0.05.

Ethical considerations

This study is part of a thesis proposal for an M.Sc. The research purpose and methodology were subjected to scrutiny by the Research Ethics Committee of the Shahid Beheshiti University of Medical Sciences (code: IR.SBMU.SME.REC.1397.048). Written informed consent was obtained from all participants before entering the study and after a comprehensive introduction to the study protocol. In addition, they were ensured of the confidentiality of their information.

Results

The Chi-square test showed no significant difference between the study groups concerning men’s and women’s age, education level, occupation, and the number of children; i.e. both groups were homogeneous. The demographic characteristics of participants are provided in Table 1.

Table 1.

Demographic characteristics of participants

Group		Frequency	%
Age
Study group	Less than 20 years	15	15/79
	20–30 years	19	20/00
	30–40 years	35	36/84
	40–50 years	26	27/37
Cascade training	Less than 20 years	17	17/89
	20–30 years	22	23/16
	30–40 years	31	32/63
	40–50 years	25	26/32
Chi-square		0.895
Education
Group training	Elementary	16	16/84
	Middle school	17	17/89
	Diploma	35	36/84
	Associate degree	9	9/47
	Bachelorette	16	16/84
	M.Sc.	2	2/11
Cascade training	Elementary	16	16/84
	Middle school	14	14/74
	Diploma	34	35/79
	Associate degree	15	15/79
	Bachelorette	14	14/74
	M.Sc.	2	2/11
Chi-square		0.858
Occupation
Group training	Hairdresser	2	2/11
	Housewife	73	76/84
	Tailor	1	1/05
	Student	2	2/11
	Government employee	3	3/16
	Farmer	1	1/05
	Student	13	13/68
Cascade training	Hairdresser	2	2/11
	Housewife	74	77/89
	Tailor	2	2/11
	Student	3	3/16
	Government employee	3	3/16
	Farmer	2	2/11
	Student	9	9/47
Chi-square		0.968
Number of children
Group training	0	19	20/00
	1	15	15/79
	2	39	41/05
	3	17	17/89
	4	3	3/16
	5	2	2/11
Cascade training	0	16	16/84
	1	22	23/16
	2	33	34/74
	3	18	18/95
	4	4	4/21
	5	2	2/11
Chi-square		0.825

The Kolmogorov–Smirnov test was applied to test for a normal distribution, which indicated non-normal distribution (sig < 0.05). Therefore, the Friedman test was used to compare the mean ranks between the study groups at three stages (i.e., immediately after, seven days later, and 90 days after the intervention). Mann–Whitney U test was administered to compare the two groups concerning study variables.

Table 2 shows a significant difference between study groups concerning the mean score of nonstructural factors before, immediately after, and seven days after the intervention (P < 0.05). However, it was not significant for 90 days after the intervention; that is, the efficacy of both methods was similar (P > 0.05).

Table 2.

Difference between study groups concerning mean score of nonstructural factors

Category		n	Mean	SD	Mann–Whitney U–z score	Sig.
Nonstructural factors before the intervention	Group training	95	0/97	1/39	-2/54	0/011
	Cascade face-to-face training	95	0/44	0/91
Nonstructural factors immediately after the intervention	Group training	95	2/94	2/11	-4/476	0/0009
	Cascade face-to-face training	95	1/54	1/93
Nonstructural factors seven days after the intervention	Group training	95	3/37	1/98	-3/492	0/0009
	Cascade face-to-face training	95	2/33	2/01
Nonstructural factors 90 days after the intervention	Group training	95	3/69	1/65	-1/298	0/194
	Cascade face-to-face training	95	3/38	1/73

Also, the findings showed a significant difference between the study groups concerning the mean score of women’s awareness about the emergency bag, communication, emergency exit, and first aid before, immediately, seven days, and 90 days after the intervention (P < 0.05). In other words, the level of awareness regarding the abovementioned factors was improved in both groups at all measurements.

Discussion

This study demonstrated increased awareness of all participants in both groups regarding earthquake preparedness for all five dimensions of nonstructural factors, emergency bag, communication, emergency exit plan, and first aid (initial splinting and bleeding management). While there was a significant difference between the study groups immediately after and seven days after the intervention, both groups had a similar level of preparedness 90 days after receiving the intervention in terms of all five dimensions. Hence, it can be argued that group and cascade training had an almost similar effect.

The effectiveness of different health education programs varies based on the applied method. Face-to-face education and group discussion are among health education programs’ most common training methods. While the literature supports face-to-face education’s higher effectiveness, its application is not feasible in all circumstances, for instance, due to the limitation of resources (e.g., human resources or equipment). Nevertheless, each method has its pros and cons.

Face-to-face paves the way for better interaction between trainer and trainee while allowing participants to ask questions.

The major limitation of this method is the unavailability of skillful trainers, which was addressed in this study. On the other hand, group training offers an opportunity for the simultaneous training of several trainers, which is highly useful in resource-constraint contexts. Several factors should be considered when choosing the most appropriate method, including topic, trainees, and available facilities.

Several studies investigated the effect of face-to-face and group discussion methods on the awareness, attitude, and performance of those suffering from various diseases. For instance, in a study comparing the effect of self-care education using personal and group training methods on the quality of life (QoL) of those undergoing chemical therapy in Mashhad (Khorasan Razavi, Iran), Ghavam Nasiri et al. reported that both methods resulted in improved QoL, while no significant difference is reported between the two methods.[30] Also, Berimannejad et al. investigated the effect of group and individual training methods on treatment follow-up and incidence of complications in patients receiving warfarin after heart valve replacement in Tehran and found both methods effective.[31] These findings are consistent with those of the present study.

As mentioned before, this study focused on earthquakes. In this line, Yari reported that educational programs provided in schools and mass media were insufficient and inappropriate concerning components such as robust housing, first aid, survival, and preservation of property and assets in the earthquake risk management process. In contrast to the present study, they reported a significant association between the residential area and education level. Therefore, strengthening earthquake risk management knowledge and expanding technical training on earthquake risk management among rural residents, while paying sufficient attention to different education methods, are necessary.[32]

There was a significant difference between rural women’s knowledge regarding nonstructural factors before and after the intervention. Those in the control group (i.e. group training) presented a higher level of awareness before, immediately after, and seven days after the intervention; however, both groups had almost a similar level of awareness 90 days after the intervention.

Both individual and group training methods resulted in improved awareness regarding nonstructural factors. Therefore, it can be argued that both methods were effective, with a higher effect for group training. Both methods had a similar long-term effect. Similar results are reported by Yari[32] and Pesiridis et al.[33]

In addition, both methods were effective in increasing awareness regarding emergency bag, with a higher effect for those in the group training method. Similar results are reported by Karampourian et al.,[34] Davati,[35] Tzeng et al.,[36] and Glow et al.[37] In addition, both methods had a similar effect on awareness regarding communication, with higher effects for group training. Meanwhile, both methods had a similar long-term effect. Amanat et al.,[38] Karampourian et al.,[34] and Rumoro et al.[39] reported similar findings.

Concerning emergency exits, both methods were effective, with a higher effect for group training. Meanwhile, both had an equal level of long-term persistence. Similar results are reported by Karampourian et al.,[34] Pesiridis et al.,[33] and Rumoro et al.[39] Furthermore, both face-to-face and group training methods effectively promoted awareness regarding first aid, with a higher effect for group training. Again, both showed a similar long-term effect. Yari,[32] Karampourian et al.,[34] Amanat et al.,[38] and Tuladhar et al.[40] reported similar findings. Overall, it can be argued that group training and face-to-face cascade methods could improve preparedness against earthquakes; however, the difference in the effectiveness of administered methods was not significant.

According to the findings of the current study, the authors believe that educating the community about facing any crisis, particularly earthquakes, is of great priority and importance. Considering the urgent need and society’s understanding of the risks and irreparable damages caused by earthquakes, training in any way can increase participants’ awareness. Therefore, Iranian policymakers, planners, and crisis managers’ emphasis on educating the public through routine, periodic, and recurring programs is crucial.

Limitations and recommendation

It is necessary to mention some limitations and biases of our study, including encouraging people to enter the research and to fill out the questionnaire three times and insufficient participants’ knowledge about the research topic. This problem was addressed through increasing the sample size by 20% due to the possible dropout.

Future studies are needed to extend our knowledge beyond the current evidence. Hence, the following subjects are suggested:

• Comparison of the effect of earthquake preparedness training with two methods of face-to-face and face-to-face cascade training in urban households;

• Examining the preparedness against natural hazards, such as earthquakes, among urban and rural households;

• Comparing the effectiveness of synthetic and virtual educational methods on earthquake preparedness among rural and urban households; and

• Investigating challenges and problems of achieving effective educational programs on earthquake preparedness among rural and urban households.

Conclusion

As Iran is an earthquake-prone country and has experienced several destructive earthquakes, leading to heavy causalities and serious damage, research in this field is vital. The findings can extend our knowledge that would translate into increased society preparedness. Regarding the significant contribution of education on disasters and emergencies in promoting awareness, attitude, and performance of families, particularly parents, the findings are beneficial in different areas of community-based health, including management, health services, and research.

Parents, particularly mothers, play a vital role in educating and nurturing their children. As earthquakes have been a major devastating natural disaster in Iran during past decades, it is recommended to increase awareness regarding its preparedness, among other natural disasters, by emphasizing the role of urban and rural healthcare centers. Such measures not only can increase awareness but also pave the way for promoting the health of mothers and families. Noteworthy, mothers contribute to strengthening preparedness against potential natural disasters. In addition, they can provide the necessary education to their children and encourage them to follow safety protocols; even they can train their neighbors and friends. Such measures lead to intimate, friendly relationships and increased public trust, as an important source of social support, and encouraging their friends or colleagues to strengthen their interactions to learn necessary measures against natural disasters.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.