Assessment of Disaster Preparedness Level of Medical Students of a University, Turkey

Introduction: In disaster-prone countries, preparedness is a very important factor in reducing the damages of disaster. The aim of this study is to determine the disaster preparedness knowledge level of a university ’ s medical students and to evaluate the relationships between possible related factors and disaster preparedness knowledge. Material and Method: This study is a cross-sectional study. The subject of research is measuring the level of disaster preparedness knowledge. The working period in which the online survey is applied is December 1-December 31, 2020. It was aimed to participate that attend the first and second grades of the medical faculty studying in the main campus of a University in Turkey. In order to compare the knowledge level of disaster preparedness among medical students, it was planned to include other faculty students as a control group. In the study, 75 medical students and 20 students from other faculties participated. A high score indicates good disaster preparedness. Chi-square, Mann Whitney U, and Kruskal Wallis were used in the statistical analyses. Results: The median value for disaster preparedness level score for all participants was 51.0 (min: 23.0; max: 63.0). Disaster preparedness knowledge level median score (54.0 [29.0-63.0]) was higher in women than men (48.5 [23.0-62.0]) (p<0.05). The median score of disaster preparedness knowledge level (53.0 [23.0-63.0]) of the second and upper grade was higher than the median score (49.0 [29.0-62.0]) of the first-year students (p<0.05). The median score of disaster preparedness knowledge level (55.0 [34.0-62.0]) was higher than the others (49.0 [23.0-63.0]) in those living in the city where their family resides (p<0.05). Conclusion: It can be said that the level of disaster preparedness for all participants is good. It is recommended to conduct a similar study in a larger study group.


INTRODUCTION
Causing physical, economic, and social losses for people; the consequences of natural, technological, and humaninduced events that affect communities by stopping or interrupting normal life and human activities and that the affected community cannot overcome by using its own means and resources are called disasters (Kadioglu and Uncu, 2018). Turkey has always been a country with various natural disaster hazards due to its tectonic formation, geological structure, topography, and meteorological features. In Turkey where earthquakes are the most important disaster, 92% of the population, 95% of the residential areas, and a significant part of the industrial facilities are located in these earthquake zones (Sengun and Kucuksen, 2019). In addition to the increasing loss of life and property every year, serious economic losses are also observed. The vast majority of the losses are caused by unconsciousness, imprudence, and lack of control. However, humanity strives to make these disasters less deadly and to reduce the consequential damages with the measures taken.
Stronger buildings and emergency plans for earthquake zones; early warning systems for disasters such as tsunami, typhoons, floods; early response systems for forest fires, and many other similar measures have reduced the mortality rate of disasters and subsequent damages (Kouadio et al., 2012;Samah et al., 2019).
In disaster-prone countries, preparedness is a very important factor in reducing the damages of disaster. There are various disaster management approaches. However, one of the common points of these approaches is that they are preventive.
The first and most important of the basic components of the preventive approach are preparation and training. It is very important to have information about taking precautions before a disaster, during, and after a disaster (Gerdan, 2014). Many deaths, injuries, and harmful consequences can be eliminated by having sufficient knowledge and the awareness provided by it (Chacko et al., 2019;Samah et al., 2019). It is thought that public employees, who have been informed about disasters or who have been trained in various experiments such as exercises, may be more useful in disaster prevention and post-disaster work (Karanci et al., 2005).
For example, physicians who are familiar with crisis protocols; Patient notification during disaster response, and immediate discharge of patients with less severe acute illnesses can play an important role in many issues, such as first aid during a crisis (Chacko et al., 2019). It is predicted that a society that is prepared for disasters should have a low level of damage from disasters (Dokmeci and Merinc, 2018).
The aim of this study is to determine the disaster preparedness knowledge level of a university's medical students and to evaluate the relationships between possible related factors and disaster preparedness knowledge.

MATERIAL AND METHOD
This study is a cross-sectional study. The subject of research is measuring the level of disaster preparedness knowledge. The study was designed as an online survey application. The working period in which the online survey is applied is December 1-December 31, 2020.
It was aimed to attend the first and second years of the medical faculty studying in the main campus of Izmir Katip Celebi University. In order to compare the knowledge level of disaster preparedness among medical students, it was planned to include other faculty students as a control group. A questionnaire was also sent to the students of the Faculty of Economics and Administrative Sciences, Faculty of Engineering and Architecture, and Faculty of Health Sciences.
Izmir Katip Celebi University, Faculty of Medicine, which was aimed to participate in the study, had 423 first and secondyear students in the 2020-2021 academic year. 75 of them (17.7%) responded to the survey. There were 1,483 students in the Faculty of Health Sciences, 1,749 in the Faculty of Economics and Administrative Sciences, and 2,877 students in the Faculty of Engineering and Architecture. Of these, 20 students who answered the questionnaire were included in the study as a control group of medical faculty students.
In this study, a questionnaire form prepared by the researchers based on the literature (1-15) was used. The 9 questions of the questionnaire contain some sociodemographic questions. The 32 propositions in the tenth question are 5-point Likert-type propositions prepared to measure disaster preparedness knowledge level. Of these; 2 nd , 3 rd , 5 th , 10 th , 14 th , 16 th , and 32 nd statements are reverse propositions. They were scored absolutely correct (2 points) and correct (1 point) in the true propositions. And in the reverse propositions, they were scored as absolutely false (2 points) and incorrect (1 point). A knowledge score between 0 and 64 was obtained for the thirty-two statements. The scale has no cut-off point. A high score indicates good disaster preparedness.
The dependent variable of the study is the level of disaster preparedness knowledge. Independent variables are faculty of education, age, gender, perceived family income level (poormedium-high), education in the city where the family is located, residence status in the education and training period, taking part in earthquake/fire drills before, damage from any previous natural disaster to see and to be a relative who suffered from any natural disaster before.
Written permission was obtained from the Dean's Office of the relevant faculties of the University, where the study was conducted. Explanatory information about the study was provided to the participants in official letters written to the Dean's offices and at the beginning of the online survey. Ethical approval numbered -20.23 (Date: 30.11.2021 was obtained from Izmir Katip Celebi University Social Research Ethics Committee in order to carry out this study. Data entry and analysis were made in SPSS 25.0 statistics program. The normal distribution of the data of numerical variables was evaluated by the Shapiro Wilk normality test and Q-Q graphics. It was observed that the normal distribution was not observed. Frequency values are presented as n (%) and the median value (min-max) for means.
Chi-square analysis was used to compare the data. Relationships between disaster preparedness level score and categorical independent variables were evaluated using Mann Whitney U test for paired groups and Kruskal Wallis analysis for groups 3 and above. A value of p≤0.05 was accepted for statistical significance.

RESULTS
In the study, 75 (78.9%) medical and 20 (21.1%) other faculties (Economic and Administrative Sciences, Engineering-Architecture and Health Sciences) students participated.
Looking at the distribution by age groups; While there were no students in the 17-18 age group in other faculties, the frequency of the age group 21 and over was higher in the other faculties than in the medical faculty students (p<0.05). The frequency of students studying in the first year was higher in the medical faculty than in the other faculties (p<0.05). No difference was found between medical faculties and other faculties in terms of other sociodemographic characteristics (p>0.05 for each).
The distribution of Faculty of Medicine and other faculty students according to some sociodemographic characteristics is presented in Table 1.
For all participants, "Have you been participated in an earthquake/fire drill before?" is asked and the number of students who gave "yes" was 84 (88.4%). There was no difference between the medical faculty and other faculty students in terms of answering "yes" to this question (p>0.05).
"Have you been harmed by any natural disaster before?" is asked and 10 (10.5%) of all students answered "yes" to the question. There was no difference between the medical faculty and other faculty students in terms of answering "yes" to this question (p>0.05).
"Have you had any relatives who suffered from any natural disaster before?" is asked and 30 (31.6%) of all students answered "yes" to the question. There was no difference between medical faculty and other faculty students in terms of answering "yes" to this question (p>0.05).
The distribution of the answers given by the Faculty of Medicine and other faculty students to some questions about disasters is presented in Table 2.
The median value for Disaster Preparedness Level score for all participants was 51.0 (min: 23.0; max: 63.0).
Disaster preparedness level score between the Faculty of Medicine and other faculties was 51.0 (min: 29.0; max: 62.0) and 51.0 (min: 23.0; max: 63.0), respectively, and no significant difference was found between the two groups (Mann Whitney U: 759.5; p: 0.931).
For all participants of the study, no relationship was found between the possible related variables (age group, family income perception, residence characteristics, participation in disaster drills, being a relative who suffered from a natural disaster, depending on damage from a natural disaster) and Disaster preparedness knowledge level score (each for one p>0.05). The distribution of the median scores of the disaster preparedness level by the various variables for all students participating in the study is presented in Table 3.
The number and percentages of students who gave correct answers by giving absolutely correct and correct (absolutely false-wrong for reverse questions) answers in a total of 32 propositions used in measuring the level of disaster preparedness are presented in Table 4.

DISCUSSION
In this study, the median disaster awareness score at the knowledge level was 51 (79.6%) out of 64 points. It is seen that disaster awareness is high at the knowledge level. Similarly, Sahin et al. (2018) calculated the level of disaster awareness as 82% with an average of 8.2 correct answers out of 10 questions. In these two studies, disaster awareness was found to be high in university students, as expected.
The average age of the students participating in our study is 19. Similar to another study, no difference was found between disaster preparedness knowledge levels among different age groups (Yigit et al., 2020). The 'median score of the knowledge level of disaster preparedness (53.0) was found to be higher than the median score of first-year students (49.0) (p<0.05). Kohn et al. obtained similar results in their study in 2012.
In our study, the median disaster preparedness knowledge score of the Faculty of Medicine was 51.0 (min: 29.0; max: 62.0), while it was 51.0 (min: 23.0; max: 63.0) in other faculties. No significant difference was found between the two groups. In a similar study by Yigit et al. (2020), it was seen that the knowledge, attitude, and behavior scores about disaster were similar according to the faculty. The Engineering Faculty students; the fact that the subject of disaster is in their field of interest in terms of their professional life and the awareness of medical school students because they take an active part in disasters as health personnel may have caused them to get similar scores. In the study conducted by Sahin et al. (2018), a difference was found between the disaster awareness levels of the students of the Faculty of Economics and Administrative Sciences, which provides four-year education, and vocational school, which provides two-year education. This situation suggests that the level of disaster preparedness knowledge is not related to age, but to the increase in the number of disaster-related education received during the education life in parallel with the academic years and to different education programs.
In our study, disaster awareness was found to be higher in women at the level of knowledge. While the median score of the disaster awareness at the knowledge level was 54 in women (n=61) who participated in our study, this score was calculated as 49 in men (n=34) (p<0.05). In the study of Sinha et al. (2018), in women; In the studies of Baris (2011) and Kadioglu and Uncu (2018), disaster awareness was calculated to be higher in men. There are also some studies in which disaster awareness does not show a gender difference (Nofal et al., 2018). In terms of disaster awareness, information and experiences learned by oneself were more effective rather than gender differences.
In our study, no significant difference was found according to family income perception. While the median score of those with 'low' family income perception is 49.5, it is 51 for those with 'medium' and 54 for those with 'high'. Sattler et al. (2000) reported that there is a positive relationship between increased family income perception and disaster awareness. Increased awareness can be expected with greater potential financial loss.
In our study, disaster awareness is higher in students living in the city where their families live. For students living in the city where their families live (n=41), the median level of disaster preparedness knowledge score was 55; For those who do not live in the city where their family lives (n=54), this score is 49 (p<0.05). Tkachuck et al. (2018) reported similar results with our study, and they have interpreted their results as the increased awareness of people with an increased tendency to feel at risk.
The median score of 84 people who took part in an earthquake or fire drill was 52, and the median score of 11 people who did not participate in the exercise was 46. No difference was found between the two groups. In the study conducted by Sahin et al. (2018), it was seen that 78.6% of the participants had not participated in an earthquake drill before, and participating in the exercise was not related to the level of disaster awareness. In the study conducted by Sen and Ersoy (2017), the rate of participants who had previously participated in an exercise was 27.1%, and a significant difference was found between the participation of the participants in the exercise and disaster awareness (p=0.056). Similarly, Kapucu and Khosa's (2013) study showed that training and exercises are positively related to disaster resilience and preparedness. The reason for the difference between the studies may be that the content of the training and exercises are different from each other.
The median score of 10 participants who were harmed by a disaster before was 55, and the median score of 85 participants who were not harmed was 50. There was no significant difference between the two groups. According to the study of Ayvazoglu et al. (2020), 10.9% of the participants were affected by a natural disaster before, while 89.1% were not. In the study conducted by Sahin et al. (2018), 38.3% of the participants were previously affected by a natural disaster; Yigit et al. (2020) reported that the rate of participants who were previously affected by a natural disaster was 52.85%. In the study by Sen and Ersoy (2017), the number of participants who were previously affected by a natural disaster was 18.6%. In a similar study by Inal et al. (2012), 81.2% of the participants had not experienced a natural disaster before, and similar to our study, it was concluded that encountering a natural disaster before was not related to the level of disaster knowledge.
Thirty (31.6%) of the students answered "yes" to the question "Have you ever had a relative who was harmed by a natural disaster before?" In the study conducted by Ayvazoglu et al. (2020), 97.8% of the participants did not lose any relatives as a result of the disaster, and it was determined that there was no relationship between the disaster risk perception levels of the participants and their previous experience of a major disaster. In the study of Sahin et al. (2018), it was seen that the rate of those who experienced disaster among family members was 49.9%, and this rate was higher than the rate of students (38.3%) who experienced a disaster themselves. In the study conducted by Yigit et al. (2020), the percentage of those whose family members encountered disasters was found to be 52.87%. This difference may have been caused by differences in geographical location and individuals' perceptions of the concept of disaster.
"It is correct to be under the column, on the balcony, and to use elevators/stairs during an earthquake." The answer was 84.2% 'absolutely wrong' 13.7% 'wrong'. After the major earthquakes in Turkey, the programs were rearranged in order to eliminate the lack of information about what to do before and during the earthquake. Society has been conscious thanks to television, the internet, brochures, etc. (Akgungor, 2014). What to do during the earthquake was mostly known correctly as expected.
"During a fire, it is necessary to bend over to avoid suffocating from smoke." The percentage of people who give the answer "absolutely correct" to the statement is 20%. Although this statement is true, the rate of those who say "absolutely true" is very low. It is seen that the students who make up the study group do not have enough knowledge about this subject. The most important cause of death in fires is acute poisoning from inhalation of carbon monoxide and other toxic substances (Økland et al., 2020). Therefore, it is necessary to move close to the ground during a fire in order to be less exposed to toxic gases (Kilic, 2010). The reason why university students do not have enough information on this subject may be that it is not as widespread for fire information as earthquakes information in our country.
"Absolutely no" was answered at a rate of 82.1% to the proposition "after a natural disaster, communication tools can also be occupied except in emergencies." After the Izmir earthquake that took place in this region shortly before the study, there was a telecommunication problem for a while as a result of the intensive use of telephones; calls are delayed. The fact that this negatively affects the coordination of postdisaster search and rescue efforts and health service delivery may have caused a high rate of no response. It is known that communication problems were experienced in previous earthquakes that caused destruction.
"Absolutely yes" was answered by 80% to the proposition "in case of any disaster, electrical appliances and dangerous areas should be avoided." The most important of the secondary damages that are not directly caused by the earthquake after the earthquake are fires; electrical failures, overturning of heating devices, contact of flammable and explosive materials with ignition sources (Kilic & Koralturk, 2000). In the study of Tuladhar et al. (2014), students were generally unaware of the related or secondary disasters that followed a major disaster and only gave correct answers to the relevant fire disaster for earthquakes.
The answer "absolutely true" was given by 84.2% to the statement "It is important that the house in which you live or will live is resistant to earthquakes and this should be investigated." As the closest example; In the Izmir earthquake of 30 October 2020, it was observed that while some buildings next to each other were intact, other buildings were destroyed. The fact that the houses on the same ground were damaged at different amounts after different earthquakes may have increased the importance given to the durability of the house to be lived in. In other studies, the effective ratio of the durability and earthquake resistance of the house to the housing preference has been observed similarly (Altun, 2017).
In the question "the 1999 Marmara earthquake in our country started a new era in disaster preparations", 27.4% answered "absolutely true" and 35.8% answered "correct", with a lower level of awareness than expected. The reason may be that the study group was mostly young at the time of the 1999 earthquake or was not born yet.
As the education and knowledge levels of individuals about natural disasters increase, the dimensions of material and moral damages caused by natural disasters, preparations for natural disasters, and behaviors during disasters also change (Inal et al., 2012). Pre-disaster preparations are the most important part of preventing the damages caused by disasters. Increasing the level of education will increase awareness of disaster risks and consequences (Gillani et al., 2020). In order to create social disaster awareness, it should be aimed to increase the knowledge and awareness of especially young people about disasters.

Limitations
Only 17.7% of the first and second-year students of Izmir Katip Celebi University, Faculty of Medicine, which constitute the target audience, responded to this online survey. Therefore, the results can only represent the participating medical students. The number of participation (n=20) that was achieved from other faculties was very low level. Extremely low numbers of participation affect the power of representation and limit our comparative results. The ability of the participants to represent the students of their own faculties was not provided. Results represent only students who answered the questionnaire.
There is no validity and reliability study for the questionnaire used in this study. A questionnaire form was prepared by the researchers based on the literature.

CONCLUSION
This study, which we conducted to determine the disaster preparedness knowledge level of medical faculty students of a university, offers some striking results despite its limitations. It can be said that the level of disaster preparedness for all participants is good. In this study group, the level of disaster preparedness was better among female students, students studying in the upper classes, and students living in the province where their families live. It is recommended that disaster preparedness and topics be included in the undergraduate curriculum not only in medical faculties but also in other health-related schools. Medical and health students should take an active role in disaster preparedness studies for the public. Additionally, it is recommended to conduct a similar study in a larger study group.