Over the past 30 years, South Korea has experienced various disasters, including an epidemic of Middle East Respiratory Syndrome, the sinking of the Sewol ferry, collapses of the Seongsu bridge and the Sampoong department store, and the Daegu subway fire. While the nature of disasters may vary depending on location, geographical features, climate, and sociocultural factors, these events in Korea were largely man-made or social, rather than natural disasters, such as earthquakes, wildfires, floods, and tornadoes. It is surmised that the casualties and costs incurred by these previous disasters might have been significantly reduced if better preparation had been in place. In response to an evaluation of these disaster events, the Korean Government has recently invested heavily in addressing disaster preparedness and response by creating disaster response teams, designating base hospitals by region, and developing an information and communication system to be used during major events. Reference Cha, Choa and Kim1
Gyeonggi Province presents a unique set of circumstances and challenges in mounting an effective response to disaster. As the most populous province in South Korea and surrounding the capital city, Seoul, its population has grown to exceed that of metropolitan Seoul (Figure 1). 2 The province’s northernmost border is shared with North Korea along with the dangerous demilitarized zone. Furthermore, the province is composed of urban, rural, and agricultural production areas. Yet despite the province’s large population, most public works infrastructures, such as roads, funding, personnel, hospitals, and other related networks, are concentrated within Seoul, which makes the ability to use limited resources efficiently in the event of a large-scale patient event an utmost priority. Reference Koenig and Schultz3 The provincial Government of Gyeonggi has recognized the importance of disaster preparedness and designated it as the most important public health issue of 2017.
FIGURE 1 The Map of South Korea and Gyeonggi Province. It Surrounds the Metropolitan Cities of Seoul and Incheon and Borders With North Korea to the North. The 8 Cities in Red Have Relatively Low Social Infrastructure Levels.
Launching a new disaster education program requires literature review and the benchmarking of well-known programs. 4 Yet disaster education programs are more effective when regional characteristics, such as priorities, needs, and the knowledge level of emergency care personnel, are taken into consideration in building a learner-oriented curriculum. Reference Cheng, Morse and Rudolph5,Reference Siegfried, Carbone and Meit6 Therefore, prior to implementation of a province-wide program, the Gyeonggi provincial committee surveyed each area hospital to gauge pre-existing knowledge of disaster response and perspectives on disaster preparedness.
The purpose of this study was to investigate discrepancies in knowledge and perception of disaster-related issues between disaster directors and general health care providers and to provide reference information necessary for experts in the provincial committee to establish a disaster preparedness plan.
METHODS
Study Settings
Gyeonggi Province consists of 31 cities, spread out over 10 171 square kilometers, with a population that exceeded 12 million in 2010. Acute care institutions in Korea are classified into 3 levels: regional emergency medical centers (level 1), local emergency medical centers (level 2), and emergency clinics, according to the mandated staffing and facility capabilities and responsibilities within the regional district. In Gyeonggi Province, there were 7 level 1 regional emergency medical centers, 24 level 2 local emergency medical centers, and 33 clinic-level institutions. Regions are considered to have low levels of infrastructure if transportation conditions render it so that more than 30% of the region’s population cannot reach emergency medical centers (level 2 or level 1) within 30 minutes via existing roads or cannot reach regional emergency medical centers (level 1) within 1 hour to attain definitive care. In the aftermath of the Sewol ferry sinking disaster in 2014, the provincial Health and Welfare Department formed a committee with the goal of improving the emergency medical system and its capabilities for responding to patient surge events. Reference Park, Cho and Kim7 The committee is composed of provincial government officials, directors of hospitals designated as base hospitals by the federal government, officials from fire departments and public health agencies, and experts in disaster and emergency medicine. Since its inception, the committee has undertaken projects, such as public cardiopulmonary resuscitation education programs, improving outcomes in out-of-hospital cardiac arrest, emergency medical technician prehospital care, and disaster preparedness. In particular, improvement of medical surge capacity of hospitals in areas with relatively underdeveloped social infrastructure was designated as a major project in 2017, and 8 institutions with emergency care facilities located in these underdeveloped areas planned to hold disaster preparedness drills (see Figure 1).
Survey Design
The committee met several times to establish a consensus on the items in the questionnaire, which was designed to examine the knowledge and perceptions of the respondents with regard to disaster-related issues (Appendix 1 in the supplementary material). The survey was organized into 4 sections. The first asked for demographic information about the respondents, such as job title, position, and work experience. The second section examined general knowledge of disaster preparedness, and the third investigated the respondents’ perceptions of their institution’s level of preparedness. The final section asked the respondents’ opinions on priority issues that need to be addressed, surge capacity, and appropriate training intervals. All questions were either multiple-choice or in a 10-point Likert scale format (from 0 = “strongly disagree” to 10 = “strongly agree”). The Korea University Institutional Review Board approved this project, and informed consent was waived (2019AS0142).
Data Collection
To collect the disaster directors’ responses, officials from the provincial Health and Welfare Department sent initial survey invitation via e-mail to a total of 64 emergency medical institutions and sent reminders to complete the survey. The survey was also distributed in the same way to acute care practitioners at the 8 selected institutions from underdeveloped regions within the province. The enrolled providers were personnel registered to attend disaster education programs voluntarily for their conveniences and comprised physicians, nurses, and administrative staff. The survey was conducted from June to September 2017. Following data collection, provincial officials and researchers constructed a database from the response sheets.
Data Analysis
The distributions of categorical data are shown as the frequencies of occurrence and percentages. The continuous variables not normally distributed are shown as medians and interquartile ranges, and normally distributed continuous variables are described as means and SDs. Categorical variables, including Likert scales, were tabulated and analyzed using the chi-square test. The analysis was conducted using the R version 3.5.1 statistical package.
RESULTS
The committee received responses from 43 (67%) of 64 disaster directors of acute care institutions in Gyeonggi province and from 145 (55.6%) of 261 general health care providers from the 8 institutions with more limited social infrastructure (Table 1).
TABLE 1 Demographic Characteristics of Survey Respondents
* Pharmacist and technicians.
IQR = interquartile range; EMT = emergency medical technician.
Table 2 shows the discrepancies in awareness of general disaster preparedness concepts between disaster directors and provider groups. How to triage in a disaster situation revealed statistically significant between the 2 groups (P = 0.023). The other issues in general concepts showed no statistical differences, but the degree of understanding or agreement by disaster directors was generally higher than for general health care providers.
TABLE 2 The Responses to the Questions Regarding General Awareness of Disaster-Related Issues
Mandatory disaster education programs implemented by the federal government have increased gradually since the Sewol ferry sinking occurred in 2014. Survey results demonstrated that both directors and general health care providers had experience with various types of disaster-related programs (88.4% vs 63.4%, respectively). However, only 49.3% of surveyed providers had real disaster experience compared to 69.8% of the director group (Appendix 2 in the supplementary material).
Table 3 presents the responses to survey items on hospital-level disaster preparedness. Most disaster directors at the individual hospitals knew who the incident commander was for disaster events. In contrast, awareness in the provider group was relatively low and statistically significant (P = 0.001). The item of manual or protocol preparation also showed statistically significant discrepancies between the 2 groups (P = 0.004). However, the discrepancies between the 2 groups in the topics of workforce, facility, equipment, communication network, and overall confidence were not significant.
TABLE 3 The Responses to Hospital Level Disaster Preparedness at the Individual Institutions
When asked how many additional patients could be accepted during a mass casualty event, “> 21 additional patients” had the highest proportion (34.9%) of responses among the directors. However, in the general health care provider group, “6~10 additional patients” had the highest proportion (25.4%) of responses (Appendix 3A in the supplementary material). There was a significant discrepancy in the numbers of perceived acceptable additional patients by the respondent groups. Both groups had similar perceptions for additional available workforce during disaster events, in that both groups believed nursing staff to be the most available (Appendix 3B in the supplementary material).
The responses to opinion questions regarding most likely disasters, priorities in disaster preparedness, and proper intervals for the government-conducted disaster education were presented (Figure 2). When asked what disasters were most likely to occur in a community, fire and traffic accidents were the most common responses in both groups (see Figure 2A). Priority issues that were thought to require improvement in individual facilities were, in descending order, additional workforce, provision of equipment, health care provider education, protocol proliferation, and publicity and education of the public (see Figure 2B). As for appropriate disaster-related education intervals, once every 6 months had the highest proportion of responses in both groups (see Figure 2C). Generally, both groups’ opinions showed similar patterns for this topic.
FIGURE 2 Bar Plots of Probable Disasters in the Future (A), Priority Issues in Disaster Preparedness (B), and Reasonable Mandatory Education Intervals for Emergency Care Personnel (C).
DISCUSSION
To improve the outcome of a disaster education program for general health care providers, it is critical to evaluate the pre-existing levels of understanding, awareness, and knowledge of disaster-related issues. Programs launched by the South Korean Federal Government focus on directors and emergency care personnel from designated base hospitals and officials in public health agencies. Reference Cha, Choa and Kim1 In this study, we found that there were areas in which the directors and providers exhibited significant discrepancies in their awareness of how to triage in a disaster situation and in their perception of command staff, manual preparation status at the individual emergency care institutions. Specifically, there were great disparities in responses to the question regarding acceptance numbers of additional disaster-related patients. These topics should be thoroughly addressed in disaster education programs in order to increase the effectiveness and efficiency of these programs targeting general health care providers.
Countries with more advanced disaster preparedness and response programs, such as the United States and Japan, have experienced catastrophic disasters in the past and have improved through these experiences. Reference Rosen, Zhu and Shao8-Reference Matsumoto, Motomura and Hara12 A thorough review and analysis of the process of coping with previous disasters could lead to a well-planned disaster preparedness system in South Korea. Previous studies of development of standardized core competencies for disaster medicine and public health revealed that these competencies were determined through an objective, specific, and scientific process. Reference Walsh, Subbarao and Gebbie13,Reference Schultz, Koenig and Whiteside14 In Korea, where the disaster scale is relatively small and incidents are rare, it is difficult to raise the subject of disaster preparedness and response to a priority within the public sphere. Disaster medicine experts are few in number and mostly comprise emergency physicians. Although public and government concern regarding nationwide disaster preparedness and response has increased since the Sewol ferry sinking in 2014, and several studies on the effect of this disaster on public health have been conducted, the development of disaster medicine is still in its infancy, largely due to limited resources investment by the federal government. Reference Kong, Song and Shin15-Reference Lee, Nam and Kim19
In 2017, North Korea performed several missile tests, heightening tensions within the Korean peninsula. Improving the medical surge capacity in the event of a mass-casualty missile launch was determined to be the highest priority disaster preparedness issue by the Gyeonggi provincial committee. This designation was made in consideration of the geographic proximity of Gyeonggi province to North Korea and the relatively low level of infrastructure compared to metropolitan Seoul. Various studies on educational program development and prioritization during medical surge have been performed. Reference Morton, DeAugustinis and Velasquez20-Reference Harris, Bell and Rollor24 However, no single standardized program has been widely endorsed. If cultural and social circumstances are sufficiently mature, emergency care personnel have a high level of awareness of disaster preparedness, and a multidisciplinary communication system is well-organized, it would be effective to perform a training program with no-notice exercises, as Waxman reported. Reference Waxman, Chan and Pillemer25 In Gyeonggi Province, beginner level and regional community-specific programs have to be implemented because some health care providers are not even aware of who the incident commander would be for disaster situations at their hospitals. Especially in disaster situations, effective communication among multidisciplinary health care providers, professionals, the public, and agency officials is a critical pathway necessary to achieve successful disaster event management. Understanding the discrepancies in awareness and addressing the knowledge gap between directors and providers will help instructors teach novice health care providers effectively in the era of learner-centered education. Reference Cheng, Morse and Rudolph5
This study had several limitations. First, the survey was sent to the disaster directors of emergency care institutions designated by the government, hence the responses may have been biased positive responses, rather than representing their own ideas. The general health care providers enrolled in this study were all registered to attend disaster education programs, and the overall responses were much more positive than the provincial committee had expected, likely because the enrolled general health care providers were more familiar with disaster topics compared to other providers. However, the purpose of this study was to evaluate the discrepancies and agreements in disaster-related issues by respondent position, and therefore the respondents’ multiple choices and Likert’s scale scores were judged to be sufficient to conduct these analyses. Second, there could be a selection bias for the general health care providers. Because the health care providers were selected from 8 hospitals in regions with relatively low levels of infrastructure, it is possible that the personnel selected from these institutions do not represent the perspectives of all general health care providers. Third, it may be difficult to apply the results of this study to other provinces and countries as the issues deemed important by the Gyeonggi provincial committee may be different from those of other regional committees, especially Seoul or other well-organized counties, where disaster-related resources and infrastructure are abundant. However, the survey construct and analysis may provide a useful starting point to establish a region-specific plan for disaster preparedness for other areas facing similar challenges in determining priority issues for education.
CONCLUSION
For successful implementation of a newly developed disaster training program for a specific region, it is essential to evaluate and understand the perspectives of the trainees. The discrepant and concordant results regarding disaster preparedness issues from this study present baseline information necessary for improving training program development.
Financial Support
This work was supported by grants from the Korea University (K1912761)
Department of Emergency Medicine, Korea University Ansan Hospital
Harbor-UCLA Medical Center, Torrance, California; Berry Consultants, LLC, Austin, Texas; and David Geffen School of Medicine at UCLA, Los Angeles, California.
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/dmp.2020.72
