The Centre for Research on Epidemiology of Disaster defines a disaster as “an occurrence that disrupts the society’s socio-economic wellbeing and results in more than 10 deaths or over 100 injuries, respectively” (p.423).1 There have been over 22 000 disasters recorded globally since 1900, according to The United Nations Office for Disaster Risk Reduction. This is followed by 7348 disaster events between 2000 to 2019 that impacted over 4.2 billion people.2 This demonstrates a growing human cost when compared to the 20 years between 1980-1999 that affected 3.25 million people.
The burden of disasters varies by nation and region. Flooding is the most common natural disaster in Saudi Arabia, with 7 of 10 significant disasters being floods.Reference Abosuliman, Kumar and Alam3 Since 1980, at least 4660 people have died, 32 000 have been adversely affected, and $US 4.65 billion in damages have been incurred due to disasters in Saudi Arabia.Reference Al Thobaity, Plummer and Innes4 For example, more than 122 people died and approximately 350 people were reported missing in 2009 due to floods in Jeddah.Reference Al-Wathinani, Alakeel and Alani5–Reference Youssef, Sefry and Pradhan6
The World Health Organization (WHO) stresses the importance of disaster preparedness to enhance the health care worker response.Reference Al-Otaibi7 Emergency medical services (EMS) workers in Saudi Arabia are the critical front-line responders dispatched to manage a disaster. EMS workers are educated on best practices and approaches to respond to, and mitigate, disasters of various types, contexts, and magnitude.Reference Al-Otaibi7–Reference Al-Wathinani, Hertelendy and Mobrad8 However, little is known about EMS workers’ perceived knowledge, skills, and preparedness for disasters.Reference Prizzia9–Reference Catlett, Jenkins and Millin10
A preliminary analysis of literature identifies a paucity of literature investigating EMS workers’ knowledge, skills, and preparedness in Saudi Arabia.Reference Al-Wathinani, Hertelendy and Mobrad8, Reference ALobaid, Gosling and McKenna11 However, most studies focus on other health care workers, such as nurses, and few include EMS workers in their study population.Reference Al Thobaity, Plummer and Innes4, Reference Ibrahim12–Reference Nofal, Alfayyad and Khan14 It is essential to understand this population’s disaster knowledge, skills, and preparedness needs. So, this study aims to assess the perceived disaster knowledge, skills, and preparedness among EMS workers in Saudi Arabia.
Methods
Collection Tool
This study used the Disaster Preparedness Evaluation Tool (DPET).Reference Al Khalaileh, Bond and Beckstrand15–Reference Labrague, Hammad and Gloe17 in a cross-sectional survey to understand the knowledge, skills, and preparedness of EMS workers in Saudi Arabia. The DPET is increasingly adapted to assess the disaster preparedness of all emergency workers.Reference Al Thobaity, Plummer and Innes4, Reference King, Spritzer and Al-Azzeh18 The tool is validated in assessing and reporting disaster self-perceived preparedness levels (Cronbach’s α = 0.90) and has been validated for Middle Eastern populations using principal component analysis (PCA) with Varimax (Cronbach’s α = 0.90).Reference Al Khalaileh, Bond and Beckstrand15
The DPET is a 65-item instrument that measures participants perceptions of their preparedness for disaster management. Forty-five items are Likert-type questions with 6 response options ranging from strongly disagree to strongly agree.Reference Al Khalaileh, Bond and Alasad19 Of these, the first 25 items relate to Pre-Disaster Preparedness grouped into 3 categories: knowledge, disaster skills, and personal preparedness. The next 16 items related to response were grouped into knowledge and patient management. The final 6 items relate to the Recovery stage of the disasters and are grouped into knowledge and management, and the professional specialty title “RN” (for registered nurse) and “Nurse Practitioner” has been replaced with “EMS.”
Sample
EMS workers from government and military hospitals in the 3 largest cities of Saudi Arabia (Riyadh, Jeddah, and Dammam) were approached as sites to recruit participants in the study to complete the DPET survey. The survey was distributed in English, as this is the medium of communication among Saudi EMS workers. The sample size was estimated using the following formula validated to estimate sample size in cross-sectional studies (add ref).
$$ n=\mathrm{Z}1\hbox{-} \unicode{x03B1} /{2}^2\left[p\;\left(1\hbox{--} p\right)\right]/{d}^2 $$
Where “n” is the sample size, Z1-α/22 is the standard normal variate (at 5% Type 1 error and 95% CI [p < 0.05] it is 1.96), P is the expected proportion in population based on previous studies, and d is the absolute error or precision. According to this formula, with an expected proportion of 80% based on previous studies and a precision of 5%, a minimum sample of 245 EMS workers was needed to produce statistically accurate results.
Data Collection Process
EMS workers were recruited to the study by receiving an email from their EMS department supervisors in each hospital. The email had the study flyer, which included a URL hyperlink with information about the study and a link to the survey. The study questionnaire was provided through the research electronic data capture (REDCap) platform. Reference Patridge and Bardyn21, Reference Obeid, McGraw and Minor20Participant responses to the survey were collected between January and April 2021.
Ethics and Analysis
Ethical approval was obtained from the relevant committees with the ethical approval number (H-2020-0350). Findings were analysed with descriptive and inferential statistics using the SPSS (version 21) software. The data were analysed descriptively using means, standard deviation, percentages, and frequencies. A regression analysis was conducted on the survey response to identify the relationship between the EMS demographic and knowledge, skills, and preparedness levels. The findings were also analysed through a correlation analysis model. Comparison and correlation between (i) the dependent variables and (ii) the independent and dependent variables was investigated (ANOVA and Independent T-test analysis).
Results and Findings
Descriptive Analysis and Summary
A total of 358 responses were received. Of these, 86 responses were incomplete and excluded, leaving 272 responses included in the analysis. Participants’ demographics are shown in Table 1.
Table 1. EMS worker participants demographic analysis
Most participants were male 84.6% (n = 230), aged between 26-35 years (63.6%, n = 173), and held a bachelor’s degree (72.4%, n = 197). More than half the participants had between 1 to 6 years of experience as an EMS worker (50.7%, n = 138), worked in a government hospital (69.5%, n = 189) between 35–60 hours per week (91%, n = 247), and had worked in a disaster situation 90.4% (n = 246).
Disaster Knowledge
EMS workers reported moderate knowledge levels regarding disasters. A high level of involvement in regular disaster drills was reported (M = 4.24, SD = 1.274). A strong level of interest was demonstrated for further disaster education opportunities (M = 5.43, SD = 1.121). A summary of the questions analysed is provided in Table 2 below.
Table 2. EMS workers’ level of knowledge for disaster management
Disaster Skills
Respondents reported a high skill level with the triage principles used in their workplace during a disaster ( M = 4.06, SD = 1.218). While most respondents reported a moderate level of disaster skills, low level skills were reported for performing isolation during bioterrorist/biological attack (M = 2.92, SD = 1.306), and decontamination procedures in bioterrorism/biological attack (M = 2.99, SD = 1.323). A summary of the questions in this category is provided in Table 3.
Table 3. EMS workers’ level of skills for disaster management
Disaster Preparedness
EMS disaster preparedness level showed a non-significant positive associated with level of experience, age, and education level. Participants in military hospitals registered a higher disaster preparedness index than their peers in government public hospitals. There was a significant positive correlation between disaster preparedness levels and age (P = 0.00), experience in years (P = 0.00), education level (P = 0.000), facility worked in (P = 0.001), and the hours worked (P = 0.01). Respondents reported moderate preparedness for disasters in most preparedness items. Low preparedness was reported in relation to familiarity with signs, symptoms, and effective treatments for biological weapons (M = 2.90, SD = 1.199). A summary of the questions in this category is provided in Table 4.
Table 4. EMS workers’ level of preparedness for disaster management
Independent and Dependent Variables Relationship
A correlational analysis was undertaken between the independent variables demographics (age, gender, experience years, facility worked in, city of residence, and the number of hours worked per week) and the dependent variables around awareness and preparedness, categorized as knowledge (Q1-13), disaster skills (Q14-24), and disaster preparedness (Q25-45). The first analysis used an independent t-test analysis for the demographic variables with 2 levels (gender and participation in disaster) (Table 5).
Table 5. T test for the EMS workers’ socio-demographic variables with 2 levels, gender and participation in disaster
The first evaluation variable was the level of disaster knowledge. The findings showed a significant relationship to 3 demographic variables: education level (P = 0.012), facility worked in (P = 0.01), and years of experience (P = 0.020) (Table 6). Level of knowledge increased with age, experience, and hospitals worked in. There were also significant findings for relationships between disaster skills age (P = 0.00), experience in years (P = 0.010), education level (P = 0.000), the place of work (P = 0.001), and working hours per week (P = 0.010) (Table 6). Participants working in military hospitals reported a higher skills level than those in the government hospitals. However, other demographics did not significantly correlate with disaster skills, including age, years of experience, and education levels (Table 6).
Table 6. One Way ANOVA analysis for independent EMS workers’ socio-demographic variables with more than 2 levels
Discussion
This cross-sectional survey was performed to investigate the factors that influence Saudi Arabian EMS workers’ disaster knowledge, skills, and preparedness (Table 7). Several statistically significant correlations were found between the EMS workers’ demographics (age, experience, educational level, facility worked in, and working hours) and the level of disaster knowledge, skills, and preparedness. Overall, EMS workers have a moderate level of disaster knowledge, skills, and preparedness. This indicates room for improvement in educating EMS workers on handling and managing disasters in Saudi Arabia. These findings are consistent with existing literature on disaster knowledge, skills, and preparedness. Corrigan and SamrasingheReference Corrigan and Samrasinghe22 and Jafari et al.Reference Jafari, Rad and Sadrabad23 found average levels of disaster knowledge, skills, and preparedness among EMS workers.Reference Shajan, Poika and Selvan24
Table 7. Pearson Correlation between the dependent variables: disaster knowledge, skills, and preparedness
** Correlation is significant at the 0.01 level (2-tailed).
Age had a significant positive correlation on the knowledge and skills level. EMS workers with higher age had a higher disaster knowledge and skills levels. This maybe due to EMS workers having more experience with disaster situations as they advanced in age. This makes the older EMS workers self-report better skills, knowledge, and preparedness for disasters than their younger peers. Existing literature found that increasing age is associated positively with workers’ knowledge, skills, and preparedness.Reference Al Khalaileh, Bond and Alasad19, Reference Jafari, Rad and Sadrabad23, Reference Albanese and Paturas28 The older the EMS workers are, the more opportunities they have to engage in training, practice exercises, and improve their disaster skills and preparedness through real-world experience.Reference Al Khalaileh, Bond and Alasad19, Reference Jafari, Rad and Sadrabad23, Reference Almukhlifi, Crowfoot and Wilson25, Reference Songwathana and Timalsina26, Reference Albanese and Paturas28 Brewer et al.Reference Brewer, Hutton and Hammad29 and Al khalaileh et al.Reference Al Khalaileh, Bond and Alasad19 reported similar findings. They found that with increasing age, workers had opportunities to engage and participate in different disaster situations, thus positively influencing their knowledge and preparedness level.
Participants with a bachelor’s or higher degree in the EMS profession recorded a significantly higher knowledge, skills, and preparedness level than their peers without the diploma. Participants with a bachelor’s or higher degree showed an interest in undertaking disaster education-related activities such as classes, conferences, seminars, and drills to increase their disaster preparedness (Table 2). Existing literature supports these findings by noting that combining educational sessions with hands-on skills training better equips EMS workers for disasters and increases their disaster preparedness.Reference Al Thobaity, Plummer and Innes4, Reference Youssef, Sefry and Pradhan6, Reference Ibrahim12–Reference Al Khalaileh, Bond and Beckstrand15, Reference Labrague, Hammad and Gloe17–Reference Al Khalaileh, Bond and Alasad19 As per previous studies, participants reported lower skills in performing isolation during bioterrorist/biological attacks.Reference Al Thobaity, Plummer and Innes4, Reference Al Khalaileh, Bond and Alasad19, Reference Öztekin, Larson and Akahoshi31 This finding is common, as this type of disaster is rare in many countries.Reference Öztekin, Larson and Akahoshi31
The type of hospital where EMS workers are employed significantly impacts their knowledge, skills, and preparedness levels. Those working in military hospitals had more opportunities to participate in disaster management drills than those in governmental hospitals. Workplace determines the level of exposure EMS workers have in coordinating, planning, and/or executing a disaster management plan and activity. The findings align with those of Tzeng et al.Reference Tzeng, Feng and Cheng32 and Al Thobaity et al.,Reference Al Thobaity, Plummer and Innes4 who demonstrated that participants working in a military hospital had a higher level of disaster knowledge, skills, and preparedness than those working in governmental hospitals. Other studies found that the availability of equipment and facilities determine the type of skills in managing and responding to disaster situations.Reference Al Khalaileh, Bond and Alasad19, Reference Suhaimi, Marzuki and Mustaffa33–Reference Martono, Satino and Nursalam34
Strengths and Limitations
This study had several strengths. First, the study recruited EMS workers from 3 different cities and facilities in Saudi Arabia. This allowed a broad representative sample of EMS workers in Saudi Arabia. An additional strength is the use of quantitative data. This helps with the ease of validation and a higher threshold for reliability and objectivity of the findings. Finally, this study used the validated DPET instrument to explore the EMS workers’ preparedness. The study also had limitations. The study only focused on regional cities, so it did not capture rural communities in Saudi Arabia. Secondly, the survey did not assess the perceived level of knowledge, skills, and preparedness for a specific type of disaster. Therefore, it is impossible to generalize the findings to prepare for different types of disasters.
Conclusion
Effective disaster response relies on the effective preparation of skilled workers. This study found that Saudi Arabian EMS workers had a moderate level of knowledge, skills, and preparation for disaster. However, there was a low level of preparedness for biological and radiological events, where skills and knowledge levels were significantly low. This is one of very few studies to assess the preparedness of EMS workers. Further studies are required to understand the facilitators and barriers among EMS workers in Saudi Arabia toward disaster preparedness.
