1. Introduction
Earthquakes, one of the most catastrophic natural events, is characterized by uncertainty in time and place; in other words, these events typically occur without any warning [1]. This unpredictability increases the risk of death and damage, creates mental and physical injuries in most of the affected populations, and is considered a significant threat to the public health [2]. Iran is a highly seismic-prone area because it is located on the Alpines-Himalaya belt and has many active faults. In the past century, the country sustained severe losses in lives, properties, and resources due to the occurrence of more than 40 medium- to large-scale earthquakes that affected the daily living and health of the population for a long time afterwards [3, 4]. The earthquake-related human losses accounted for more than 150.000 deaths in Iran, which is 45 percent of all natural disaster casualties in the country [5]. this accounts for 6 percent of the whole mortality rate aftermath earthquakes while Iranian population is only 1 percent of the total population in the world [3]. A summary of major earthquake consequences in the past two decades in Iran is presented in Table 1.There are 3 to 4 times more chances of death and up to 40 times of more injuries related to natural disasters in the developing countries compared to the developed countries [6]. This can result from the significant diversity in the available resources, information and services for people due to their different socioeconomic classes and community situations, which tend to result in different levels of knowledge, awareness, attitude and the ability to predict, prevent and evaluate the consequences of a hazard among them. In developed countries, the victims’ behaviors and authorities’ decisions are considered important for critical outcomes of a disaster. In contrast, in developing countries, the crises arises mainly due to the lack of information and irrational/traditional knowledge that can be prevented only through managing and supervising the environment. Therefore, this shows that the communities define their own capabilities and vulnerabilities and have the option to decide which risks are important [7].
The consequences of earthquakes depend on its magnitude, the focal distance from the urban area, the preparedness level, and the mitigation measures in the nearby residence [2]. Preparedness represents the essential steps that could raise the probability of avoidance or minimize the calamitous consequences of a hazard, which is considered as a basic component in any disaster risk reduction. These kinds of efforts have a predominant focus on human behaviors deriving from different factors [8]. 
Recently, international approaches to risk management have focused on the integrated process of pre-disaster risk reduction (prevention, mitigation and preparedness behaviors) followed by planning for post disaster actions for enhancing the resilience in the community to proactively decrease the impacts of the disaster. This has become a national strategy and the basis of reducing hazard risk in developed countries [9]. But studies suggested that despite the serious threat of seismic events, the levels of adoption of preparedness measures in developed and developing countries is low. This increases the magnitude of (preventable) losses that have occurred [4].
Despite the effort and considerable expenditure on public education, the level of individual and community earthquake preparedness among people living in highly vulnerable regions of Iran is low [4, 7, 10-13]. Furthermore, there is little evidence of people learning lessons from the destructive earthquakes that have occurred in recent decades [14, 15]. There is a discrepancy between risk knowledge and perception and preparedness behaviors in people living in Iran [4, 10, 11, 16]. In addition to issues concerning risk acceptance, factors such as social class, gender and/or other special conditions act to influence preparedness behavior [17]. Taken together, these factors identify a need to define which factors influence the people’s preparation decisions regarding hazards such as earthquakes. 
A review of research literature can provide meaningful information on identifying the gaps that need to be filled and articulate the opportunities that exist for enhancing the rates of preparedness at all levels of society. Considering the lack of any previous review of Iranian research literature on earthquake preparedness behavior, the present study was conducted to rectify this and identify the factors associated with earthquake preparedness in Iranian people.
2. Materials and Methods
This review was conducted to describe and analyze Iranian research literature regarding the factors associated 

 

with earthquake preparedness. We found no prior literature review related to this topic via the Cochrane Library.
Search strategy
Key words and MeSH terms were used to search in eight medical, psychological, public health and social sciences electronic databases in both English and Persian languages. The databases, key words and terms are summarized in Table 2. We also searched the related references of the selected articles in Google Scholar and found 3 other relevant full papers, which were included in the 15 articles selected at the end of our search. Searching of databases ended on 25th February 2017.
Inclusion criteria
We included all the documents that presented the factors associated with public earthquake preparedness behavior all around Iran. Original articles, clinical trials, case presentation/studies, review articles and available electronic books and book chapters were reviewed. The outcome incorporated in this review was public earthquake preparedness behavior; accordingly, we defined it as the public behaviors which could meet two major goals: preparing the necessary supplements or an emergency kit and having a mitigation plan for the family and/or the neighborhood. All the included studies were reported in English or Persian languages. This review started on 19th February 2017 and finished on 15th August 2017 and had no time limitations for the publication dates.
Review protocol
All the retrieved titles and abstracts were screened to identify and remove duplicates and ineligible studies. This selection and full text articles were double screened and agreement measured. All the study team approved the selection. 
We then identified the candidate documents through the following screening process. Firstly, all the found documents (N=10524) were refined by examining the relevance of their titles relevance. This resulted in 129 articles (99+31 duplications) related to the Iranian population. We then applied the inclusion criteria to the abstracts and finally selected 15 full-text articles for inclusion in this review study. All of the selected articles were related to earthquake preparedness and its associating factors in the Iranian people (Figure 1).
We included both original research designs (qualitative/quantitative) in this review in order to obtain the 

 

broadest available evidences. Studies on post-event issues and those responding to disaster and rehabilitation, managerial elements, buildings mitigation engineering and geophysical parameters rather than discussing public preparedness behavior were excluded. In addition, an editorial, a letter to editor, and a brief report were also excluded.
3. Results
In total, 15 articles met the inclusion criteria. Tehran citizens were the participants in seven studies published between 1997 and 2016. Households comprised the most common subject groups in all the studies. The majority of the selected studies were quantitative research projects that employed self-made and/or standard questionnaires. The qualitative studies mostly used in-depth interviews and focus group discussions.
The source articles were assessed for reporting validity and reliability. Eight articles reported acceptable ranges of Cronbach’s alpha as the reliability measure of the instrument. The evidences of at least one validity measurements of the tools were produced in eight papers. Standardized instruments were used in two source articles. One source was purely qualitative and used content analysis of literature and documents. Validity and reliability measures for the tools used in three surveys and two field work interventional studies were not introduced. Twelve source articles provided sufficient details of their sampling strategies. Systematic Random cluster or multi-stage sampling was the most common sampling methods used in these studies. Purposive or convenient sampling was employed in 2 smaller qualitative studies. A few studies (4 of 15) addressed the issues of missing data and response rate.
Earthquake preparedness
Preparedness is a multidisciplinary concept that draws expertise from various fields such as economics, information technology, medicine, psychology, social studies, and public health. This diversity means that the definitions and measures of preparedness vary considerably between scientists and researchers in different disciplines. Academicians generally defined the frame of earthquake preparedness as collecting a standard set of supply stockings besides having a plan for mitigation. They have tried to identify both the barriers to earthquake preparedness and its facilitators. Most studies identified insufficient disaster preparedness of communities and households all over the country [4, 7, 10, 11, 13, 15, 20-22]. 
Low knowledge and attitude about earthquake mitigation activities in communities were accompanied with less preparedness practice [4, 19]. However, public awareness regarding earthquake mitigation was commonly reported to be infrequent [4, 15, 18-23]. Five studies noted the positive effect of public education in improving knowledge and practice 15, 18, 21-23] while two others demonstrated that preparedness would not often be improved only by providing related education and information for people [10, 20].
Some results emphasized on the effectiveness of community-based activities on public awareness, attitude and actions of preparedness [7, 21, 22]. Communities rarely collaborated with their local authorities related to mitigation and preparation. There are cultural and fatalistic beliefs/attitudes that could inhibit positive outcome expectancies and impose the doubt of ineffectiveness of mitigation and preparedness against disasters like earthquake [4] while affecting disaster preparedness [15] in the whole country.
Factors influencing public preparedness
Demographic determinants
Primarily, demographic characteristics have shown different impacts on earthquake preparedness of Iranian people. Age was mentioned in 7 articles (in one not as a significant factor [13]; in the others, it had direct [4, 6, 16, 22] and/or indirect [10, 19] effect on preparedness. This work indicated that younger people were inclined to be more aware and prepared [21]. Job position [4, 11, 16, 19], income level and socioeconomic status [7, 10, 11, 20], education [4,  7, 10, 13, 16, 18, 19, 21] were identified as having both direct and indirect positive impacts on preparedness knowledge and behavior. Gender [6, 16], marriage status [4], and having previous experience of earthquake [19] were also indicated as having a significant positive influence on increasing awareness and readiness in some studies, whereas other studies reported them to be insignificant [11, 13, 19, 21]. Home ownership [11, 19] and family size [11, 13] were not found to influence public preparedness. However, house location or the region in which people lived [4, 11, 18] was identified as having a positive impact on preparedness.
Earthquake preparedness awareness
Some variations in knowledge about general earthquake preparedness in the communities were observed. However, the impact of education on knowledge, attitude and practice revealed different findings. Exposure to preparedness information was associated with increasing knowledge, perception of risk, and practice in some studies [18, 21, 23], whereas good knowledge of earthquake risk and high risk perception was not necessarily associated with preparedness behavior in some others [10, 20]. The higher levels of education and better awareness is related to the behavior of preparedness among the general public [4, 6, 7, 13, 16, 19], which was also correlated with their prior experiences of such event [11, 13, 19].
Psychosocial predictors
Some studies suggested psychosocial factors that can increase knowledge, attitude and behavior of earthquake preparedness in different Iranian communities. The positive direct impacts found for participatory interventions were mediated by empowering local communities and mutual trust [21], risk perception [10], sense of belonging to the place of living [6], community contribution, social and familial relations and general trust [24]. Accordingly, the responsibility belief, optimistic biases, self-efficacy, and the need for protection were mentioned as the predicting factors that showed indirect impacts through increasing risk perception on the seismic preparation activities in the communities [10]. Controllability, trust to emergency authorities [10], technical, informational and physical shortages in community organizations [16] were found to be the factors that could hinder the preparedness action in different societies (Table 3). 
The limitations of the current study were as follows: It is possible that we have missed some relevant publications (e.g. research reports that do not have wide circulation) in spite of the systematic search protocol used in this review. Although both English and Persian databases were included, we cannot discount the possibility that some potentially relevant studies may have been omitted due to the used search strategy and inclusion criteria. However, considering these limitations, the present review could identify several articles with pertinent topics and content. The research methods used in these fifteen studies were diverse, but we included all of them to optimize the scope and integration of the literature included in the review. This can give us a more authentic picture of the current research into the actual earthquake preparedness in Iran.
4. Conclusion
This review suggested the necessity of providing clear, realistic, operational and trustable preparedness directives for the general public soliciting their own collaboration. The literature is inconclusive about the influencing and hindering factors meanwhile contradictory in some aspects. The topics did not include perceived versus actual preparedness, preferable sources of information, the exact role of government and authorities, and the influencing factors on the preparedness of minorities and special groups. Operationally, the lack of necessary information, fatalistic attitudes and low level of general trust and collaboration in the general public have been mentioned as inhibiting factors. It appears that specific instructions based on community participation besides encouraging the activities that enhance general trust and eliminate mistrust to the authorities and the information resources they provide may have positive impacts on the potential resiliency and actual preparedness against earthquake. Understanding how community members perceive the relevance of preparedness and vulnerability to their own lives needs to be investigated. 
Acknowledgments
This article reports the initiating part of the study collaboration between the Social Determinants of Health Research Center and The Institute of Humanities and Social Studies. 
Conflict of Interest
The authors declared no conflicts of interest.


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