1. Introduction
Almost all references which have been written about disasters in Iran have noted that Iran is susceptible to natural hazards induced by disasters and have stated that the size, geographical location, and climate diversity of this country increase the incidence of these disasters [1, 2]. In the past century, around 181 disasters have occurred in Iran, which resulted in over 160000 death, more than 170000 injured, and 44 million affected people [2, 3]. In the past decade, on average, 4000 were killed, and 55000 were injured annually [3]. The occurrence of more than 10000 natural hazards in the country has been recorded for 40 years, from 1970 to 2010 [4]. Disasters are devastating events, and as a result of their destruction, the infrastructure and performance of the community are disrupted. Despite the huge amount of needs, the infrastructure services encounter problems [5, 6]. Among these services, health care services and hospitals play the first and the most important role in providing the community with health services [7, 8]. The timely and effective activities of hospitals can play a decisive role in the mitigation of the effects of disasters [7, 9]. 
In addition to deaths, injuries, and physical and psychological damages caused by disasters, many diseases reappear due to the interruption in health programs [10]. These programs include vaccination and disease management programs. Also, by the destruction of agricultural productions, food warehouses, and food distribution systems, food insecurity occurs. We can add to this list environmental changes, increased feeding locations of carriers, the proliferation of rodents and flies, high population displacement and their residence in busy camps with low health status, inappropriate personal health conditions, and no access to safe drinking water among the others. Therefore, health services can be very influential [8, 9, 10, 11, 12, 13, 14, 15]. 
On the evening of November 12, 2017, at 21:48 local time, an earthquake happened in Kermanshah Province with a magnitude of 7.3 on Richter scale, at a focal depth of 18 km, at a distance of 10 km from Ezgheleh and about 37 km northwest of Saralpul Zahab [14]. As a result of the earthquake, 620 were killed [15], 9388 were injured, and 70000 were made homeless. Therefore, there was a need for help and relief from other communities [16]. Since Kermanshah University of Medical Sciences (KUMS) could not respond to the quake-stricken people’s needs alone, the Ministry of Health urged other universities to assist KUMS. In this regard, a team of 180 specialists and health experts from Tabriz University of Medical Sciences (TAUMS) was dispatched to the affected area in December 2017 and provided the people with health services for more than 10 days. The present study aims to learn and analyze their experiences.

2. Materials and Methods
After the return of the dispatched team of TAUMS from the earthquake-stricken areas of Kermanshah Province (Sarpol Zahab, Salas Babajani, and West Islamabad cities), a 3-h session was held with the participation of about 60 members of the dispatched team in TAUMS to investigate their experiences and determine the weaknesses and strengths of the relief program. The meeting was held in a friendly environment. The conversations in the meeting were recorded with the participants’ permission. Then, the recorded text was transcribed verbatim and coded and analyzed utilizing content analysis. Next, the repetitive codes were deleted, and the similar codes were merged. Moreover, similar codes formed subcategories, and similar subcategories formed the main categories. 

3. Results
The analysis of the group discussions in the 3-h session resulted in the creation of 157 codes. Merging similar codes led to the production of 85 codes. Twenty-three subcategories were developed based on these codes. These subcategories fell into 9 main categories:
1. Delay in recalling and its challenges 
2. Lack of preparedness 
3. Using the cyberspace capacity for risk communication 
4. Lack of proper assessment of the health needs in the disaster-affected area and the estimation of facilities 
5. The management experience of the team on the dispatch route 
6. Shortcomings and imperfections
7. Managerial challenges
 8. Lack of coordination
 9. Setting up field hospitals without planning 
Details of the codes, subcategories, and categories are presented in Table 1.


Delay in the process of the call for forces and its relevant challenges
This category involved a delay in the call, lack of a prior plan, lack of criteria for selecting team members, and lack of legal obligation to be present in the team. Although all university departments were called regarding the formation of the team and its urgent dispatch to the earthquake-stricken areas, the group members were not chosen until the last minute. Many people were interested in helping but were not required to be in the team. On the other hand, there were people who, despite the need for their presence, were not dispatched at the last minute for various reasons. Moreover, the EOC of the Ministry of Health expressed various views on the composition of forces. Since there was not a legal obligation for the people to be present, some of them changed their decisions quickly. A sample of participants’ comments is provided below:
“…The call for forces was made with a considerable delay…”. “...Our own evaluated team was not accepted. Unfortunately, the ministry came in, intervened and formed a team of 180 people for us ...” “Unfortunately, the combination of forces until the morning of the dispatch day was not determined, that is, we had one case who volunteered in the morning of the dispatch day ...” “Until the morning of the day of dispatch, the last dispatch team was being compiled. Someone was displaced, someone called, and a group boss called and told that someone could not be present, we replaced them with someone else...” 

Lack of preparedness
Lack of preparedness is a challenge that is present in nearly all disasters. It was also mentioned in this experience and had different dimensions. Its subcategories involved a lack of general preparedness of the health system, preparedness of the members of the dispatched team, preparedness of KUMS, and preparedness of TAUMS. 
Most of the dispatched people were not familiar with the conditions of the affected area, the probable problems in the area, and their exact responsibilities in the relevant area. There were no specific guidelines other than the Emergency Operation Center (EOP) developed by the Ministry of Health. The hospitals which were affiliated with KUMS were not familiar with interaction with supporting teams. None of the personnel, even team leaders, had not been trained to interact with the media and lacked experience in this regard. In some cases, the present reporters in the region completely debriefed them. The training was not done before, and lack of preparedness was evident in all areas. Some of the issues which the participants discussed are provided below:
“…We could not really prepare a written job description for the command team, and we could not provide the command and financial support team with this description. We presumed that everyone had sufficient information on administrative regulations...”. “...The disciplinary controls of the team had not been defined, and we had gone there without preparation ... .”

The use of the cyberspace capacity for risk communication
In this experience, the cyberspace capacity enabled the team members to communicate with each other. Also, a group was formed which involved not only the members of the team but also the university staff. People shared their experiences and documentation with the other members and exchanged experiences. Announcements and calls were shared in the group, and officials at the department of university constantly monitored the performance of the team. However, due to the presence of high-ranking university officials in the group, members occasionally made some old complaints, discussed irrelevant issues in the group, and disturbed the peace in the group. A sample of the members’ perspectives is provided below:
“... The presence of the dean chancellor of the university in the telegram group was both a positive and a negative aspect. The positive aspect was the colleagues’ motivation and the chancellor’s support. It was really effective and extremely raised the colleagues’ spirits. However, it had a negative aspect.” “It can be said that the chancellor was really concerned about the condition. That night, he checked the telegram group at 2 AM and commented on the relevant issues. Moreover, he reproached us in the group.”

Lack of proper assessment of the health needs of the disaster-affected area and the estimation of facilities
Although two of the university officials had gone to the affected area to assess the situation and determine their health needs, the team and the officials encountered several challenges due to inaccurate estimations. The inappropriate location of the dispatched team was one of these challenges. There was a long distance between the considered place and the field hospital, and the members could not commute between these places on foot. Furthermore, it lacked basic facilities. The preparation method of the food for the members had not been determined, and the team had relied on the resources of the Kermanshah University of Medical Sciences. This issue caused several problems. One of the most critical shortcomings of the assessment was the lack of prediction about the need for cars. Some of the participants’ comments are provided below:
“...The accommodation facilities of the command team had not been predicted; Conex box with contact and computer facilities and the like had not been foreseen” “... We had not predicted the basic temporary facilities, heating appliances, blankets, pillows, and tents.” “We had to be ready. We should have presumed that we could not find a tent to stay there even though we had identified the tents in preliminary assessments.” 

The management experience of the team on the dispatch route
This category involved two subcategories of accomplished measures and route challenges. To get to the destination, the team used relatively modern buses, and an administrator was chosen for each bus. The list of passengers was prepared and given to the administrators. Moreover, the commander of the team and the bus administrators were constantly in touch on the way and exchanged information. Two teams called “forerunner” and “terminal” were selected. The forerunner team moved before all other buses, and the terminal team moved behind all of the buses. Some of the dispatched employees left the area before the determined time, which caused problems for the coordination of return plans. Some drivers were not familiar with positioning systems. As a result, one of the buses lost the route and got to the destination late. It was decided to serve dinner and lunch on the way. Notwithstanding, due to the lack of an appropriate restaurant, the team commander was forced to choose two places. The selection of these places led to a waste of time and a delay in getting to the destination. Some of the participants’ perspectives on this issue are provided below:
“…We had the dispatch information package.” “We had provided the colleagues, bus administrators, and city administrators with the map of the relevant area.” “The selection of the forerunner team and the terminal team was a positive action. These teams were not exchanged with other teams. We had a forerunner team and a terminal team before we arrived in Kermanshah. The forerunner team moved ahead of the other teams, and the terminal team moved behind them .” “We could not coordinate the team members on the way. We could not find a restaurant with enough space for 170 people. We had to find two restaurants and this issue wasted a lot of time.”

Shortcomings and imperfections
The shortcomings stemmed mainly from a lack of preparedness of the personnel and the accurate assessment of the needs of the area. The team members had not been provided with individual hygiene packages and other packages for doing some things and worship. There was not a bathroom in the lodging. Moreover, the bathroom which was set up later could not be used in most cases. None of the dispatched forces were familiar with the area. Most of them had not been provided with a map of the area and encountered problems on the way in some cases. The teams lacked some of the needed essentials to offer service in the earthquake-stricken area. This issue was problematic for the team when it offered service in the relevant area. 

Managerial challenges
The planning team did not consist of experienced and expert specialists. Moreover, there were no experienced people to monitor the quality of the provided clinical and health services. There was not an administrator to manage the various hospitals, and, at times, there were threats to the safety of personnel. The women’s resting place was not safe in terms of security.

Poor coordination
According to the participants, there was a lack of coordination from the beginning. When the call for forces began, there was no coordination even in the preparation of uniforms, their color, and shape. The media was not informed about the dispatch of the team, and there was no centralized management of the local and the dispatched forces, and their actions were nearly independent of each other. Several field hospitals were set up in close proximity without coordination. The time of the end of the mission was not determined. Rumors were constantly spread about this issue. Eventually, some team members did not come. On the first day, the teams of the former university had left the area without coordination and delivering up the patients to the hospital. Some of the participant perspectives on this issue are provided below:
“…Unfortunately, the dear colleagues had left the area .” “…The shift along with the hospital beds hospital department, equipment, anesthesia department, and patients was not handed over to our team.” “…Unfortunately, we did not have any information on several patients who were handed over to our team.” “… It was 2 AM, imagine that, our colleagues had not slept and rested since 5 AM from the day before and had been traveling by bus.” 

Setting up field hospitals without planning 
The universities of medical sciences, the army, and the security forces had set up two adjacent field hospitals in the earthquake-stricken areas of Sarpol Zahab. Many people went to all three hospitals on the same day. Besides, a field hospital was set up in one of the villages.

4. Discussion 
In the aftermath of the earthquake of November 12, 2017, in Kermanshah Province, a team of 180 members consisted of specialists and general practitioners, nurses, practical nurses, and health experts, among the others, was dispatched to the cities of Sarpol Zahab, Salas Babajani, West Islamabad, and Dalaho due to the request of the Ministry of Health and Medical Education and to help KUMS to offer services to the people in earthquake-stricken areas. This team provided the people with health services for about 10 days in the mentioned areas. This study examined this experience. The data analysis based on the perspectives of 60 participants in the aforementioned team led to 85 codes, 23 subcategories, and 9 categories. The main categories comprised delay in the process of the call for forces and its relevant challenges, lack of preparedness, use of the cyberspace capacity, lack of proper assessment of the health needs of the area and the estimation of facilities, the management experience of the team on the dispatch route, shortcomings and imperfections, managerial challenges, lack of coordination, and setting up field hospitals without planning.
Service capacity needs to be increased in the aftermath of disasters [17, 18]. Human resources [19] is one of the fundamental essentials for increasing the services and depends on the call for volunteer forces. In previous studies such as Gorji, Davidson, and Epstein et al., the challenges of increasing human resources, who offer help in the disaster-affected areas, have been discussed in detail. Having a baby, pregnancy, illness, and physical problems, work-related problems, family health concerns, concerns regarding one’s self and the safety of property, employees’ materialism and low commitment, and lack of obligation and low motivation are among these challenges. In the present study, most employees were volunteers and had high motivation. Notwithstanding, several employees did not join the team due to the above reasons. 
The lack of preparedness to deal with disasters is a significant concern for many organizations and communities and has been carefully examined in previous studies [20, 21, 22]. In the earthquake which happened in Haiti, the staff believed that they were not ready for such a situation [23]. In Bahrami et al. study, the employees’ prior preparedness and training with regard to the job description and the service conditions were discussed [24]. In their study, Khanke et al. emphasized the role of lack or deficiency of plans to offer health services, the need for prior preparedness, and the need to develop preparedness plans at various levels [22]. In response to the September 11 incident, it was shown that most of the people who volunteered to help the affected people did not have prior training and experience.
The lack of training harmed the volunteers themselves [25]. In examining the capabilities and limitations of Khoram Abad hospitals, it was mentioned that these hospitals lacked comprehensive and coherent action plans in disasters. Moreover, the present action plans were not implemented in an appropriate way [26]. Masoodi [23]stated that various beneficial actions had been taken to prepare the plans in the aftermath of the Bam earthquake. Nonetheless, he noted that, as shown in the earthquake in Azerbaijan, there was not complete preparedness in the health system [27]. In Nakhai et al. study, lack of prior preparedness was one of the responses of the health field to the past disasters [28]. In the present study, lack of preparedness was noticeable in all aspects of the action plan and affected all of the offered services. Tabriz University of Medical Sciences, which was hundreds of kilometers away from the affected areas, had not suffered any harm. However, it had sufficient information on the affected areas and their purpose in the mentioned areas and was aware of the range of the needed services. 
Communication is one of the main components of planning, responding to disasters, and recovering from disasters. Effective communication can prevent or reduce the effects of a disaster. Therefore, the development of an active communication process should be a priority in times of disaster [29]. In the present experience, the team did not develop a plan to communicate with the media, and various individuals communicated with the media based on their prior experiences. Notwithstanding, a telegram group was formed to enable the team members to stay in touch. This group made notifications, enabled the members to share their (sometimes incomplete) experiences with the other members, and informed the officials of the matters. Moreover, there are experiences in the world, including using the capacity of the Twitter messenger [30]. To offer any service in disasters and to formulate interventions, it is essential to identify the problems and needs of the region, including health needs, appropriately [31] because, in most cases, there is insufficient information on these issues. Furthermore, the present information might not be useful [32]. To overcome this problem, rapid assessment of needs in the disaster-affected areas is usually carried out. The needs assessment is a technical issue and requires specific skills and tools, and should be carried out by experienced individuals [31]. In the present study, certain assessments had been carried out. Notwithstanding, their inaccuracy caused several problems. In previous studies, the researchers have discussed these challenges in detail [31, 32, 33]. Nearly all of the previously experienced problems were encountered in the present case. 
Receiving assistance from other areas and organizations in times of disaster will continue for all of the major disasters in the future. As mentioned earlier, this issue stems from the fact that the created health needs cannot be satisfied by the available services and capacities in the disaster-affected areas. These processes will be challenging, mainly if they are not carried out according to initial plans. Therefore, the timely response and effectiveness of this kind of assistance depend on prior preparedness (including the preparedness of human resources, the preparedness of equipment, the availability of instructions and guidelines, and managerial capacities) and coordination between the contributing areas the disaster-affected area. It is hoped that these kinds of preparations are made and practiced at times of peacefulness and the managerial coordination be improved and accelerated at times of disaster. 

Ethical Considerations
Compliance with ethical guidelines
All ethical principles are considered in this article.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
Both authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest. 

Acknowledgments
The authors would like to thank the Tabriz University of Medical Sciences relief team who was involved in the Kermanshah earthquake.


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