1. Introduction
Disasters, whether natural or man-made, are increasing globally [1, 2]. According to the World Health Organization (WHO), “a disaster is a serious disruption to the functioning of society that causes widespread human, material, economic, or environmental damage that may be beyond the ability of society to cope with its resources” [3]. According to the 2020 world disaster report, between 2008 and 2019, there were 1231 natural disasters worldwide, affecting nearly 2 billion people in 115 countries [4]. As a result of disasters, many deaths and complies occur, the demand for health care increases suddenly and uncontrollably, and people rush to health centers and hospitals [5]. In such situations, health and medical staff play a significant role. If only the hospital itself is in disaster, it is an internal disaster, otherwise, it is an external disaster. Disasters can be caused by natural events (such as hurricanes, droughts, earthquakes, and communicable diseases), technology-related events (such as explosions, structural collapse, and radiological events), or civil/political events (such as strikes, terrorist attacks, and biological wars) [3]. Unexpected events have adverse effects on medical centers including delays or lack of proper and timely information, confusion of staff, lack and rapid completion of emergency capacity, lack of equipment and consumable materials, disruption of the normal operation of the medical center due to the breakdown of equipment, facilities and the crowds. These incidents create unique problems that require a different kind of planning than the day-to-day operation of hospitals. Therefore, disaster management and the existence of a complete and codified program in all medical centers are necessary to reduce the effects of the disaster [6]. Considering the occurrence of disasters in different parts of Iran, disaster risk management reducing the damage and its consequences, identification of its infrastructure, and assessment of the ability of all treatment centers are necessary to appropriately plan and deal with disasters [7]. Disaster management is possible if all medical staff are aware of their responsibilities and work as a team under an integrated management system [6, 8, 9]. Given the spread of disaster in the world and the importance and the vital role of hospitals and health care centers in disaster management and treatment of patients, as well as the lack of studies on hospitals staff in Iran, the present study aimed to investigate the level of knowledge, attitude, and practice of hospital staff in Shiraz to prepare them for the disaster.

2. Materials and Methods
Study design and participants
This cross-sectional analytical descriptive study aimed to measure the knowledge, attitude, and practice of hospital staff in terms of disaster preparedness at Shiraz University of Medical Sciences. The inclusion criteria were more than one year of work experience.

Sample size and sampling method
To determine the sample size, a pilot study was first conducted. In the pilot study, a standard deviation of 4.14 was obtained. Considering a confidence level of 95% and an error of 4, the sample size of 292 people was obtained. Considering a drop rate of 20%, the sample size was considered to be 350. For data collection, the cluster sampling method was used. Based on this method, each hospital was considered as a cluster (17 clusters). Then, 21 people from each hospital were randomly selected and included in the study. Finally, the questionnaire was distributed among them. 

Data gathering tools
The data was collected using a researcher-made four-part questionnaire including demographic information (gender, marital status, education, job, and work experience), knowledge (12 questions), attitude (9 questions), and practice (8 questions). All questions were developed based on an extensive review of the related literature. For instrument validation, in the first step, the questionnaire was sent to 15 professors of Shiraz University of Medical Sciences in the fields of health education and health promotion, environmental health engineering, ergonomics, and occupational health engineering about disaster preparedness. In the second step, experts› comments and opinions were applied to different parts of the questionnaire. Finally, the CVI and CVR tests were used as validation tests. The CVI and CVR tests showed a value of 0.83 and 0.75 respectively. The questionnaire reliability was confirmed by the Cronbach α test and obtained 0.75. for the Knowledge answers were correct (1 point), wrong and I don›t know (0 points). The attitude was measured based on a 5-point Likert scale from strongly disagree (score 1) to strongly agree (score 5). The Disaster preparedness practice was scored yes (score 2), not yet held (score 1), and no (score 0). 

Data analysis
The SPSS software, version 21 was used to analyze the collected data. First, the Smirnov-Kolmogorov test was used to assess the normality of the data. Due to the non-normality of data, Mann-Whitney and Kruskal-Wallis tests were also used. 

3. Results
In this study, 350 participants completed the questionnaire. The mean age of the participants was 33.42±8.04 years (Table 1), and 65% were women and 62.6% were married, 66% had a bachelor’s degree and 46% had a degree in nursing.

The mean work experience was 9.74±7.26 years and most of the subjects (60%) had less than 10 years of work experience. The Mean±SD for knowledge, attitude, and practice were 9.44±1.53, 39.26±4.80, and 7.26±3.66, respectively (Table 2).

Besides, 74.5%, 24.8%, and 0.7% of participants showed good, moderate, and weak knowledge, respectively, and 89.5 % of hospital staff had good attitudes while 9.9% and 0.6% had moderate and weak attitudes, respectively (Figure 1).

The percentage of good practice was 27.7%, 42% of participants had medium and 25.1% of them had weak practice. Table 3 indicates the relationship among the knowledge, attitude, practice, and demographic variables. The demographic information did not show a meaningful relationship between knowledge and attitude.

The gender of participants had a significant relationship with practice (P=0.009) and females had higher scores of practice than men. The marital status of subjects also was meaningfully related to practice (P=0.006) and married participants had higher scores than singles. The practice showed different levels (P=0.001), and physical protection and technicians had the highest and the lowest scores, respectively. The practice dimension also had a meaningful relationship with work experience (P=0.002). Participants with 20-11 years of work experience had the highest scores and those under 10 years of work experience showed the lowest practice. Moreover, the Spearman correlation test showed a significant relationship between knowledge and attitude (r=254, P<0.001), knowledge, and practice (r=205, P<0.001), attitude, and practice (r=161, P=0.004). 

4. Discussion
The study aimed to determine the level of knowledge, attitude, and practice of the hospital’s staff in terms of disaster preparedness at Shiraz city, and 745% of participants showed good knowledge. This outcome was in contrast with Ahayalimudin et al.’s study conducted on emergency nurses and health clinic nurses in Selangor state in Malaysia. They indicated that both groups of nurses had similar inadequate knowledge but a positive attitude toward disaster management [10]. In Nofal et al.’s study that assessed the knowledge, practices, and attitudes regarding disaster and emergency preparedness among the staff of the emergency department, the participants with more than 5 years of experience had a statistically significant (P=0.009) knowledge score for disaster and emergency preparedness [11]. The managers of different hospital departments in South Africa were also aware of disaster preparedness and disaster management guidelines that were consistent with this study’s result [12]. In Bandar Abbas, the knowledge of hospital staff about disaster preparedness needed to be strengthened to improve self-efficacy during disaster management [13]. Also, the knowledge of disaster management and disaster preparedness was low or moderate in 93.9% of final-year nursing students and more than 80% of nurses, respectively [14]. Furthermore, in other similar studies [5, 15, 16] on health center workers in Dehloran, Saudi Arabia, and Japan, participants had inadequate knowledge about disaster preparedness. About 90% of staff had a good attitude toward disaster preparedness which was consistent with the results of Khan et al.’s study on nurses in Lahore [17]. Moreover, participants had a positive attitude toward disaster preparedness same as the managers of different wards of the hospital in Moabi et al.’s study [12]. Also, the mean attitude score for hospital staff at Dehloran city was 23.27, and 89.39% of them had a positive attitude toward disaster preparedness [5]. Although in Yemeni health professions, the attitude among different jobs was not statistically significant, technicians and physical protection showed a higher score. The level of attitude regarding disaster planning among them was statistically different and medical teachers appeared higher in attitude to disaster management [8]. The findings also elicited that the participant practice in disaster preparedness was moderate (7.26±3.66). Although the knowledge and attitude of most of the employees were at an acceptable level, they need appropriate practical and training programs in terms of their practice.
In the current research, demographic information was not related to knowledge and attitude dimensions that were consistent with Munasinghe et al.’s study. They found that gender, work experience, and job type were not attributed to disaster preparedness [1]. Jourvand et al.’s study also showed the same results [5]. While education level was a key factor in the knowledge level of Yemeni health professionals. Yemeni Physicians were better in knowledge than other subgroups of health specialties [8]. 
In contrast with knowledge and attitude, demographic information was attributed to the practice of participants in the current research. Females and married participants showed better practice than men. 
Participants with 11-20 years of work experience had the highest score of practice. Moreover, physical protection and technicians had the highest and the lowest scores, respectively. 
In addition, the trained staff mentioned that they knew what to do during the disaster regarding their role and their received training but, the rest of them did not know about the required actions due to a lack of received training and unspecified roles during disaster management. In Khan et al. [17] and Ahayalimudin et al.’s [10] studies, nurses had sufficient practice and were consistent with the present results. In contrast, in Saudi, Bandar Abas, and India, EMS students, health care workers, and medical internship students showed poor performance, respectively. They stated that they were not prepared to respond to the disaster [3, 15, 18]. Also, in Moabi et al.’s study, the practice of individuals was defective and the staff required firefighting training, practice, and periodic review of instructions [12]. One reason for the inconsistency of some of the above studies with the present study was the staff’s lack of motivation to participate in disaster preparedness programs due to the high workload. Also, due to the lack of operational maneuvers and experience, individuals have low practice in dealing with disasters. Different factors such as studied areas, environmental and regional conditions, type of hospital, and how to develop and implement training programs related to disaster preparedness can affect these differences. 
Some studies on health professionals propose some actions to enhance their preparedness against disasters. In Adams et al.’s study, nurses acknowledged that some barriers affect their availability for work following a disaster, and the right solutions should be considered for them [19]. Cotanda et al. reported that the implementation of training programs improved the knowledge of pediatric emergency department staff [20]. Gowing et al. did a systematic review of health professionals and support staff in terms of disaster preparedness. They reported that health professionals and support staff may not be fully prepared for disasters. They emphasized that the whole healthcare team, including allied health professionals and support staff, needed more attention for both internal and external disasters [21]. Khankeh et al. reported that the establishment hospital incident command system can improve the hospitals’ preparedness at times of disasters in many aspects [22]. Sawano et al. proposed that the potential health impact of hospital evacuation during disasters should be considered in the disaster preparedness policies, pre-planning, training, and pre-testing of these plans [23]. Moreover, the results of a systematic review showed that developing educational and training programs to strengthen the knowledge and skills of nurses for disaster preparedness is necessary [24]. 

5. Conclusion
In this study, the knowledge and attitude of participants in terms of disaster preparedness were at a good level. They showed moderate practice. In addition to disaster preparedness policies, using theoretical and practical training programs and operational maneuvers is necessary to improve their practice. Moreover, developing educational and training programs to strengthen the knowledge and skills of the hospital’s staff is a key element. 
Regarding the low sample size as a limitation, it is suggested that future studies consider a bigger sample size. Another limitation was using a questionnaire. It is suggested that future studies try to measure the performance of individuals in practice by holding operational maneuvers.

Ethical Considerations
Compliance with ethical guidelines
In this research, written consent was obtained from all participants. Due to the non-interventional nature of the study, the ethics code was not assigned to the research committee. 

Funding
This study was financially supported by Shiraz University of Medical Sciences, (Grant No.: 98-01-04-19656).

Authors' contributions
Conceptualization and supervision: Mehdi Jahangiri and Zahra Motlagh; Methodology: Mehdi Jhangiri, Fateme Omidvari and Raziyeh Janizadeh; Investigation, writing – original draft, review & editing: All authors; Data collection: Fateme Omidvari and Raziyeh Janizadeh; Data analysis: Fateme Omidvari, Zahra Motlagh.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank the Shiraz University of Medical Sciences for its financial support.


References

1. Munasinghe NL, Matsui K. Examining disaster preparedness at Matara district general hospital in Sri Lanka. International Journal of Disaster Risk Reduction. 2019; 40:101154. [DOI:10.1016/j.ijdrr.2019.101154]
2. Estevão C, Costa C. Natural disaster management in tourist destinations: A systematic literature review. European Journal of Tourism Research. 2020; 25:2502. [DOI:10.54055/ejtr.v25i.417]
3. Singhal Y, Bhatnagar R, Lal B, Paliwal B. Knowledge, attitudes, and practices of medical internship students regarding disaster preparedness at a Tertiary-Care Hospital of Udaipur, Rajasthan, India. International Journal of Medical Science Public Health 2016; 5(8):1613-6. [DOI:10.5455/ijmsph.2016.25112015263]
4. CIFRC. World disaster report. Genrva: CIFRC; 2018. [Link]
5. Jourvand R, Sadeghirad K, Golami OA, Vejdani M, Panahi R, Heydarabadi AB. [Disasters preparedness of health workers in Dehloran, Iran (Persian)]. Journal of Health in the Field. 2015; 3(3):13-8. [Link]
6. Cariaso-Sugay J, Hultgren M, Browder BA, Chen JL. Nurse leaders’ knowledge and confidence managing disasters in the acute care setting. Nursing Administration Quarterly. 2021; 45(2):142-51. [DOI:10.1097/NAQ.0000000000000468] [PMID]
7. Mirzaei S, Eftekhari A, Sadeghian MR, Kazemi S, Nadjarzadeh A. The effect of disaster management training program on knowledge, attitude, and practice of hospital staff in natural disasters. Journal of Disaster and Emergency Research. 2020; 2(1):9-16. [DOI:10.18502/jder.v2i1.566]
8. Naser WN, Saleem HB. Emergency and disaster management training; knowledge and attitude of Yemeni health professionals-a cross-sectional study. BMC emergency medicine. 2018; 18(1):23. [DOI:10.1186/s12873-018-0174-5] [PMID] [PMCID]
9. Nakhaei M, Tabiee Sh, Saadatjou S, SabzehKar F. The effect of educational intervention on nurses’ preparedness in emergencies and disasters. Journal of Birjand University of Medical Sciences. 2019; 26(3):237-48. [DOI:10.32592/JBirjandUnivMedSci.2019.26.3.105]
10. Ahayalimudin N, Ismail A, Saiboon IM. Disaster management: A study on knowledge, attitude and practice of emergency nurse and community health nurse. BMC Public Health. 2012; 12(S 2):A3. [Link]
11. Nofal A, Alfayyad I, Khan A, Al Aseri Z, Abu-Shaheen A. Knowledge, attitudes, and practices of emergency department staff towards disaster and emergency preparedness at tertiary health care hospital in central Saudi Arabia. Saudi Medical Journal. 2018; 39(11):1123-9. [DOI:10.15537/smj.2018.11.23026] [PMID] [PMCID]
12. Moabi RM. Knowledge, attitudes and practices of health care workers regarding disaster preparedness at Johannesburg hospital in Gauteng Province, South Africa [MSc Thesis]. Johannesburg: University of the Witwatersrand; 2008. [Link]
13. Lakbala P. Hospital workers disaster management and hospital nonstructural: A study in Bandar Abbas, Iran. Global Journal of Health Science. 2016; 8(4):221-6. [DOI:10.5539/gjhs.v8n4p221] [PMID] [PMCID]
14. Khoshnazar T, Moghadamnia M, Khankah H, Ahmadi S. Awarencess of nursing students toward disaster preparedness in the health care system. Paper presented at: 5^th International Congress on Health and Crisis Management in Disasters; 2011.
15. Ibrahim FAA. Nurses’ knowledge, attitudes, practices and familiarity regarding disaster and emergency preparedness-Saudi Arabia. American Journal of Nursing Science. 2014; 3(2):18-25. [DOI:10.11648/j.ajns.20140302.12]
16. Öztekin SD, Larson EE, Akahoshi M, Öztekin İ. J apanese nurses’ perception of their preparedness for disasters: Quantitative survey research on one prefecture in Japan. Japan Journal of Nursing Science. 2016; 13(3):391-401. [DOI:10.1111/jjns.12121] [PMID]
17. Khan S, Kausar S, Ghani M. Knowledge of disaster preparedess among nurses at two tertiary care hospitals in LAHORE. Biomedica. 2017; 33(1):29-38. [Link].
18. Alrazeeni D. Saudi EMS students’ perception of and attitudes toward their preparedness for disaster management. Journal of education practice 2015; 6(35):110-6. [Link]
19. Adams LM, Melius J. Prepared to respond? Exploring Personal disaster preparedness and nursing staff response to disasters. Disaster Medicine and public Health Preparedness. 2021; 15(5):557-62. [DOI:10.1017/dmp.2020.47] [PMID]
20. Cotanda CP, Martínez MR, de la Maza VTS, Cubells CL. Impact of a disaster preparedness training programme on health staff. Anales de Pediatría (English Edition). 2016; 85(3):149-54. [DOI:10.1016/j.anpede.2015.07.040]
21. Gowing JR WK, Elmer SL, Cummings EA. Disaster preparedness among health professionals and support staff: what is effective? An integrative literature review. Prehospital and Disaster Medicine. 2017; 32(3):321-8. [DOI:10.1017/S1049023X1700019X] [PMID]
22. Khankeh HR, Lotfolahbeygi M, Dalvandi A, Amanat N. Effects hospital incident command system establishment on disaster preparedness of Tehran hospitals affiliated to law enforcement staff under simulated conditions. Health in emergencies and disasters quarterly. 2018; 3(4):207-14. [DOI:10.32598/hdq.3.4.207]

23. Sawano T, Senoo Y, Yoshida I, Ozaki A, Nishikawa Y, Hori A, et al. Emergency hospital evacuation from a hospital within 5 km radius of Fukushima Daiichi Nuclear Power Plant: A retrospective analysis of disaster preparedness for hospitalized patients. Disaster Medicine and Public Health Preparedness. 2022; 16(5):2190-3. [DOI:10.1017/dmp.2021.265] [PMID]
24. Tas F, Cakir M. Nurses’ knowledge levels and preparedness for disasters: A systematic review. International Journal of Disaster Risk Reduction. 2022; 80:103230. [DOI:10.1016/j.ijdrr.2022.103230]