, Introduction
Hemodialysis (HD) is a life-sustaining therapy that is heavily reliant on stable social infrastructure such as electricity, clean water, and ground transportation. Consequently, patients receiving HD are especially vulnerable during disasters, which often compromise these essential services [1,2]. As demonstrated during the coronavirus disease 2019 pandemic [3] and other large-scale emergencies [4], disruptions in healthcare systems can disproportionately affect HD patients, underscoring the need for dedicated disaster preparedness in HD facilities.
In South Korea, although there is growing awareness of the vulnerability of HD services to natural and man-made disasters, systematic disaster preparedness tailored specifically to the needs of HD units is still in its early stages of development [5,6]. Previous research has shown that disaster preparedness is significantly influenced not only by patient education but also by the perceptions, experiences, and prior training of healthcare workers, including dialysis unit staff and medical personnel [7]. However, most existing studies have not specifically targeted dialysis staff or facilities, nor have they utilized tools validated in such settings. Notably, studies conducted among primary care physicians [8] and college students [9] highlight how disaster awareness is shaped by both professional and sociodemographic contexts.
In the aspects of dialysis-specific disaster awareness, Japan’s national survey among dialysis physicians used a structured self-administered questionnaire to evaluate disaster preparedness plans (DPs) and found that staff self-efficacy and perceived institutional support were critical determinants of effective DP implementation [10]. Similarly, a study from medical staff demonstrated that training and simulation were essential in enhancing disaster-related knowledge, attitudes, and practices of nurses [11–13]. In South Korea, the perception of disaster preparedness of emergency nurses has been shown to correlate strongly with both personal experience and institutional training [11]. A systematic review by Labrague et al. [14] highlighted that targeted disaster training and simulation significantly enhance the disaster-related knowledge, attitudes, and practices of nurses, emphasizing the critical need to raise awareness and preparedness for effective disaster response among healthcare workers. Given this background, this study aimed to investigate the level of disaster preparedness and awareness among nephrologists who are members of the Korean Society of Nephrology (KSN) using a structured questionnaire survey.
Methods
Study design and population
This was a cross-sectional survey study targeting physicians currently practicing in HD units across South Korea. Eligible participants included the members of the KSN or those of the Korean Society for Dialysis Therapy who are actively involved in the care of HD patients. Participation required an online agreement to the informed consent using a Google Forms questionnaire. Participants were invited via email distributed by the KSN. The survey was administered using a Google Form, with a mobile-friendly interface for ease of completion. The survey instrument was adapted from a validated questionnaire developed by the Japanese Association of Dialysis Physicians [10]. The questionnaire was translated into Korean and adapted through expert panel review involving nephrologists, disaster medicine specialists, and public health professionals. Permission to use the Korean version of the questionnaire was obtained from the original authors. Content validity was ensured through a 4-point Likert scale evaluation by internal and external experts, followed by consensus discussions [15].
Survey content
The survey collected comprehensive information across several categories, including demographic details such as age, sex, type of HD facility, and geographical region. It also assessed the personal experiences of respondents with disasters by inquiring about their history of encountering disaster events within the HD units. Furthermore, the survey evaluated preparedness through perceived readiness in critical areas such as patient management during emergencies, administrative and safety protocols, and the effectiveness of existing inter-facility communication and coordination networks. Additionally, it explores the awareness and attitudes of respondents by examining their risk perceptions, expectations of disaster-related outcomes, levels of self-efficacy, and perceived responsibilities during disaster situations. Finally, the survey addressed institutional support and training by capturing respondents’ participation in disaster preparedness training programs and evaluating their perceptions regarding the overall preparedness and responsiveness of their institutions.
Measurements
Disaster preparedness was evaluated across four key domains: patient management, administrative readiness, interinstitutional networking, and facility safety measures. The patient management domain includes four items, while the administrative readiness domain includes nine items. The reliability of these domains was evaluated using a Cronbach alpha. The reliability of the patient management domain was 0.726, and that of administrative readiness was 0.666. One item each is included in the interinstitutional networking domain and the facility safety domain. Answers to each item were recorded in binary format, and the implementation rates for each item were calculated in proportion. The average implementation rate for each domain was calculated as the mean of implementation rates of each item.
Cognitive factors related to disaster preparedness were measured using four separate scales: “risk perception,” “outcome expectancy,” “self-efficacy,” and “self-responsibility” (Supplementary Table 1, available online). Questions regarding cognitive factors were evaluated using a 4-point scale: “Strongly disagree,” “Disagree,” “Agree,” and “Strongly agree.” Each choice was assigned a score from 1 to 4 for quantification. The scoring of each scale was conducted by the simple addition of the scores for each item. The reliability of each scale was evaluated using a Cronbach alpha. The reliability of risk perception scale was 0.793, that of outcome expectancy was 0.915, and that of self-efficacy was 0.654. The reliability for self-responsibility was not calculated because it consists of one item.
Statistical analysis and ethical considerations
Descriptive statistics were used for demographic and survey item summaries. Disaster experience was recorded as a proportion. Factors associated with disaster experience were analyzed using the chi-square test. A multiple logistic regression model was used to evaluate the association between cognitive factors and disaster preparedness. Age group, sex, types of facility, and location of HD unit were included as control variables. Before performing logistic regression analysis, the values of each domain in disaster preparedness were transformed into a binary format. The median value was used as the cutoff value. When performing multiple comparisons, the p-value was adjusted with Bonferroni’s adjustment. Statistical significance for multiple logistic regression analysis was set at p < 0.01.
This study was conducted in accordance with the Declaration of Helsinki after approval by the Institutional Review Board of Ulsan University Hospital (No. UUH2024-01-017 and No. UUH2023-10-034). Informed consent was obtained electronically. No personal identifiers were collected, and all responses were anonymized and securely stored.
Results
Baseline characteristics of the respondents
Among 2,010 members of KSN, a total of 170 dialysis physicians responded to the survey (8.5%). Baseline characteristics of the respondents are shown in Table 1. Among the survey respondents, those in the 40–49-year and 50–59-year age groups accounted for the largest proportions (37.6% each). The ratio of men and women was equal. The types of HD facilities included tertiary general hospitals (n = 33, 19.4%), general hospitals (n = 53, 31.2%), hospital (n = 14, 8.2%), and clinics (n = 70, 41.2%). Most of the respondents were from the capital region (Seoul, Incheon, or Gyeonggi Province) accounting for 58.2%, but responses were received from all over the country.
Disaster experience in hemodialysis units
A proportion of respondents reported prior experience with disaster-related events in their HD units, including power outages, water supply disruption, fires, flooding, and earthquakes. Specifically, 70 respondents (41.2%) reported prior experience of power outages, 63 (37.1%) reported water supply disruption, 14 (8.2%) reported flooding, 10 (5.9%) reported fire, and one (0.6%) reported earthquake (Fig. 1A). The other disaster experiences included snowstorm, computer system outage, and patient violence.
These experiences varied by region and facility type, reflecting differences in regional disaster vulnerability and infrastructure. The power outage was more frequently occurred among clinics (58.6%) compared to tertiary general hospital (30.3%), general hospital (26.4%) or hospital (35.7%, p = 0.001) (Fig. 1B). The disruption of water supply was also more common among clinics (52.9%) and hospitals (42.9%) compared to tertiary general hospital (24.2%) and general hospital (22.6%, p = 0.002). However, there was no difference in the occurrence of power outage or water supply disruption according to regional location. On the other hand, flooding disasters were concentrated among non-capital regions (Fig. 1C), especially in the South of Korean Peninsula (13 out of 14 disasters, 92.9%).
Implementation rates of disaster preparedness
Implementation rates of disaster preparedness are summarized in Table 2. The highest implementation rate was 90.6% for the facility safety domain, followed by 78.2% in the interinstitutional networking domain, 71.8% in the administrative readiness domain, and 71.2% in the patient management domain. Among the patient management domain, the range of implementation rates for each item was narrow (61.8% to 86.5%). However, the ranges of implementation rates for each item in the administrative readiness domain were wide (25.3% to 89.2%). Interestingly, the implementation rate for “making a manual for disaster preparedness” was as high as 79.4%, but the implementation rate for “regularly revising a manual” was as low as 32.4%. Likewise, the implementation rate for “implementing annual disaster education for the staff” was as high as 65.9% while the implementation rate for “conducting annual disaster drills for the staff” was as low as 25.3%.
Cognitive factors related to disaster preparedness
Cognitive factors regarding disaster preparedness were evaluated in four scales: “risk perception,” “outcome expectancy,” “self-efficacy,” and “self-responsibility” (Supplementary Table 1, available online). Most respondents acknowledged the likelihood of future disasters affecting dialysis services and expressed a strong sense of responsibility and willingness to engage in preparedness despite heavy workloads. The overall risk perception about future disasters among respondents was measured using a 1- to 10-point scale, and the average risk score was 6.96. Three questions were answered in the “risk perception” scale. A total of 122 respondents (71.7%) agreed that a massive disaster may occur in their HD unit within 5 years. A total of 112 participants (65.9%) thought their facilities would suffer serious damage in a disaster situation. In addition, a total of 136 respondents (80.0%) assumed that a power outage or water supply shortage would occur as a result of a disaster. As the risk perception was high among respondents, their outcome expectancy as a result of disaster preparedness was also high. A total of 43 respondents (25.3%) strongly agreed and 113 (66.5%) agreed that disaster preparedness can minimize the impact of a disaster. A large number of respondents (94.1%) were confident that disaster preparedness can save the lives of the patients in their HD units. Two questions were answered in the “self-efficacy” scale. Most of the respondents (92.9%) were willing to advance disaster preparedness even if they are very busy. About 96.5% of the respondents were willing to implement disaster preparedness even if their patients are not concerned about disasters. About 88% of the respondents thought it was their responsibility to conduct disaster preparedness.
Table 3 demonstrates the association between cognitive factors and the domains of disaster preparedness. Multiple logistic regression analysis was performed after adjusting for age group, sex, types of facility, and location of HD unit. Among cognitive factors, risk perception was strongly correlated with administrative readiness (standardized coefficient β = 1.315; 95% confidence interval [95% CI], 1.075–1.608; p = 0.008) while outcome expectancy was correlated with safety facility domain (β = 2.951; 95% CI, 1.573–5.535; p < 0.001). Self-efficacy and self-responsibility did not correlate with disaster preparedness.
Perceptions of the role of the Disaster Preparedness and Response Committee of the Korean Society of Nephrology
A majority of participants indicated that there is a need for the KSN to take an active role in producing and distributing disaster preparedness manuals. About 60% of respondents also supported the idea that the disaster preparedness education and drills should be mandatorily provided by KSN.
Discussion
This study is the first survey study to investigate disaster experiences, disaster preparedness, and disaster awareness among medical staff in Korea. More than half of respondents (n = 98, 57.6%) have experienced more than one type of disaster in HD units. The power outage and water supply disruption were the most common disaster situations among Korean HD units. Implementation rates of disaster preparedness varied by domains with the highest rates (90.6%) in the facility safety domain and the lowest rates (71.2%) in the patient management domain. Overall, the Korean dialysis unit medical staff showed a high sense of crisis regarding disaster (7 out of 10). The respondents expected the KSN to play a more active role in disaster response.
Disasters are largely divided into natural disasters and man-made disasters. Korea has been considered a disaster-free country. Unlike Japan, it is not in an earthquake-active zone, and the climate has not been so dry that the risk of fire has been low. However, due to recent climate change and global warming, the frequency of disasters is increasing as heavy rain and dry weather warnings are issued frequently. A previous report of Yoo et al. [2] demonstrated that a DP should be launched among HD units in Korea since it is no longer safe from natural disasters. In addition to climate change, man-made disasters such as arson and landslides caused by indiscriminate development are also increasing. Our study also demonstrated that over half of the survey respondents experienced more than one type of disaster in HD units. Therefore, we should be aware of disaster risk in our HD facilities and should prepare accordingly to minimize its outcome.
Our study demonstrated that the power outage and the water shortage are the two most common disaster patterns in Korean HD units. Previous reports from the Great East Japan Earthquake Academic Research Working Group of the Japanese Society for Dialysis Therapy also mentioned that the most common reasons for inability to operate HD units were damage to water and power supplies [16,17]. Although the responses from our study did not mention the displacement of HD patients to other regions, a previous report from the 2011 Christchurch earthquake demonstrated that it is common to reallocate patients to other locations due to power or water shortage [18].
The implementation rates of disaster preparedness in our study were higher than those from the Japanese study [10]. In the Japanese study, the implementation rate for patient, administration, networks, and safety domains were 38.4%, 57.9%, 48.3%, and 81.8%, respectively. In our study, the implementation rates were higher showing 71.2%, 71.8%, 78.2%, and 90.6%. One possible explanation for this is the difference in the items included in the survey. The survey we used was created based on the Japanese survey, but some items were modified to take into account the fact that there are fewer earthquakes and more other disasters in Korea than in Japan. The Japanese survey items are specialized for earthquakes. Therefore, there may be differences in the implementation rates of disaster preparedness. In addition, the Japanese survey targeted all medical staff working in each HD unit, such as doctors, nurses, and technicians, while our study targeted only doctors. Lastly, there can be a possibility that only those who are well-managed or particularly interested in disaster preparedness participated in the survey. Although we sent out survey e-mails and texts several times, the response rate was lower than 10%. In the previous study of the Japanese survey, they showed a higher response rate of 57.2% [10]. The higher response rate from the Japanese study can be the result of their prior experiences of major earthquakes. It is possible that these experiences have increased dialysis staff’s awareness of disaster preparedness and thereby increased the response rate. On the other hand, the low response rate in our study may reflect the low awareness of disaster preparedness in Korea, which can be a major limitation of this study.
Of note, although efforts are being made to create a disaster preparedness manual, to conduct training, and to establish an emergency contact network, it has been confirmed that revising the manual, conducting annual drills, and checking whether the emergency contact network is functioning properly are not being followed. In the future, efforts should be made in these areas to improve disaster preparedness in each HD unit.
“Disaster awareness” in healthcare staff refers to their knowledge of potential disasters, risk perceptions, training received, and confidence in handling emergency situations. In HD units, both physicians and nurses must be acutely aware of disaster risks and protocols, as an effective response can save the lives of the patients who are dependent on regular HD. Research in the past decade has examined whether enhancing staff awareness and perception of disaster readiness translates into concrete preparedness actions and better performance during actual events. Studies of nurses and other providers consistently find that those with higher knowledge or training in disaster management demonstrate higher levels of preparedness activities [14], including unique context of conflict disaster [19]—characterized by rapidly changing conditions and limited resources—further emphasizes the need for targeted medical readiness training to enhance professional competence and effective decision-making among healthcare providers. However, the inconsistent results have been demonstrated regarding the influence of specific cognitive factors upon disaster preparedness. Cliff et al. [20] in their previous report showed that risk perception did not affect overall disaster preparedness. On the other hand, Sugisawa et al. [10] demonstrated that risk perception was positively associated with the patient domain of disaster preparedness. In our study, risk perception was positively associated with administrative readiness. In the work by Sugisawa et al. [10], outcome expectancy negatively influenced the patient domain. In our study, outcome expectancy did not influence patient management but was positively associated with facility safety. The Japanese survey study showed that self-efficacy was significantly associated with all four domains of disaster preparedness. However, in our study, the self-efficacy was not associated with any of the domains. One possible explanation is that the reliability of the “self-efficacy” and “self-responsibility” scales is too low. The Cronbach alpha for “self-efficacy” was 0.654, demonstrating low reliability. The Cronbach alpha for the “self-responsibility” scale was not calculated because it consists of one item. The second possible explanation would be the difference in disaster awareness. Our survey demonstrated a lower response rate of 8.5% compared to the Japanese study (57.2%). Similar survey studies performed among the members of KSN also demonstrated a low response rate, with the number of respondents under 200 [21,22]. Since Japanese society has experienced two great earthquakes, HD personnel in Japanese dialysis clinics may have higher awareness of the disaster situation. The low response rate in our study may indirectly reflect the low awareness of the importance of disaster preparedness. Therefore, the influence of cognitive factors upon disaster preparedness is unclear at this time.
This study has several limitations. The first is the low response rate to the survey. We sent out the survey form through e-mails and only received answers from 170 participants. The rest of the members from KSN may have low awareness and disaster preparedness. The second limitation would be the validity of this survey. Even though we adopted the Japanese survey questions and modified them in Korean, it has not been validated in the Korean population. Moreover, the disaster patterns and preparedness should be different by culture and environment. Especially, the items regarding interinstitutional networking and facility safety only included a single question, which may not reflect the true aspects of disaster preparedness. In addition, the scales of “self-efficacy” and “self-responsibility” also included a few items. Lastly, since this study is a cross-sectional study, only the association between disaster preparedness and cognitive factors can be analyzed. Future studies should be warranted to reveal a causal inference.
In conclusion, there were high levels of disaster preparedness and awareness among medical staff in HD units. Cooperation between each HD unit, KSN, and the national government should be warranted to deal with future disasters in HD units.
PDF Links
PubReader
ePub Link
XML Download
Full text via DOI
Download Citation
Supplement table 1
Print
