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ABSTRACT “The future depends on what you do today” Mahatma Gandhi

April 11, 2019 0 Comment

ABSTRACT
“The future depends on what you do today”
Mahatma Gandhi.

BACKGROUND:
Today in this digital era of 21st century, while reading newspaper, you will come across many reports highlighting about all sorts of natural and man-made disasters. Not a single day passes without any news on media in connection with disasters. Human, financial, environmental losses are the common features of disaster. Due to disaster, human beings are affected with injury, disability, death etc. People affected by disasters admitted as patients for treatments in hospitals. Hence hospitals are among the most important shelter, as they are viewed as the refuge where affected people are treated.
Hospital word is derived from the word “Hospice” meaning home who is providing care for the sick. Hospitals and its staff are closely connected to disasters and patient care. Costs of devastation of hospitals due to disaster are very expensive than the cost spent on making hospital safe from disasters. Hence hospital disaster preparedness is an important subject for the investigation. From the literature review, it was found that majority of the studies for hospital disaster preparedness is conducted on hospital staff knowledge attitude and practices. There are limited studies available on hospital disaster preparedness with respect to hospital disaster management plan and hospital infrastructure. As per Indian Disaster Management Act, 2005, hospital disaster plan is mandatory requirement. Very few studies are documented on hospital infrastructure in combination with human resource disaster preparedness. This is a need of the hour and no such study is conducted so far in Navi Mumbai location. This has prompted researcher to study disaster preparedness for the hospitals of Navi Mumbai.
Navi Mumbai is planned and newly developed satellite city nearby to Mumbai which is commercial capital of India. Majority of the hospitals in Navi Mumbai are established in last two decades. The study is serving dual purpose; firstly it is assessing the hospital disaster management plan and hospital infrastructure including the knowledge, attitude and practices of hospital staff. Secondly study is also comparing the three categories of hospitals within Navi Mumbai, namely corporate, teaching and government hospitals for set of parameters mentioned above. Present study explored disaster preparedness at ten selected large hospitals in Navi Mumbai. It comprised of four corporate hospitals, three teaching hospitals in the private sector and three government hospitals. Disaster Management Plan and Infrastructure of these hospitals were evaluated in terms of their disaster preparedness. Hospital staff is expected to possess knowledge, attitude, and practices for discharging their duties effectively. The study’s main focus is to assess and improve upon the human resource development of hospital staffs possessing above mentioned skills in disaster preparedness. Hence the hospital staffs working in these hospitals were interviewed towards this arena. They were selected from different categories as per their position held at the hospitals.
OBJECTIVES:
To assess Disaster Management Plan and hospital infrastructure disaster preparedness at selected Hospitals in Navi Mumbai.

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To compare the gap observed between pre-test and post- test score on Disaster Management Plan and suitable Hospital Infrastructure regarding disaster preparedness in selected hospitals in Navi Mumbai.

To assess the knowledge, attitudes, practices (KAP) score among different cadres of hospital staff on disaster preparedness, before and after the training.

To compare the effect of training intervention on score of knowledge, attitude and practices among hospital staff regarding disaster preparedness.

To measure the association between selected demographic variables of hospital staff with knowledge, attitude and practices initial score obtained and changed score obtained.

To provide guidelines to hospitals regarding disaster preparedness based on identified gaps.

METHODOLOGY:
It was a cross sectional study conducted at Navi Mumbai selected hospitals. Duration of the study was from April 2015 to March 2018. Quantitative and qualitative research methods were used in combination with descriptive and interventional methods. Stratified sampling techniques were applied. Study population included all the hospitals in Navi Mumbai and all the health care workers available in these hospitals. Hospitals by categories and respondents according to occupation or current position held at the hospital were stratified. On the day of questionnaire administration, hospital administrator allotted the people among above strata who were available on the duty. The sample size was ten large hospitals, and from these hospitals 140 staff in following cadres (i) Administrative (ii) Nurses (iii) Paramedical staff (iv) Class IV employees were selected for the study.

Tools: There were three tools used in the study as follows.

Tool 1 : Hospital Disaster Management Plan checklist
Tool 2: Hospital Infrastructure checklist.

Tool 3 : Hospital Staff’s Knowledge, Attitude, Practices questionnaire
Tool 1. Hospital Disaster Management Plan checklist: It was having total 11 components 1. General Consideration, 2. Command and control, 3. Communication, 4. Safety and security, 5. Key area selection, 6. Key staff selection and staff tasking 7. Infrastructure and equipment 8. Training and education 9. Monitoring and evaluation 10. Response 11. Post disaster recovery.

Tool 2: Hospital infrastructure checklist was having total 15 components 1.Regulatory and Statutory compliance, 2. Activation of onsite guidelines and emergency codes, 3. Presence of functional disaster management committee, 4.Fire safety committee in place, 5. Fire safety officer with control room and other compliant, 6.Emergency medicine and medical gases and equipment availability, 7.Emergency catering and laundry facility, 8. External coordination and networking communication, 9.Evacuation Mock drill and table top exercises, 10.Functioning of Fire safety equipment and other electrical safety equipment, 11. Emergency exit signage’s and access control, 12.Emergency staircase, 13. Availability of transport and ambulance services in hospital, 14. Morgue facility / Dead body management, 15. Casualty infrastructure.

Tool 3. Hospital Staffs Knowledge, Attitude, Practices level questionnaire: For each participant under the study, KAP questionnaires were distributed and filled in responses were collected. Questionnaire consisted of participant’s socio economic profile, knowledge, attitude and practices questions. Responses were received in terms of frequencies. Participant’s answers in frequencies were coded as Yes = 1 score, No = 0 score: Do not know = 0 score. Total score of pre-test, post-test 1, post-test 2 and post-test 3, were obtained in terms of frequencies. These frequencies were converted to percentage. The percentages were further graded as follows.
Score Grading:
Score 1 to 25% = Poor; 26 to 50% = Fair; 51 to75%= Good; 76 to 100%= Excellent
Gap Analysis: Gap means the difference between highest possible score and observed score of various types of hospitals that is corporate, teaching and government based on score of checklist of disaster management plan and hospital infrastructure as well as questions on knowledge, attitude and practices as mentioned above for hospital staff. Total score divided into 4 grades as follows.
Score allotment and grading: For Disaster Management Plan and Hospital Infrastructure score: For each hospital under the study, DM Plan and Hospital infrastructure checklist component wise score is obtained. The score obtained was in terms of frequencies and those were converted to percentage. These percentages were further graded as follows.
Score Grading:
Score 1 to 25% = Poor; 26 to 50% = Fair; 51 to75%= Good; 76 to 100%= Excellent
For knowledge level score of the participants: For each participant under the study, questionnaires were distributed and filled in responses were collected. The response was in terms of frequencies. Participant’s answers in frequencies were coded as Yes = 1 score, No = 0 score: Do not know = 0 score. Total score of pre-test, post-test 1, post-test 2 and post-test 3, were obtained in terms of frequencies. These frequencies were converted to percentage. The percentages were further graded as follows.
Score Grading:
Score 1 to 25% = Poor; 26 to 50% = Fair; 51 to75%= Good; 76 to 100%= Excellent
For attitude level score of the participants: For each participant under the study, questionnaires were distributed and filled in responses were collected. Participants answers were coded as Yes = 1 score, No = 0 score: Do not know = 0 score. Total score of pre-test, post-test 1, post-test 2 and post-test 3 were obtained in terms of frequencies. These frequencies were converted to percentage. The percentages were further graded as follows.
Score Grading:
Percentage >= 50% = Positive attitude; Percentage <= 50% Negative attitude
For practices level score of the participants: For each participant under the study, questionnaires were distributed and filled in responses were collected. Participants answers were coded as Yes = 1 score, No = 0 score: Do not know = 0 score. Total score of pre-test, post-test 1, post-test 2 and post-test 3 were obtained in terms of frequencies. These frequencies were converted to percentage. The percentages were further graded as follows.
Score Grading:
Score 1 to 25% = Poor; 26 to 50% = Fair; 51 to75%= Good; 76 to 100%= Excellent.

DATA COLLECTION: Firstly the base line data of every hospital under the study was collected using checklist regarding; the disaster preparedness (which is their existing Disaster Management Plan, existing Hospital Infrastructure and the hospital staff knowledge, attitude and practices score regarding disaster preparedness of before the training – Pre-test). Researcher asked hospital authority person to fill the checklist regarding DM plan (pre-test). Same day extensive disaster preparation training with fire safety workshop and live demonstration was imparted to all hospital staff inclusive of selected study participants.
For Disaster management plan and hospital infrastructure, inspection was again done after six months (post-test). The researcher had taken rounds with hospital authority person who filled the pre-test checklist regarding hospital infrastructure. For DM plan and hospital infrastructure checklist, after period of six months same checklist was been asked to be filled in by hospital authority (Post-test). Individual hospital score for Disaster Management plan checklist and hospital infrastructure checklist were collected for all the hospitals under the study. The scores were graded and compared within and between the hospitals.
For participant’s knowledge, attitude and practices score post-test was conducted at the interval of one month, two months intervals using the same questionnaire (post-test1 and post-test 2). In addition after a wide gap of six months knowledge, attitude and practices changed score data was collected (post-test 3) to seek the retention level on KAP score among participants.
FINDINGS OF THE STUDY: The data analysis was done using univariate and bivariate analysis by SPSS version 24. The results are presented as follows.

Assessment of overall hospitals Disaster management plan: Data reveals that pre-test mean score was (26.10+5.76) and after the training post-test mean score was (54.60+10.59). This shows two fold increases in the mean score of DM plan. Using paired t test it was found that there was a highly significant difference between and pre test and post test at p;0.001 level of significance. Mean and standard deviation are calculated to find out the significant difference between the hospitals. Regarding hospital disaster management plan, there was statistically significant difference between pre-test and post-test mean score at p;0.001.
Assessment of overall hospitals infrastructure: During the base line (pre) assessment by using checklist, of overall hospital infrastructure components such as statutory compliances, emergency exit signage, fire safety equipment, evacuation drill, training exercises, casualty infrastructure etc. was done. The pre-test inspection means score of all hospitals infrastructure was (39.00+13.59) and after the disaster preparedness training the post-test inspection score was (48.90+16.38). Regarding hospital infrastructure checklist score, there was significant difference in post-test inspection as compared to pre-test inspection score at p;0.001.

Gap Analysis: Disaster Management Plan mean score for Individual hospital: Assessment of pre-test and post-test score of Disaster management plan as well as for hospital infrastructure for all hospitals under the study was analysed. Data reveals that pre-test score for DM Plan was the lowest (13%) for Government Hospital 3 (GH 3), which was graded as poor. Pre-test mean score for DM plan was highest (36%) for Corporate Hospital 1 (CH1), which was graded as good. After the training, post-test score for all hospitals DM Plan improved. During post-test assessment after the training, lowest score among all 10 hospitals was observed for Government Hospital 3 (GH3), which was improved to (26%), graded as good. Post-test highest score observed for Corporate Hospital 2 (CH2) which was improved to (72%) graded as very good.
Gap Analysis: Hospitals infrastructures mean score for Individual hospital:
Data reveals that assessment of pre-test mean score for hospital infrastructure was lowest for Government Hospital 3 (GH3scored 12%) which was graded as poor. During pre-test, Corporate Hospital 1 (CH1 scored 42%), as the highest score which was graded as good. After the training, post-test lowest score improved for Government Hospital 3 (GH3 – 23%), graded as poor. After conducting the training sessions, post-test score improved. The group of corporate hospital heading with corporate hospital one (CH1 scored 57%) as highest score, which was graded as good. This reveals that there is a significant effect of intervention. It was further found that if we look between the hospitals groups, the corporate hospitals have succeeded the teaching and government hospitals respectively for disaster management plan as well as for the hospital infrastructure checklist score.

Assessment of participants on Knowledge level: The data indicates that during pre-test, majority 68(50%) of the hospital staff out of total 137 hospital staff had poor mean score in knowledge parameter. During post-test 1, majority 77(56%) hospital staff means score, marginally improved to fair knowledge. During post-test 2, majority 68(50%) hospital staff, knowledge mean score improved to good grade. During post-test 3, majority 78(57%), of hospital staff knowledge mean score declined to grade fair.

Assessment of participants on Practices level: The data indicates that, during pre-test, majority 65(47%) hospital staff out of total 137 hospital staff had fair practices. During post-test 1, majority 68(50%) hospital staff had good practices. During post-test 2, majority 78(57%) hospital staff had good practices. However, during post-test 3, the score declined to 69(50%) hospital staff, had fair practices. Hence it illustrates that in case of knowledge and practices score; there is an upward trend of poor, fair and good grading of score during pre-test to post-test 1 and post-test 2. However post-test 3 is showing the downwards trend, since the scores are declining. This may be due to the fact that the wide gap of six months between pre-test and post-test 3. From this we can conclude that there is a need of training intervention after periodic intervals.

Assessment of participants on Attitude Level: The data indicates that during pre-test majority 71(52%) hospital staff, out of total 137 hospital staff, were having positive attitude. During post-test one, score improved to 102(74%) hospital staff, had positive attitude, during post-test 2 it was further improved to 106 (77%) participants, had positive attitude. However during post-test 3; the attitude score declined to 85(62%) towards positive attitude for disaster preparation.
Comparing the effect of intervention on KAP score of the participants:
Table 1: Effect of intervention on Knowledge, Attitude and Practices score of the participants.

Knowledge Score Attitude Score Practices Score
Particulars Mean + S.D. t-value p-value Mean + S.D. t-value p-value Mean +SD t-value p value
Pre-test 2.88+1.507 5.09 + 2.036 3.77 + 1.404 Post-test1 4.07+1.208 19.831 0.001** 5.85 + 1.810 14.88 0.001** 4.59 + 1.108 18.486 0.001**
Post-test 2 4.52+1.099 21.828 0.001** 6.03 + 1.782 15.891 0.001** 4.80 + 0.991 17.308 0.001**
Post-test 3 4.15+1.200 16.088 0.001** 5.53 + 1.855 6.076 0.001** 4.58 + 1.089 11.719 0.001**
Post-test 1 4.07+1.208 5.85 + 1.810 4.59 + 1.108 Post-test 2 4.52+1.099 9.538 0.001** 6.03 + 1.782 4.671 0.001** 4.80 + 0.991 5.378 0.001**
Post-test 3 4.15+1.200 1.44 0.152 5.53 + 1.855 5.321 0.001** 4.58 + 1.089 0.142 0.887
Post-test 2 4.52+1.099 6.03 + 1.782 4.80 + 0.991 Post-test 3 4.15+1.200 7.365 0.001** 5.53 + 1.855 11.116 0.001** 4.58 + 1.089 6.175 0.001**
P ;0.001**
The mean score of intervention was compared using t test (multiple comparison of two means for pre-test, post-test1, post-test 2 and post-test 3). Study Participants Knowledge
Attitude and Practices mean score comparison of pre-test mean score with post-test1; post-test 2 and post-test 3 were highly significant p ; 0.001. For Attitude level mean score of participants Post-test 2 comparison with post-test 3 mean score also was highly significant p;0.001. The data indicates that the mean difference is the true difference because of training imparted and not by chance. It clearly indicates that the intervention was highly significant in improving the KAP score of the participants.
Knowledge and Practices Post-test 1 mean score comparison of knowledge and practices mean score for post-test 3, the difference was not significant. These findings were also tested by paired sample t test. The mean score of paired t test value was 1.44 for knowledge and 0.142 for practices. This concludes that disaster training should happen on regular intervals. If there is a wide gap between two training intervals, the knowledge and practices level of the participants start declining
Association of Demographic variable and KAP score for disaster preparedness:
1. Knowledge Level findings
a. Association of demographic variable gender and KAP score: The data indicates that there is no significant association between gender and knowledge attitude and practices score of the pre-test and all the 3 post-test’s p> 0.001.
b. Association of demographic variable age and knowledge score: The data indicates that there is a significant association between age and knowledge score of multiple comparison of pre-test and all the 3 post-tests score participants’ p; 0.001. Higher the age better was the knowledge.
c. Association of demographic variable education and knowledge score: The data indicates that there was significant association between education and knowledge level of the participants.

2. Attitude Level Findings:
Association of demographic variable age, education and attitude score: The data indicates that age and education had positive influence on attitude, p;0.001. Upward trend has been observed with age and education having positive influence on participant’s attitude.
3. Practices Level Findings:
a. Association of demographic variable age, education and practices score Demographic variable age influence practices p< 0.001. Higher the age better was the practices. Education had positive influence on practices p< 0.001.
b. Association of demographic variable experience and KAP score
Demographic variable experience did not influence knowledge; attitude and practices score of participant’s regarding disaster preparedness p;0.001.

Guidelines to all hospitals under the study regarding disaster preparedness: Based on gap analysis of DM Plan, infrastructure of each hospital and KAP test’s scores obtained the data analysis was done. It has been analysed that there is scope for further improvement to bridge the gap. Accordingly based on these findings, guidelines were prepared and handed over to each hospital under the study for the implementation. These guidelines were based on National Disaster Management Guidelines for hospitals safety by Government of India.

CONCLUSION:
The study concluded that the intervention was effective in improving knowledge, attitude and practices of participants. However there remained room for improvement. Risk and hazards are supposed to be identified for disaster plan, with periodic updating. Requirement of Disaster Plan implementation is mandatory for all the hospitals , non compliance should be penalised. Every staff should be trained periodically in safety and evacuation drill, table top exercises and first aid training. Workshops and refreshers program must happen more often and should be linked to performance appraisal for better participation and compliance.

CHAPTER 1
INTRODUCTION
Disasters
“The earth provides enough resources to satisfy human need and not just the greed”
…. Mahatma Gandhi
GENERAL INTRODUCTION:
One should remember these words of Mahatma Gandhi and must resolve to simplify our needs. The environment is serving us for our basic needs. According to the Greek Philosopher Empedocles, as well as Indian mythologies, the universe is consisting of five elements; the earth, fire, air, sun, and water. From all these elements if our need is converted to greed, it is bound to turn into an effect that could be disastrous such as earthquake, volcanoes, cyclones, droughts and floods, described as ‘Pralaya’ in Vedic literature.

1.2 BACKGROUND OF THE STUDY:
Looking at any newspaper headlines or listening to any news channel today, we mostly come across highlights on news related to all sorts of natural calamities and man-made disasters including terrorism, violence etc. Disaster comes uninformed and it is an unfortunate event which creates damages to human life, environment and properties. Due to heavy losses incurred during disaster, growth of the country hampers because of human, financial and environmental losses. Disasters are always related to hospitals directly or indirectly to support the afflicted community. Therefore, capacity building of the health care community is one of the important aspects of health services. Hospital staff need professional competency in terms of knowledge, behaviour, awareness, attitude and practices to act promptly to handle any emergency. Success of any hospital disaster preparedness depends upon efficient team work through learning, practicing evacuation drills and by attending periodical training workshops involving all hospital staff.
.Disaster management can be defined as management of available scarce resources for handling of the emergencies to reduce the impact over disaster situations. According to, report on EMDAT first semester 2017, the database for emergency events about natural disasters, preliminary data shows that 149 disasters happened in 73 countries. Total 504 earthquakes occurred worldwide during the year 2000 to 2017. This has impacted 3,162 deaths; more than 80 million peoples were affected. Out of 149 disasters, 44% of events were of flood, resulting into 44% of economic damage. 11% of the events were from landslides which were resulted into 25% of total death toll.

Justification of the study explores the fact that hospital safety is the basic right of the community. Hence hospital and its staff members must be aware of their roles during disasters and implement the safety practices in hospital on regular intervals. According to Tae Yoo, during the disaster, networking and coordinating with other hospitals and with society for providing relief, aid and the trained hospital staff to deliver life-saving treatment is basic and important activity of the hospitals. Training intervention with the workshop on disaster preparedness is an easy way of practical learning. Hence researcher has taken an initiative for imparting training program and asses its effectiveness on the hospital staff.
Chaffe in his book “The Role of Hospitals in Disasters” has defined hospitals role as the heart of the health systems, whose caring staff member are receiving injured and affected patients during natural and manmade disasters. Hence hospital is the place where the affected people will get relief, life saving care and comfort at the hospitals.. It is beyond the human level to prevent most of disasters; however we can alleviate its effects by preparing for it in advance. This includes education on disaster management aimed at developing knowledge, change in attitude and implementing continuous practices at all levels.
The Government of India as a part of the formulation of the twelfth five-year plan (2012-2017) vide planning commission; reference, 12016/03/201, PAMD dt. 06.04.2011 has constituted a framework on Disaster management to implement disaster management policy and plan for provision on manmade and natural disaster at centre and state level.
1.3. DISASTER DEFINITIONS:
1.3.1 Oxford English Dictionary defines disaster as, disaster word is derived from the 16th century French word “Desastre”, and combining two terms ‘Des’ meaning bad or evil and ‘aster’ meaning star. Accordingly the expression of term disaster is an evil star.

1.3.2 The World Health Organization Collaborating Centre for Research on the Epidemiology of Disasters (CRED) 2012 defines disaster as, sudden emergency situation which is happening on national and international level causing heavy human and financial losses as well as degradation to environment.

1.3.3 Disaster Management Act (2005) of India, under this act, disaster is defined as a sudden and unfortunate event occurred to a specific area because of natural or manmade reasons. This may happened by accident or by carelessness. Due to this there are heavy losses to human, property and also results into degradation of environment. It is having financial burden to country for such heavy losses to community.

1.4. CLASSIFICATION OF DISASTER: Disaster can be classified in two categories
1. Natural Disasters: are the natural processes that causes losses of life, injury or other health impacts, property damage, loss of livelihoods and services, social and economic disruption or environmental damage.

2. Man Made Disasters: are the disasters due to human activities which could be unintentional, but it lacks safety measures, rules and regulations. Most of these events are due to certain accidents and coordinated events like terrorist activities, bomb blast, wars, riots, technology related accidents at road, ship or air mode, chemical and nuclear explosion and it also includes industrial accidents etc. which are listed into table no. 2 as follows.

Table:2 Types of Disasters ( Natural and Manmade Disaster)
Types of Disasters
___________________________________
Man-made Disasters
Bomb Explosion
Fire
Road Accidents
Conventional warfare
Nuclear & Chemical warfare
Collapse of building
Chemical Poisoning
Hurricane
Toxic material
Pollutions
Civil unrest (riots, conflicts)
Communicable disease
Global Warming
Natural Disasters
Earthquake
Volcanic eruptions
Landslides
Avalanches
Windstorms
Tornadoes
Storms
Floods Droughts
Hurricane
Cyclone
Drought
Floods

Source: Annual Disaster Statistical Review 20159
Every year disaster affects human being with huge losses of mankind, animals and other species, losses of physical assets, property and environment. Disasters can be classified as natural and manmade disasters. Disaster in any form, natural or manmade, affects all the countries and their resident population.
Disaster is grouped into 5 major subgroups as follows.

Geophysical: means disaster events which are originating from solid earth. Examples are earthquake, volcanoes etc.

Meteorological: means disaster events which are caused by air and atmospheric changes. Examples are Strom.

Hydrological: means disaster events which are caused due to deviation in water cycle. An example is flood.

Climatologically: means disaster events which are caused due to inter season’s variations. Examples are extreme temperature, wildfire, drought etc.

Biological: means disaster events caused due to germs and toxicity. Examples are Epidemic, Insect infestation, Animal stampede etc.

1.5. DISASTER – INTERNATIONAL SCENARIO:

Figure 1: Trends in occurrence of disasters and victims
Source: Annual Disaster Statistical Review 2015 – The numbers and trends
Figure 1 represents numbers of reported disasters from the year 1990 to 2011 and number of victims reported in millions. The upward trend is observed from the year 1996- 2000 vtreporting with major 186 disasters.

1.5.1 As per World Disaster Report 2016, total 6090 disasters per continents were reported worldwide. Highest numbers of disasters were reported in Somalia (Africa), Haiti (America), Myanmar (Asia) Russian Federation (Europe) and Australia (Oceania). Major disaster of year 2017, occurred in Syria (ISIS), Afghanistan and Myanmar (Rohingya’s refugees). It has been reported that from the year 2002 to 2015, total of 357 natural disasters were reported. Total of 9,655 people were killed and 124.5 million peoples were victimized worldwide. Accordingly for emergency preparedness on long term basis, continuous planning is required to increase the overall capacity building of any country with proper direction, systems and procedure, utilizing all the available resources on war footing. It will help to provide timely assistance to victims and to facilitate relief measures and rehabilitation.
Rapidly changing world faces numerous challenges such as rail, road traffic accidents, air crash, terrorist violence, stampede and natural calamities like earthquake, floods, tsunami, and cyclone etc. From the last two decades, many disasters occurred in world, some of them can be quoted as, September 11, 2001 attack on World Trade Centre, United States of America, December 26th, 2003, Bam (Iran) Earthquake, December 26th, 2004, Asian Earthquake and Tsunami, Tropical cyclone Hurricane Katrina August 29th, 2005, October 8th, 2005 Kashmir region of Pakistan Earthquake, May 2nd, 2008 Cyclone Nargis Myanmar, May 12th, 2008, Sichuan (China) Earthquake, Jan 12, 2010 Haiti Earthquake, March 28, 2009 to December 8th 2009, Global Swine Flu Outbreak, June 30th 2010 to August 30, 2010 Russian Heat Wave, March 11, 2011 Japan earthquake and tsunami; USA Tsunami Dated 2nd August 2017, Mexico earthquake on September, 8th 2017, Myanmar floods and landslides on July, 2017, Bangladesh floods and landslides in June 2017 and many more.
1.5.2 Natural Disasters –Global scenario
Table 3: Natural Disasters during 2015 and averages from the year 2005-2014.
Number of Natural Disasters
No. of Natural Disasters Africa America Asia Europe Oceania Global
Climatological 2015 15 15 6 1 8 45
Avg. 2005-2014 12.7 9.7 7.3 8.0 1.5 39.2
Geophysical 2015 1 8 20 0 0 29
Avg. 2005-2014 1.9 6.6 19.6 1.7 2.1 31.9
Hydrological 2015 33 40 79 19 4 175
Avg. 2005-2014 44.8 37.9 82.8 21.8 5.0 192.3
Meteorological 2015 13 33 62 7 12 127
Avg. 2005-2014 8.5 34.9 45 23.8 4.6 116.8
Total 2015 62 96 167 27 24 376
Avg. 2005-2014 67.9 89.1 154.7 55.3 13.2 380.2
Source: Annual Disaster Statistical Review 2015 – The numbers and trends8
Table 3, represents number of natural disasters during 2015, globally, classified into four categories of disasters as Climatologically happened disasters, Geophysical disasters, Hydrological disasters, Meteorological disasters and averages from the year 2005-2014.

It can be observed from table 3 that out of total 376 natural disasters, major disasters happened during 2015 was 175 Hydrological disasters. Hydrological disasters are harmful, violent disasters which are happening due to earths water movement e.g. flood, avalanches
1.5.3 Victims affected by disasters globally.

Table 4: Number of victims affected during 2015 and averages (2005-2014).

Number of Victims
No. of Victims (millions)* Africa America Asia Europe Oceania Global
Climatological 2015 27.96 3.95 20.34 0.01 2.07 54.33
Avg. 2005-2014 22.44 4.11 30.19 0.13 0 56.87
Geophysical 2015 0 1.64 6.5 0.0 0 8.14
Avg. 2005-2014 0.04 1.01 7.45 0.20 0.07 8.77
Hydrological 2015 2.76 1.76 31.46 0.20 0.02 36.20
Avg. 2005-2014 3.05 4.59 79.15 0.39 0.09 87.27
Meteorological 2015 0.19 0.32 10.84 0.03 0.29 11.67
Avg. 2005-2014 0.26 1.75 41.35 0.16 0.04 43.56
Total 2015 30.92 7.67 69.14 0.23 2.38 110.34
Avg. 2005-2014 25.79 11.46 158.15 0.70 0.20 196.30
Source: Annual Disaster Statistical Review 2015 – The numbers and trends8
Table 4, represents number of victims affected by disasters during the year 2015 worldwide, classified into four categories of disasters as above and also averages from the year 2005-2014.

The data indicates that during 2015 major victims happened due to climatologically happened disasters with 54.32 million victims. Climatologically happened disasters are natural hazards which are occurring due to physical earth movement clubbed into geophysical movement such as earthquakes, volcano disruption, landslides, and tsunami.

1.6 DISASTER INDIAN SCENARIO:

Figure 2: Seismic Zone map of India
Source: National Institute of Disaster Management, Ministry of Home affairs, Govt. of India.

1.6.1 INDIA VULNERABILITY PROFILE: With total area of 3,287,283 square kilometers, India is the seventh largest country in the world. Because of its geo climatic conditions, disaster such as flood, drought, cyclone, earthquake and landslies of various intensites are common in the country. Among world population, India ranks second among 196 countries, with a population of 1,324,171,354 people. With 403 people staying per square kilometer makes India 178th in rank according to density of population in 2016. Because of its geopolitical conditions, India is vulnerable to many disasters. Approximately 58.6% of landmass is having risk prone of earthquakes ranging from moderate to very high intensity. More than 40 million hectares (12%) of the land is having risk of floods and river gradual destruction. Out of the total 7,516 kilometers long coastline, 5,700 kilometers of coast line is having risk of cyclones, tsunamis and terrorist attack. Approximately 68% of area under cultivation is having risk of droughts. These are mostly the hilly areas which are having risk of landslides and avalanches.
India is having threat of chemical, biological, radiological and nuclear (CBRN), natural or manmade disasters. Disaster risks in India are increasing due to various reasons such as environmental degradation, climatic condition, geological hazards, and epidemics due to insect and animal infections. All these are threats to Indian economy due to changing demography, geo political stress, poor socio economic conditions, unplanned townships and urban area planning which are developing community movements in high risk zone. All these are contributing to putting Indian economy and its large population into high risk which may affect the overall development of country in near future10.
National Disaster Management Authority, (NDMA) Government of India
National Disaster Management Authority is an agency headed by prime minister as chairperson. This agency was established in December 2005, by Government of India. NDMA is responsible for framing disaster related policies, implementing guidelines, Standard Operating Procedures, best practices creating, sharing and coordinating with every Indian State Disaster Management Authorities (SDMAs).

NDMA Policy,64: May 2009-2016 (Ministry of Home Affairs, Government of India): Disaster management policy is developed by government of India. According to this policy the major objective is building partnership with society as main and important stakeholders. The same was done at National and International levels for sharing the community wise best practices all over the country.

NDMA Plan : May 2016 (Ministry of Home Affairs, Government of India): This plan is developed to make India more disaster resistant and also to increase the level of disaster preparedness for building the response for all disasters. The Sendai Framework is adopted which is based on Disaster Risk Reduction Program under NDMA plan through out the year 2015-2030.

NDMA has given guidelines pertaining to Hospitals disaster preparedness under Disaster Management Act 2005 under section 306 as follows.

If hospital building is lacking in fire safety preparedness related mechanism and earthquake proof safety structure, affiliation should not be given to new government or private hospital by government authorities.
As per National Building Code of India, hospital should implement safety measures.

Within 6 months of its date of functioning, Fire extinguishing equipment should be installed in a government and private hospitals.

Material inside the hospital should be stored separately and safely.
Structural inspection of the hospital building should be done periodically.

Training should happen on fire extinguishing equipments on regular intervals.
1.6.2 INDIA: MAJOR NATURAL DISASTERS:
Floods, tsunami and earthquakes which can be stated as major natural disasters happened in Indian history. I am herewith listing last 23 years major natural disasters as follows.
1993 Earthquake in Latur and Landslide in Khillari district Maharashtra.
1999 cyclone named Phailin affected Orissa: which is also known as super cyclone 05B . It was most dangerous and destructive tropical cyclone in the Indian Ocean since 1971. Due to this cyclone 15000 people died and had caused heavy financial losses.
2001 Gujarat Earthquake: The massive earthquake occurred on India’s republic day on January 26, 2001 at Bhachau Taluka of Kutch District of Gujarat. This earth quake had a magnitude of between 7.6 and 7.7. It had resulted into around 20,000 people killed.
2001 Bihar Flood: which was listed as worst hit flood destroyed thousand of human lives as well as livestock and millions worth assets.

2002 Indian Heat Wave: at south region killed more than 1000 people in the state of Andhra Pradesh. This intensive heat wave made bird to fell from the skies, even ponds and rivers were dried up.
2004 Indian Ocean Tsunami: The Indian Ocean Tsunami occurred in 2004 at the west coast of Sumatra, killing over 230,000 people. Indian Ocean Tsunami was one of the deadliest natural disasters in history of India.
2005 Kashmir Earthquake with cyclone, cloud burst and so on is chill memories. These disasters and many horrifying memories in recent remote past have shown that they strike crippling blow to the society.
2005 Mumbai excessive rain: Mumbai the capital city of Maharashtra was badly affected and flooded by worst catastrophes resulted into killing at least 5,000 people and loss of properties.

2010 Eastern India Strom: was a severe storm which spanned for 30-40 minutes killing 91 people and destroying more than 91, 000 houses were destroyed and also damaged.
2013 Drought in Maharashtra: The state was affected by the regions worst drought in last 40 years by the famines at Jalgaon and Dhule district. These two district were the most affected areas in the state. Millions of people in Maharashtra were affected by two years of low rainfall in the region.
2013 Disastrous flood in Uttarakhand: The state was affected by landslides with heavy floods. It has reported into human losses of 5000 people approximately and property damage.

2016 Maharashtra Bridge collapse due to heavy rains, an old bridge connecting to the Mumbai Goa highway over Savitri river in Mahad taluka of Raigad district collapsed on 4th august, 2016. Reported human losses of more than 10 vehicles full with passengers were victimized.

1.6.3 INDIA: MANMADE DISASTERS.
I have listed manmade disasters for 9 years during 1996-2004.

1996 Horrible temple stampedes: such as Amarnath Yatra Tragedy.

2013 Madher devi temple stampede and Sabrimala Kerala Stampede are the worst manmade disasters in Indian history.

2003 -2004 Major train accidents:
Vaibhavwadi train crash in Maharashtra state of India, on 23rd June, 2003.

Karanjadi passenger train crash on 17th June, 2004, in Maharashtra, India, due to heavy monsoon in which 20 people were killed and more than 100 injured in the train crash.
1.6.4 INDIA: DEVASTATING HOSPITAL TRAGEDIES
I am herewith listing most devastating hospital tragedies from the year 2001 to 2016.

2001 Erwadi mental asylum tragedy: Mental home in Tamilnadu State caught devastating fire result into 28 patient dead on August 6, 2001.

2008 Bomb blast in Ahmedabad civil hospital: On 26 July 2008, series of 21 bomb blasts hit Ahmadabad civil hospital within a span of 70 minutes. 56 people were killed and over 200 people were injured in a cultural and commercial heart of Gujarat state and a large part of western India.
2011 AMRI Hospital Kolkatta fire tragedy: On December 2011, a major fire broke out in AMRI hospital at Kolkata which was destroyed in fire with more than 90 casualties including helpless patients in ICU.

2013 PBM hospital, Bikaner fire tragedy: In January 2013, fire claims the lives of four infants. They were injured when a fire broke out in the nursery ward of PBM government hospital in Bikaner.

2015 Cuttack hospital fire: In November 2015, a fire broke out at Shishu Bhawan hospital in Cuttack resulted into the deaths of several infants due to negligence of doctors that destroyed machines worth Rs 11 lakh. 
2016 Gorakhpur hospital tragedy: on 11th August, 2016, wherein 63 children died at the state-run Baba Raghav Das (BRD) Medical College and Hospital in Gorakhpur after the supply of oxygen cylinders to the hospital was disrupted.  It is our country’s mismanaged, health care system to be blamed which denied ambulance to children dying due to lack of timely intervention resulting in death of several innocent people. Followed by similar incident wherein 800 children were died in Jharkhand hospital.
2016 Bhubaneshwar hospital fire: On 17 October 2016, 22 people were killed and 120 injured in a major fire at SUM Hospital in Bhubaneshwar.

When the Children’s Hospital in Jammu collapsed, or thousands of people died in Bhuj and Latur earthquake, the world was stunned. Ahmadabad’s civil hospitals were reduced to a heap of debris when it was needed the most by the community in these areas. These and other disasters that occurred throughout the world serve as a gruesome reminder that we live in a world full of hazards; and we do not know when a disaster will occur.
1.6.5 INDIA- MAJOR TERRORIST ATTACK:
2001 Indian Parliament attack : was the most shocking terrorist attack at the Parliament of India in New Delhi, on 13th December, 2001.
2008 Terrorist attack on Hotel Taj in Mumbai : November 26-29, 2008, horrified terrorist attacks on the iconic Taj hotel in India’s Mumbai City, resulted into 172 killed and 304 innocent injured people.
1.7 Statement of the Problem:
The approach of the study is specific towards the hospital preparedness during manmade and natural disasters in and around hospitals. Absence of disaster planning and preparedness for patient safety in emergency situations sometimes turns into tragedy, which may causes deaths. Biological hazards, bomb threat, terrorist attack, child abduction, viral infections etc are the modern form of hazards which needs to be taken care for hospitals in nearby busy and crowded city of Mumbai and its satellite city Navi Mumbai.
1.8 Rationale for the study:
As per the National Disaster Management Act (NDMA, India), 20055 it is mandatory for all hospitals in India to have a disaster management contingency plan. The components of a disaster response cycle include response, rescue, recovery, mitigation, risk reduction, prevention and preparedness. The very important component of the cycle is to become proactive with a hospital disaster management plan and preparedness to deal with the emergency inside and around the hospital.
Near by city Mumbai is the capital metropolitan city of state of Maharashtra in India. It is the second most populous metropolitan city in India. It is the financial, commercial and entertainment capital of India. There had been an increase in the number of emergencies attended to Mumbai region, which happens to be the economic capital of the country. As a busy financial and commercial place, it faced lot of emergencies in day to day life. These emergencies had been a result of natural and manmade disasters. Since last two decades numbers of disasters which were faced by Mumbai and Navi Mumbai area, include building collapse, bomb blast, terrorist attacks, flood and train accidents etc.

The study has become important because very less attention is being made in this area. There are very less literature available about hospital safety and disaster management preparedness of the hospitals. It is observed that the researchers have shown limited interest in this potential research area. The topic of hospital safety and disaster management has got weight age in early 2000’s. Previously fire accidents were treated as common but were not taken seriously. In developed European countries, stringent laws exist under government control to protect hospitals from disasters. But in India, the initiative is not up to the mark. Even though all laws and guidelines are made, their implementation is not satisfactory. Ignorance, non-vigilance and lack of monitoring are common parlance, couple with lack of political will. The availability of information on disaster preparedness at hospitals located in Navi Mumbai hospitals is very limited. This prompted the researcher and supervisors to assess the emergency and disaster preparedness status of Navi Mumbai Hospitals. This study focused on the emergency and disaster preparedness of certain randomly selected hospitals by evaluating their disaster plan in place and available infrastructure to cope up with situation. Study also assessed the knowledge, attitudes and practices of the healthcare workers regarding disaster preparedness. The study is bound to generate evidence-based solutions for hospital disaster preparedness helping and guiding the hospitals and policy planners in a betterway.

Navi Mumbai city is a counter magnet to Mumbai city which was added as the mega settlement zone of the Mumbai Metropolitan Region during 1970s. Infrastructure such as well designed road connectivity, railway network and recently added metro system attracts heavy population to Navi Mumbai region adjudged as the 9th cleanest city at national level in 2018. Basic facility like water supply, power, sewerage and rain water discharge was meticulously designed for this city. It is high time to check the disaster preparedness for the hospitals around the region for the broader aim of patient safety and disaster mitigation.

Patient safety in the hospital is basic right of civilized community. There is an urgent need to adopt multidimensional, multidisciplinary and multi spectral approach to reduce heavy losses of lives and property due to disasters. At the same time, it is needless to over emphasized that our health care system is required to be geared up to efficiently face such eventualities at par with developed nations, without any loss of time. Any health care establishment needs proper infrastructure to facilitate care during disasters. Hospital health care workers are the most receptive group to act during emergency situations by education, training, evacuation drills, and experience if prepared in advance. On that basis they can easily handle the situation faster and in a scientific manner, as and when need arises. They share the valuable education with family, thereby spreading the knowledge, attitude and practices in the whole community. Recognizing the value of such information and professional skill, the hospital health care workers are a valuable social group to educate and plan for disaster preparedness. This strategy will go a long way in proving its long-term effectiveness in a continuous manner. Training on hospital safety and emergency measures during disaster for implementation in and outside hospital is bound to provide immense knowledge and safety practices in hospitals, particularly in vulnerable areas.

Disaster management training manual, handouts are easy ways of learning at own pace as the preferred means to learn. The study would help to identify problems if any in the local hospitals. The information’s are likely to help develop hospital friendly “Standard Operating Practices” for the benefit of all stake holders. Education for disaster management is a trans-disciplinary exercise, aimed at developing and spreading knowledge, skill and values at all levels. The Government of India has emphasized the need to enhance such attributes to reduce the impact of disasters on the Health Care sector. This is intended to build in a culture of safety and resilience at all levels in the Health care sector as well as in the community, considering the victims themselves happen to be the first responders in sudden disaster situations.
CHAPTER 2
AIM, OBJECTIVES AND HYPOTHESIS
2.1 AIM OF THE STUDY:
To study and asses extent of disaster preparedness in selected hospitals in Navi Mumbai.
2.2 OBJECTIVES:
To assess Disaster Management Plan and hospital infrastructure regarding disaster preparedness at selected Hospitals in Navi Mumbai.

To compare the gap observed between pre-test and post-test score on Disaster Management Plan and Hospital Infrastructure regarding disaster preparedness in selected hospitals in Navi Mumbai.

To assess the knowledge, attitudes, practices (KAP) score among different cadres of hospital staff on disaster preparedness, before and after the training.

To compare the effect of training on score of knowledge, attitude and practices among hospital staff regarding disaster preparedness.

To measure the association between selected demographic variables with knowledge, attitude and practices initial score and changed score for hospital staff.

To provide guidelines to hospitals regarding disaster preparedness based on identified gaps.

2.3. HYPOTHESIS: Hypothesis are tested at p;0.001 level of significance.

H01: There is no significant difference in disaster preparedness among selected three categories of hospitals in Navi Mumbai that is corporate, teaching and government hospitals in relation to Disaster Management Plan and Hospital Infrastructure.

H1: There is significant difference in disaster preparedness among selected three categories of hospitals in Navi Mumbai that is corporate, teaching and government hospitals in relation to Disaster Management Plan and Hospital Infrastructure.
H02: There is no significant difference between pre-test and post-test mean scores of knowledge of selected hospital staff in Navi Mumbai regarding disaster preparedness.

H2: There is significant difference between pre-test and post-test mean scores of knowledge of selected hospital staff in Navi Mumbai regarding disaster preparedness.

H03: There is no significant difference between pre-test and post-test mean scores of attitude of selected hospital staff in Navi Mumbai regarding disaster preparedness.

H3: There is significant difference between pre-test and post-test mean scores of attitude of selected hospital staff in Navi Mumbai regarding disaster preparedness.

H04: There is no significant difference between pre-test and post-test mean scores of practices of selected hospital staff in Navi Mumbai regarding disaster preparedness.

H4: There is significant difference between pre-test and post-test mean scores of practices of selected hospital staff in Navi Mumbai regarding disaster preparedness.

H05: There is no significant correlation between pre-test and post-test mean scores of knowledge, attitude and practices of selected hospital staff in Navi Mumbai regarding disaster preparedness.

H5: There is significant correlation between pre-test and post-test mean scores of knowledge, attitude and practices of selected hospital staff in Navi Mumbai regarding disaster preparedness.

H06: There is no significant association between pre-test and post-test mean scores of knowledge, attitude and practices of selected hospital staff in Navi Mumbai regarding disaster preparedness.

H6: There is significant association between pre-test and post-test mean scores of knowledge attitude and practices of selected hospital staff in Navi Mumbai regarding disaster preparedness.

CHAPTER 3
LITERATURE REVIEW
“We cannot stop natural disasters but we can arm ourselves with knowledge: so many lives wouldn’t have to be lost if there was enough disaster preparedness.” Petra Nemcova
3.1. Literature Review: According to S K Sharma review of literature is an in depth analysis of articles, journals, publications on research subject. Literature is a well organized summary of related material available which provides the base work for the further research expansion in the study. Literature review is one of the important steps in research activity. Literature can be defined as what relevant studies have been done in the research area and the studies published by other research scholars. Regarding this study, researcher carried out an extensive literature review regarding the research topic to get in depth insight into the problem to get maximum information from other studies which has provided the base for conducting present study in a scientific manner. Review of literature for the study has been organized under the following themes related to hospital disaster preparedness.

(a) Literature reviews related to general information on disaster management.

(b) Literature reviews related to earthquake management.

(c) Literature reviews related to fire safety management.

3.2 Literature reviews related to general information on disaster management.
This thesis in mainly focussing on disaster preparedness of hospitals. Hence it is vital to explain the concepts involved in reducing the hospitals disaster threats for better understandings.
3.2.1 Disaster: The term Disaster is defined has a serious impact on overall functioning of the mass community which involves the human, animal, economic and environmental losses. It is very difficult for a community to cope with the losses which is a result of these serious major overhauling. The losses due to disaster can be losses to human lives, property and health. It spreads diseases and it is very difficult to be taken care like by community’s limited resources and this is done to such an extent that community is not in a position to cope with it.
3.2.2. Economic Impact of Disasters: During last five decades, the rise in the natural disasters has increased the economic and financial loss which describes the macroeconomic impact over the GDP of the countries suffered due to disaster. As per IMF working paper by Kondo, the moderate kind of disasters has rising effect on investment in real estate companies in reconstruction activities. However the scene t is not so positive during the severe disasters. Major disaster may reduce the GDP of the country by 0.6% to 1%. Major natural disasters negatively influence the export and increase debts on import of food and heavy reconstruction material. This causes deficit in foreign currency, resulting into currency rate fluctuation in an International market. This also affects the fiscal account and public debt. For example India’s world bank-debt again increased which has serious threats to countries status in an international market.

3.3.3 Disaster Planning: Community does not have the power the stop the occurring of disasters. However it is certainly within the scope of mankind to plan proactively for reducing the disaster impact for survival.. God has given power to mankind to think over, as compare to any other species. ‘like animals. From ancient times, even though the natural disasters are destroying the species of mankind and their belongings, human beings are developing certain innovative tricks and ideas to fight against the disasters in a planned manner. In other words we can say that the disaster risk and reduction planning is the activity which human beings were managing since primitive stages for minimising the impact of disasters. Well preparedness is the key for managing any community crisis. This can be done by analysing the important potential phenomenal problem and carefully taking the precautions for non recurrence. Hence one can say that fatal accidents and disasters can be controlled by mastering over the planning for disasters.
3.3.4 Emergency
An emergency is defined by the World Health Organisation as, it is an immediate threatening event which requires immediate attention as well as action to minimise its impact towards adverse condition. The term emergency can be used as an administrative term which requires the level of response required from various administrative level of community. These levels can be categorised into three levels of community response:
Level I: These are the incidences or level 1 emergency which requires response from the local level. For example in case of motor vehicle accident local ambulances and administrative authorities help is required.

Level II: In this type of emergency, response from local level is not sufficient and is escalated to regional support.

Level III: This type of emergency needs national level response support.

3.2.5 Mass Casualty Incident (MCI)
As per World Health Organization/ PAHO, MCI is a mass casualty incident due to an emergency which requires the services of health care professionals to take care of large number of victims. It also requires special and additional emergency service arrangement to manage the addional surge or increase in number of patients.
3.2.6 Hazard: Hazard is a natural physical event having a potential to convert into disaster. It may cause injury or death and damage to public or private property and also the environment. This event also causes sudden surge or increase in patients. It is important for the community to identify the hazards and its probability which may invite the disasters in near future.
3.2.7 Risk: It is a probability of loss due to hazardous events which may turn to negative disaster possibilities.
3.2.8 Vulnerability: It can define as inability to control the hazard or the situations which can be converted to disasters. Vulnerability depends upon other factors such as age, gender, education of people, local environmental conditions, position or location of residence / buildings with respect to hazards.
3.2.9 Disaster preparedness: Disaster preparedness is use of knowledge, capacities, practices developed by government agencies, academicians, professional organization, communities and individuals to anticipate and respond effectively to the impact of natural events36.

3.2.10 Disaster risk reduction: it is an act of reducing disaster risk by study the root cause analysis of hazards, vulnerability. The goal of disaster risk reduction program is to reduce the damage caused by disaster in general by preventing or limiting the adverse effect of disasters. Various efforts are being made by different countries over the continents to reduce the disaster risk which includes halving poverty. Disaster often impacts on people’s health may be it results into spreading of epidemics or human losses. Death, injuries, disabilities, psychological and other health impacts can be minimized by disaster risk reduction programs. Hence everyone should be involved in disaster risk reduction programs
3.2.11 Internal and External Disaster: Disaster which happened in house or within the hospital premises are called as internal disaster. Hospital need to have trained manpower to take care of patients or if needed evacuation of patients. This may be due to an accident within the premises of hospital, for example fire or bomb explosion within hospital. An external disaster can be the disaster outside the hospital premises within nearby vicinity in the community. Patients can be brought in the hospital in major numbers for the treatment. .

3.2.12 Disaster Management: It a set of activities to control on disaster situations for helping the persons who are at risk to avoid disaster or recover from the disaster impact. Disaster management helps the people before, during and post disaster event
3.2.13 Disaster Management Plan: It is a written set of action plan to be followed by disaster management team in the event of a disaster within community38. Disaster preparation is an action plan so that the impact of disaster occurrence can be minimized with planned efforts. Preparedness is a continuous and never ending process. DM plan is plan of action and the processes to be followed during the disaster events. However only a written plan in place does not guarantee the disaster preparedness; it can be called as kaizen or continuous process
3.2.14 Hospital: Hospital is an institution equipped with specialized staff and equipments for patient treatment. In olden day’s hospitals were being health care institutions usually funded by government or public sector, profit or nonprofit making organizations or private trusts or charitable trust. In Europe, hospitals were funded by religious institutions or leaders. In India, Ayurveda, being prevalent and traditional healthcare system, hospitals were run by Saint or Muni’s at their ashrams or at residences. They were funded by Kings or charitable institutions. In India hospitals were called as ‘Dawakhana’ in Hindi, inclination towards pharmacy. Now a day’s health care institutes depending upon the capacity of hospital is treating the patients for diagnosis, giving treatments at care centres. At some places it also contains pharmacy within hospitals. Private Hospitals however have all facilities in house including the laboratory inside the hospitals which is called as super specialty hospitals.

3.2.15 Hospitals role during disasters: As per Government of India, United Nations development Programme, 2002, hospital plays very important role during disasters by providing emergency care services. Hospitals are the crucial resources providing health care diagnosis, treatment and follow up for both physical and psychological care (GOI/UNDP). During mass casualties, the main goal of the hospital is to save as many lives as possible utilizing the limited resources in a best possible manner43. Hospitals are expected to treat the patient with whatsoever form they receive, and do it right the first time. Hospitals are like the safe haven during disaster and related health problems for people5. Hospitals are also the indicators of communities well being and status of community health and social progress representing economic development of particular country43.

3.2.16 Safe Hospitals: World Bank dedicated the World Disaster Reduction Campaign 2008-2009 towards the “Hospitals Safe from Disasters: Reduce Risk, Protect Health Facilities, Save lives” with support from World Health Organization (WHO) and the United Nations International Strategy for Disaster Reduction (UN/ISDR). Safe hospital is been defined as a hospital that will not collapse during disasters, resulting into killing of patients and staff. Safe hospital will continue to provide its services when it is required and needed the most. These hospitals disaster management plans will be in place and hospital staff will be trained for the disaster management.
The Pan American Health Organization (PAHO) and the World Health Organization (WHO) have defined hospital as a centre for taking patient care during critical disaster events with its trained hospital staff. Therefore, special planning and preparedness should be undertaken, so that hospitals are safe internally, externally as well as safe structurally. Health care workers are sensibly trained to professionally handle the emergency situations 57. S. Mehta in Journal of Postgraduate Medicines topic on how well are we prepared?, which was published during March 2011 issue, based on theme of the importance of hospitals mentioned to have well documented and tested disaster management plans for the hospitals for preparing them to handle the unusual workload
The scene is different at various countries. At United States of America, there is a statutory regulation, which requires all hospitals should seek accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to have disaster response plans. International Federation of Red Cross and Red Crescent Movement stated that if an earthquake or volcano eruption occurs in a place, which did not affect human habitat, they are not classified as disasters.

3.3 Global Reviews: Various studies have been undertaken about the disaster preparedness theme since last 20 years. WHO and other organisations are working continuously for the development of standardised tools for assessment on disaster management techniques. This has resulted into increase in horizon of hospital disaster preparedness and research areas focussing major events which is affecting the community. The attack of September 11, 2001 in the United States and Anthrax scare, the disaster preparedness approach has to be thought upon new threats, new disaster detection technologies and improvised communication channels for pointing out the threats to community. Various research studies conducted globally on Disaster preparedness at hospitals. It is an important task to identify the teaching module for hospital disaster preparedness for its employees. Hospital disaster management plans has been challenged by certain studies as they claim that the mere written plan availability in hospital does not represent the disaster preparedness the study also mentioned about the fact that the obligation on written plan in hospital wipe off the attention from the disaster planning and preparedness process39. In United States, before September 11 attacks, survey was done for 30 hospitals. They were 22 rural hospitals and 8 urban hospitals. They survey was about the hospital preparedness for chemical, biological and nuclear disaster. The study represented that rural hospital respondents did not believe that their hospitals also have chances of above mentioned disasters and they were not prepared for the same. However urban hospitals were somewhat having the ideas about the chances of chemical, biological and nuclear disasters on their hospital and they were somewhat prepared for the same.
During 2006, a study was conducted based on theme of assessing levels of hospital emergency preparedness. This was done by Emergency and Disaster Management Division, Ministry of Health, Israel, on emergency preparedness with major force on planning for emergency preparedness. An annual assessment of the emergency plan is required to assure emergency preparedness. The assessments should include various components as mentioned in the study such as disaster planning; coordination and communication; training and drills; surge capacity ; skilled staff, medical equipments; and stockpiles of medical supplies, laboratory facility28. During the same year a study was conducted on disaster and subsequent health care utilization scheme among victims of their family members. The study concluded that attention should be paid to the primary care needs of affected individuals and those who have witnessed the disaster. During 2007 in United States, similar study was undertaken to check the disaster preparedness of the emergency department, the result showed that the emergency department were understaffed and were might not in a position to provide the response during the disasters
Studies based on knowledge, attitude and Practices: During 1995, the study was conducted, to describe the knowledge, education and planning for disaster preparedness at the Viborg, Danish hospitals. Questionnaire was sent to the chief doctors and chief nurses, besides to all doctors and nurses in the region. These participants had participated in one or more courses in disaster medicine during the period 1990-1995. In a study conducted in 2002, the result showed that most health care personnel, showed lacuna in the area of knowledge managing the disasters. During the year 2002, similar study was conducted based on knowledge and awareness concerning chemical and biological terrorism. was done to assess the knowledge base of health care providers at an urban medical centre in preparation for developing a workshop on domestic terrorism preparedness. A total of 291 nurses, physicians, nursing and medical students completed the knowledge and awareness survey. The knowledge scores of the respondents were low, with less than one fourth of the knowledge questions answered correctly.
Similar study was conducted during 2007, which was conducted on assessment of hospital disaster preparedness and level of knowledge regarding disaster preparedness in various health care departments. The target population was physicians, nurses, public health and mental health professionals, health educators, veterinarians, pharmacists, dental professionals, law enforcement and emergency/ fire personal. The findings revealed that the highest awareness and knowledge levels occurred with physicians, nurses and public health professionals. On site coordination and communication systems were the weakest aspects of coordinated community response. During the year 2008 the study was done by nurses in Hong Kong, the result as per the study conducted portrays that the nurses are not prepared for disasters situations. However they are aware of the need for that preparation. Hence the study concluded that syllabus of disaster management techniques should be part of nurse education. .
Similar study was conducted in Pune city on the theme of assessment of knowledge, attitude and practices score about disaster preparedness of 200 nursing staff. The study represented that the nurse’s knowledge level was good for their role however; the preparedness percentage was on the lower side comparatively. The attitude of nurses towards disaster preparedness was positive. The study also represented that 31% of the nurses was undergoing regular practices on periodic intervals in their hospitals. Another study was conducted during the 2017-18 to assess the effectiveness of evacuation drill on the pre-test and post-test scores among B.Sc. Nursing students. Participants were selected by stratified sampling technique. Data was collected by using structured questionnaire. Results represented that pre – test mean score was 13.54 and post- test mean score was 28.56. The t value was 27.57 which was highly significant at p;0.001 level..
3.4 Disaster preparedness at Schools:
Study was conducted during 2007, which was a quasi experimental study based on effectiveness of disaster management training manual in terms of change in knowledge and practices on 540 school teachers was conducted in 30 selected secondary schools of Pune city. The research design used was an interventional approach of group pre-test post- test by selecting simple random samples. The statistical result was presented that overall pre-test mean knowledge score on disaster management was 15.9 i.e. 53% and post-test mean score found to be 24.07 (80%). this findings also tested by paired t test the calculated value was greater than table value at 0.05 and 0.001 level of significance which was highly significant. The study reveals that for achieving highest safety in schools; each school and civic society must take the disaster management preparedness concept seriously and implement the continuous practices for preparedness to achieve the highest safety standard in schools. Here role of a teacher is very important in training of students and improve the practices of disaster preparedness. Training manual was proved to be very effective in building disaster preparedness of school children’s..
3.5 Hurricane: During 1999 a study was conducted on hurricane related orthopaedic surgical admissions to an emergency department. They examined records of all patients treated at the emergency department in the same time interval, on the first three Fridays in December from 1994 to 1998. 68% of the recorded injuries were injuries to the upper and lower extremities and 22% of the head and neck. The study concluded that hurricanes, can lead to substantial morbidity and mortality. Early warning is the most effective way of reducing the number of deaths and injury. People should seek cover and follow the instructions given by the media. Educational programs for the medical staff of the emergency department should be available.
3.6 Chemical, biological and nuclear disasters: During 2001, a study was conducted in north western state based on theme to examine the hospital preparedness for the disaster events with chemical or biological weapons. 224 hospitals emergency departments were covered in these states. The hospital disaster management plans, emergency training, hospital emergency staff their roles, medication stores inventories were evaluated. The study concluded with the result which was presented as the hospitals are not prepared enough to treat patients of chemical or biological terrorism.
During 2005, a study was conducted in Israel, with special seminar by a bioterrorism expert for the hospital emergency department and medicine ward member. As the result presented, the emergency department were found to have high knowledge in medical and logistical aspect regarding bioterrorist threats. The study also concluded that by giving continuous lectures, drill and disaster poster to the staff members helps to improve upon the knowledge level of the staff. During 2007 a pilot study was conducted based on theme to assess the effectiveness of disaster conferences among 200 health care providers. The study concluded with result has shown that among the 200 respondents, registered nurses and physicians were the largest categories of providers. Most of the respondent’s recommendations received about the improvement in action for disaster preparedness and also about the continual training enforcement .
3.7 Disaster Drill : During 2007 a media as a technology tool oriented study was conducted based on theme of effect of video learning of disaster drill education on registrars. It was a pre and post interventional study of 15 minutes video about disaster management plan of hospital and principals of disaster management. The study suggested that educational video is an effective media tools for disaster preparedness training program and it should be included in staff orientation program. Similar study was conducting during 2008, which was based on theme of disaster preparedness training course using multimodality teaching. It was a 16 hours course about hospital Disaster Life Support program. Participants of the study were Physicians, 40 nurses, 23 administrators / directors and 10 other personnel participated. The study concluded that Hospital Disaster Life Support (HDLS) program added more value on disaster knowledge gain and high satisfaction obtained from their experiences during the HDLS program.

A similar study was conducted during 2008 on theme to assess perceptions of preparedness for disasters and access to support mechanisms, particularly for nurses in emergency and critical care units in Canada. A total of 1,543 nurses completed the survey. The results indicate that nurses felt unprepared to respond to large-scale disasters / attacks. They concluded that more training and information are needed for Nurses to enhance preparedness.
Railway Disasters: During 2011, a descriptive study was conducted based on theme related to railway disasters globally. Total 529 railway disasters incidences was taken care on the components of number of railway disasters, people killed, and injured during disasters during last four decade from 1979-2009). 73% that is highest railway disasters occurred in Asia, Africa, and South and Central America. 26% of railways disasters occurred in Europe, North America, and Oceania. Since 1980, railways disasters increased in Asia and Africa during the year 1970-2009. The number of persons killed during disaster events were highest in Africa (n= 55), in South and Central America it was (n=47), and in Asia (n = 44). The lowest rate was found in North America (n = 10) and Europe (n = 29). The study represented that in spite of avoiding of crash by railway signalling and modern gadget and advance safety systems and injury reduction technologies, railway crashes occur on all continents. It indicates that disaster planning and training must be accounted for in disaster planning and training.

3.8 Literature reviews related to theme of earthquake management.
During the year 2001, a study was conducted based on theme to evaluate mental health and psychological change after the earthquake as part community health assessment. The findings indicated that majority (67%) of the respondents experienced six or more mental health complaints continuously for two or more weeks after the earthquake. Similar study was conducted during 2004 in Japan for earthquake disaster preparedness which is related to experience and education of 1065 numbers of high school students of first grade. The study reveals that family and community education with training on visual aids to develop culture of disaster preparedness for taking right decision at the time of emergency situations.
In the same year a study was conducted to evaluate the effectiveness of public awareness campaigns on theme of earthquake and tsunami hazards. The questionnaires were distributed to the participants who were mainly government officials in disaster management agencies, community leaders, village heads and local people. Majority of the respondents had a moderate to high level of understanding on the disasters, with more than 60% respondents aware of the disaster risks in their area of residence. Majority of them preferred the mass media, particularly television networks to receive the latest information on the disasters. More than half of the respondents have the knowledge and awareness to act appropriately in the event of any earthquake or tsunami disaster. In general, the public awareness campaign on earthquake and tsunami hazards had tremendous effect in imparting knowledge and increasing awareness to the people.
A study was conducted at Nepal during the year 2005 based on theme of natural disasters like earth quake, flood and landslides. The study was conducted for connecting with mental health and psycho social aspects after an earthquake. Study reveals that even though there is a health sector emergency plan of the Nepal state ministry of health, disaster relief measures are not addressed in the plan adequately. Therefore study concluded that important relief measures for mental health and psychosocial aspects of disaster preparedness is needed for emergency preparedness on priority.

During 2005 a study was conducted in United States on theme of knowledge of earthquake management among 823 students from 5th to 8th grades using new concept of systematic network. Two cities name Aydin, Turkey which is a high-risk earthquake zone; and Columbus, which is in a low-risk zone in U.S. were selected for the study. In high zone majority of students received formal instructions about earth quake. However such instructions were not passed on to students in Turkey. The result reveals that U.S. student’s scientific knowledge about earthquake was higher than that of Turkish students. Even though they had less experience about earthquake in US, however they had certain belief about how earthquake happens and what is the definition of earthquake. Even though the Turkish students experience is better in facing earthquake their knowledge level was not enough for the earthquake..
During 2008, the study was conducted on health services based on theme of earthquake psychological problems resulting from an earthquake in Turkey. 2007 samples were surveyed at two sites using self reporting measures of traumatic stress, depression and use of health services. The study concluded that there is a need of psychological treatment to be given to survivor of earthquake. During 2009, a cross-sectional study was conducted in Tehran city on the theme of knowledge, attitude and practices of 1195 residents aged 15 years and more for an earthquake and disaster related components. The result showed that out of 1195 residents, 1076 (90.0%) of residents, 1160 (97.1%) of total residents, and 490 (41.0%) of the study participants scored only 50% scores for the knowledge, attitude, and practice components, respectively. As per the study the result reveals that people in high risk zone with lower educational background should get preparedness program training more often. Community should work on increasing community knowledge awareness program to fight with future uncertainties related to earthquake..
During 2010, a cross-sectional study and a door-to-door survey were carried out among residents from 22 municipal districts. It involved a total of 211 individuals above 15 years. The theme of the study was Information about the different methods of public education on earthquake preparedness, preferred media for earthquake preparedness was collected. Majority (72%) selected Television, followed by radio with (52%) as the appropriate media for communication to reach to public during earthquake. 70% among the participants felt that earthquake news should be communicated through media. 87% listed aid centre’s during disasters, mosques, newspapers and televisions as the most important places during and aftermath of the earthquake. Similar study was conducted in Tehran, based on theme of “effects of earthquake training intervention educational program on health volunteers about their knowledge level for approach to earthquake in health centre’s in east of the city”. A semi experimental study was done on 82 health volunteers. The data were analyzed by SPSS 14, using paired sample t-test and Pearson’s correlation coefficient. The study represented that the health care volunteers knowledge level can be increased by conducting continuous training on disaster preparedness and by conducting workshops..
3.9 Literature reviews related to fire management.

During 2005, a study was conducted to describe on theme of lessons learned from a night club fire on February 20, 2003 caused a multiple casualty disaster with 215 victims requiring treatment at hospitals. Information on the fire was obtained from hospital reports, and questionnaires sent to regional hospitals. The result showed that 28 (60%) of the patients admitted to RIH were incubated for inhalation injury. For patients admitted to RIH, the extent of the total body surface burn was less than 20% in 33 patients (70%), 21% to 40% in patients (26%), and greater than 40% in patients (4%). The study concluded that lessons were learned that will further improve readiness for future disaster.
A study was conducted during 2008 in Ghana based on theme of survival and mortality trends in four fire disasters and to find out the measures that can minimise the risk of future fire disasters. For the study data base was generated from hospital clinical records and ICU of burn centres. The result showed that, from four burn disasters 212 victims were injured, 37 people (17%) died on the spot; 175 people (83%) reported to the Casualty Unit. Among them 46 people (26%) were admitted in hospital. The study result reveals that disaster preparedness periodic training with fire safety demonstration is to be used effectively as preventive measures to control death and disabilities of fire related disaster victims.
During 2011, a study was conducted in London; it was a cross sectional study based on theme of ICU fire evacuation preparedness in London postgraduate deanery. The sample consisted of 50 paediatric Intensive Control Unit. The study concluded that there is room for planning of urgent evacuation improvement through regular training and rehearsal.
Similar study was conducted during 2012 in the journal of acute disease about review of hospital fire disaster preparedness theme and level of knowledge of hospital staff regarding fire safety management. It was about the risk and vulnerability evaluation analysis of two hospitals. The result showed that even though hospital disaster management plan is available in the hospitals, knowledge level of hospital staff and other preparedness was inadequate to perform evacuation operations systematically. Study concluded that continuous monitoring and practicing of evacuation drill and training based on risk and assessment of vulnerability will help to manage future disasters.
During 2013, a study was conducted on knowledge, attitude and practices (KAP) among 630 students among which (359 female, 266 male, 5 unidentified) in 32 elementary schools in Thailand towards theme of fire safety and prevention. The findings revealed that the students who had not been trained in fire evacuation had more inappropriate behaviour or practices and poorer attitude towards fire, than those who had the experience. Hence study concluded that the strategy planning to improve attitudes and practices through proper training for fire evacuation among the students are very much required.
During 2016 a cross sectional study was conducted based on theme to assess the knowledge and attitude of fire safety among undergraduates, post graduates dental students and staff in Amrita school of dentistry in manipal. The data was collected by using self administered questionnaire from 270 students. It was found in the study that more than 90% of the students believed that prosthodontics department was at a higher risk of fire accidents. Only 15% of the participants were aware about the different types of fire extinguishers and 6.75% of the participants knew that PASS method of that (Pull, Aim, Squeeze and Sweep) of using a fire extinguishers. There was no significant association between knowledge of fire safety preparedness and education level of the participants. There was an appreciable level of positive attitude towards fire safety and control among the dental students and staff. Study concluded that knowledge level of the dental professional could be improved by emphasizing on fire control practices.

Similar Studies regarding the theme of hospitals disaster preparedness has been conducted which are also helpful for supporting the research work in Riyadh, Saudi Arabia. It was a combination of descriptive and interventional study was conducted to evaluate hospital disaster preparedness (HDP) in Jeddah. The theme was monitoring of disaster preparedness with hospital infrastructure indicators. In this study hospital infrastructure was divided into eight field of various 33 indicators, such as structural, architectural and furnishings, lifeline facilities and safety, hospital location, utilities, maintenance, surge capacity, emergency and disaster plan and control of communication and coordination. Sample of Six hospitals participated in the study and rated to the extent of disaster preparedness for each hospital disaster preparedness indicators. The findings shows that hospitals included in this study have tools and indicators in hospital preparedness but hospitals disaster preparedness is lacking with training and management which is required to be done on continuous basis for disaster preparation. Hence this research work also shed light on hospital disaster preparedness with continuous monitoring of the role of hospital staff during the disasters, supported with adequate training periodically. Considering the importance of preparedness in disaster it is important and necessary for the hospitals to develop systems for disaster preparedness training and continuous monitoring
The similar study was conducted on disaster response performance of hospitals in Taiwan during, 2010. The theme of the study was to check the disaster preparedness performance based on three factors such as facility, manpower and disaster management plan along with drill mode for selected emergency medical services (EMS) hospitals at Taiwan. This study finding says that hospitals need disaster response planning and temporary shelters to rescue victims in disasters. This study concluded with an outcome that, at Taiwan, on average private hospitals performs better than public hospitals and medical centres perform better than regional hospitals. However, the differences are not statistically significant.
In our study we have evaluated the performance of corporate hospitals, teaching and government hospitals. And the results were the similar that the difference in this hospital performance regarding disaster preparedness was not statistically significant. Also about the performance of the staff level in their knowledge, attitude and practices were statistically not significant based on their staff category.
Similar study on disaster preparedness was conducted during 2015, in Sichuan, China.The study reveals that although public health services have been responding to emergencies for a long time, public health emergency preparedness is an evolving field it is making progress in slow pace. This is resulting into lack of understanding of the disaster preparedness topic and emergency response planning and preparedness. The study concluded that it is difficult to make improvements in disaster preparedness at china because of lack of a capacity planning to measure the objective of public health emergency preparedness (PHEP). Majorly the cause is lack of principle awareness in China towards disaster preparation leading to public health emergency preparedness.

A Study on theme of disaster preparedness on hospital staff nurses about their knowledge, attitude and practices regarding hospital disaster preparedness was conducted. This was a descriptive study which was conducted to determine the knowledge, attitude and practices of nurses in different department like emergency, trauma care intensive care unit on disaster preparedness. The sample consisted of 90 staff and student nurses of tertiary care hospitals were known about disaster management. The result says that 72.2% of participants were unaware of the finding of the disaster management plan. 90% of participants were agreed that the management should be adequately prepared for disaster occurrences however 10% of the population did not agree for it. The study concluded that there is an urgent need to proactively establish co-ordination and management procedures in advance of any crisis. However the study was silent about the other staff preparation as well as for hospital infrastructure preparedness.
Similar study on disaster preparedness major focus on fire safety preparedness for knowledge, awareness of the fire safety was conducted. This was a cross sectional study which was conducted at multispecialty hospital in Mumbai Maharashtra (India), during March-April 2014. Fire safety preparedness framework (FSPF) was designed with four domains (risk and vulnerability assessment, response mechanism and strategies, preparedness plan and information management for evaluation of fire safety preparedness of hospital employees. Out of 20 questions, awareness was high (>90%) only for three questions from “Response mechanism and strategies” domain. For the remaining questions awareness was moderate to low. The awareness varied highly with the type of employees. The study concludes that the FSPF is a reliable tool for application disaster preparedness mechanism. Disaster preparedness training and drill need to involve employees from all departments as awareness levels is differing with type of employee.
In our study also the same finding regarding the awareness was statistically proved that demographic variable gender does not affect knowledge, awareness, attitude and practices. Knowledge had positive influence on education. Age and education positively influence attitude. Age is not influencing the practices however education positively influences the practices.
Similar study was also conducted on subject of hospital disaster preparedness and response performance indicator. The study reflects the ability of the hospitals to cope with any eventuality if happens. In this study researcher studied the capacity of the hospitals to tackle any unforeseen event on basis of three parameters – Fixed structure of the hospitals, availability of trained personnel and Disaster Management Planning and Drill. After Analysis of all factors them by DEA ( Data envelope Analysis) method shows very clearly that Government Hospital stand better than that of Medical College and Super speciality in meeting necessary requirements to tackle any disaster effectively. Difference between scores of Government Hospitals and Medical College is very marginal but it could be easily inferred that government hospitals have been at forefront in deploying the resources for meeting any unforeseen eventuality and it reflects approach of government hospital to handle any disaster as compare to medical college and super speciality hospital.
It can be observed that most of the studies related to disaster preparedness were done in advance western countries. Hence this is an effort to see the level of disaster preparedness for the Navi Mumbai Hospitals, to identify the gap and to improve upon the emergency preparation immediate needs. At at administrative level this can be done by funding and encouraging research scholars in health preparedness surveys in near future. This study also stimulates further research in Navi Mumbai emergency preparedness arena in order to bridge the gap identified which is highlighted by this study.
CHAPTER 4
Material and Methods
This chapter deals with the methodology adopted for assessing disaster preparedness among selected hospitals of Navi Mumbai. Assessment is done with the help of three tools 1. Disaster management plan checklist. 2. Hospital infrastructure checklist. 3. Questionnaire regarding Knowledge, Attitude and Practices of the hospital staff as participants. It includes description of research approach, research design, period and setting of the study, population and sample, sampling techniques, criteria for sample selection, description of tools, data collection process and data analysis techniques.
4.1 Research Approach: A qualitative and quantitative approach was used for this study.

4.2 Research Design: This study was a combination of descriptive and interventional study design involving the health care workers at selected hospitals of Navi Mumbai. In order to meet the study objective and better understanding of research problem, the research was focussed on collecting and analysing data by quantitative and qualitative data with the help on above mentioned checklist.

Pre-test – Intervention – Post-test research design is adopted for this study.

4.3 Variables:
Table 5: Dependent and Independent variables
Independent Variable Dependent Variable
DM Training with live demonstration Questionnaire for participants score of knowledge, attitude and practices towards Disaster Preparedness DM Plan Checklist.

” DM Plan and Hospital Infrastructure checklist
4.4. Setting of the study: Location of the study was Navi Mumbai selected hospitals. This study involved the selected large 3 categories of hospitals in Navi Mumbai categorized into Corporate Hospitals, Teaching Hospitals, and Government Hospitals. Study participants included 140 representatives drawn from 14 different cadres per hospitals such as (i) Administrative (ii) Nurses (iii) Paramedical staff (iv) Class IV employees
4.4.1: Navi Mumbai City Information

Figure 3: Navi Mumbai City Map
Source: URL https://www.mapsofindia.com/maps/maharashtra/navi-mumbai.html
4.4.2 Demography: Navi Mumbai a well planned city which was established in 1972. It is located in west coast of state of Maharashtra. It is a planning and creation of City and Industrial Development Corporation (CIDCO). The total area of this city is 343.70 sq km which includes 95 villages of Raigad district, Thane district southern part and Uran taluka of Raigad district.. Nerul, Vashi, Belapur and Panvel are the main suburban stations at harbor railway line. As per Census provisional report of India 2011, Navi Mumbai’s population is 1,119,477, which includes 611,501 males and females are 507,976 respectively. 831 females per 1000 males is the population sex ratio of Navi Mumbai. 91.57 percent is the average literacy rate of Navi Mumbai which includes 95.05 male literacy rate and 87.33 female literacy rate.
4.4.3. Health Care: The types of health care institutions of Navi Mumbai are given in the following table
Table 6: Health Infrastructure at Navi Mumbai
Health System Resources Number
General Hospitals 75
Nursing Homes /Speciality Hospitals 53
Health Centres/ Other Hospitals ; Dispensaries 48
Number of Beds 6036
Number of Private Clinics 1177
Number of Private Pathology Labs 97
As indicated in table 6, Navi Mumbai city has 75 general hospitals and more than 50 nursing and specialty services hospital and nearly 1200 private clinics which include allopathic, homeopathic, ayurvedic clinics. Total bed capacities of the hospitals in city are 6036 number of beds.
4.5 POPULATION
4.5.1 Selection of hospitals for the study: when disaster happens, burden of patients on bigger hospitals having larger capacity of beds, increases as compare to smaller bed capacity hospitals. Hence we have considered large hospitals under the study having 100 beds or more. Accordingly selection of hospital is done as per flowchart in figure 4.
Figure 4: Flowchart: Participation of hospitals
General Hospitals in Navi Mumbai (n = 75)

Large hospitals having more than 100+ beds in Navi Mumbai (n= 16)

Received permission from hospital authorities to participate in the study (n= 10)

Government Hospitals in Navi Mumbai 06, Out of which 03 hospitals given permission to conduct the study
(n = 3)
1.NMMC Gen. Hospital Vashi
2.NMMC Gen. Hospital, Nerul.

3. Sub district Hospital, Panvel
Teaching Hospital in Navi Mumbai 03, all 3 hospitals given permission to conduct the study (n = 3)
1. D.Y. Patil medical College Hospital, Nerul (Private)
2.Terna Medical College Hospital, Nerul (Private)
3. MGM Medical College Hospital, Kamothe (Private)
Corporate Hospitals in Navi Mumbai 05, out of which 04 hospitals given permission to conduct the study (n = 4)
1. Fortis Hiranandani, Vashi
2. MGM Hospital Vashi
3. Life Line Hospital Panvel
4. MGM Hospital Belapur

4.5.2 Selection of participants for the study – In present study, entire hospitals in Navi Mumbai and their staff members are considered as population. Initially we requested all the large hospitals in Navi Mumbai, ( n=16) having 100+ beds to allow us to conduct the study. However the permission was received only from above mentioned 10 hospitals after repeated follow-ups. This process has consumed long time duration. Accordingly administrative permissions were received from hospital authorities (n=10) for participating in the study. Government hospitals and teaching hospitals were not readily allowing us to participate in the study. However researcher with the help of supervisor has to get the permission by escalating the matter to NMMC Head Quarters, health department officials regarding the study permission from the above hospitals. Thereafter with NMMC Health Department official letter, which was address to government and teaching hospitals, permission to participate in study was taken from respective hospitals administrative department. For government hospitals permission were taken by Health Department Officer, Navi Mumbai Municipal Corporation (NMMC). For sub district hospital, written permission was taken from civil surgeon. This is done by writing a letter specifying study objective and purpose of study, training program along with approximate date and period of training, content of the program, expected participants were briefly mentioned in the letter. Also specifically mentioned about the availability of 14 categories of the participants individually 1 from each cadre to be available on the day of questionnaire administration.
4.6 Sample and Sampling Techniques:
Stratified Sampling techniques were used for the study. Above study participants divided into cadres as per their designation. Accessible populations for the present study are the key people in the hospital who have information regarding hospital disaster preparedness. These participants have been allotted for research study by the hospital management. It included selected 140 representatives totally from all hospitals under the study. Total 140 hospital staff was divided in to four strata which included 14 different cadres as mentioned below. From 14 different categories of hospital staff, one representative each was allotted by hospital and was considered for the study per hospital. Accordingly the strata were classified as 1. Administrative Staff, 2. Nurses, 3. Paramedical Staff, 4. Class IV Employees.
1. Administrative Staff
1. Medical Superintendent
2. Hospital Administrator
3. In charge Nursing
4. In charge Security
5. Fire Safety Officer
2. Nurses
6. Nurse Casualty
7. Nurse ICU
8. Nurse General
9. Nurse Maternity

3. Paramedical Staff
10. In charge Pharmacist
11. In charge Laboratory
4. Class IV Employees
12. Ward Attendant
13. Sweeper Male
14. Sweeper Female
4.7 Criteria for Sample selection:
Inclusion Criteria
Large Hospitals located in Navi Mumbai, having 100+ beds were included for the study.

Those hospitals who have given permission to participate in the study were included in the study.

3. Participants those who were available on the day of training and permitted by hospital administration were included in study.
Exclusion criteria
Dental hospitals and Ayurvedic hospitals in Navi Mumbai were excluded from the studies.

Those hospitals who have not given the permission to participate in the study were excluded.

4.7.1 Ethical Approval: The research was approved by MGM Ethical committee for Research on Human subjects. Ethical committee clearance certificate, reference MGM HIS/RES. 02/2015-16 letter dated 15.04.2015, was collected before approaching the hospitals for the survey
4.8 TOOLS AND TECHNIQUES
4.8.1 Development of Tools: The tool is a mechanism that could gather the data related to the study. Following is the process by which the tool was administered.

1. Review of literature was done in the area related to hospital disaster management based on international and national study.

2. Expert opinion from disaster management field was taken for tool formation.

3 Referred various books on the disaster management subject, journals, reports and published journal and unpublished dissertations were cited.

4. Visited places like Disaster control unit of Greater Mumbai, met their senior officials for gathering information about the subject and formation of tool.

5. My Study tool was designed by considering contents on legislation, guidelines governing disaster and emergency preparedness in India. These includes,
The Disaster Management Act, 23rd December, 2005- (Extends to whole of India)5
National Policy on Disaster Management11.

National Disaster Management Guidelines – Hospital Safety
4.8.2 Description of the tools
Applied standard tools which were used in an international study on hospital disaster preparedness. A total of three tools were developed. Each tool was designed, validated ; pretested in a hospital, which is not part of the study. The pre-testing was done using the final approved draft by MGM ethical committee.

Tool 1: Checklist to asses Hospital D. M. Plan (Total Score 96) -APPENDIX A.

Tool 2: Checklist to assess Hospital Infrastructure (Total Score 150) APPENDIX B.

Tool 3: Self reporting Questionnaire, responses to questions were obtained in Knowledge, Attitude, Practices score (Total questions 30 – score 30) APPENDIX C.
Tool 3, Questionnaire for hospital staff, was divided into following sub-sections regarding disaster preparedness..

Section 1- Demographics
Section 2 – Hospital staff Knowledge, Awareness and Experience
Section 3 – Attitude
Section 4 – Practices
Score marking criteria: For right answer = 1: For wrong answer = 0
Score Grading: Score 1 – 25 = Poor; 26-50 = Good; 51 -75= V. Good; 76 -100= Excellent
Responses to questionnaire were categorized on 30 questions related to knowledge, attitude and practices questions regarding disaster preparedness for hospital staffs. Pre-test for Knowledge, attitude and practices for the participants were done on the same day of training imparted by the researcher. Post test were conducted in different occasion at a gap of 1 month, 2 month and 6 months intervals. Same tool was applied for pre-test and post-test of above all the three tools.

4.8.3 Figure 5: Flowchart – Tool Application in the study.
H O S P I T A LS

4.8.4 Tool 1 – Checklist to asses Hospital DM Plan. (Attached in Appendix A)
Hospital disaster management plan is guidelines and instructions for preparation of disaster preparedness by World Health Organization. It describes the structure of organization; predefine roles and responsibilities of teams, structure of hospital as an organization, disaster preparedness strategies and major resources for disaster planning and preparing towards disaster events recovery, (WHO, 1999-70). Carley ; Mackway-Jones (2006:28) have recommended the related components that should be included in hospital disaster management plan. Similar components were included in this checklist.

4.8.5 DM Plan Components – Total 11 components were included in hospital disaster management plan checklist as per Appendix A.
General Consideration : score = 8
Command and control : score = 5
Communication : score = 9
Safety and security : score = 5
Key area selection : score = 15
Key staff selection and staff tasking : score = 11
Infrastructure and equipments : score = 8
Training and education: score = 4
Monitoring and evaluation : score = 5
Response : score = 22
Post disaster recovery : score = 4
Maximum possible score Total = 96
Table 7: Disaster Management Plan checklist component wise content
Item No. Component Content
1 General Consideration Availability of Hospital Disaster Plan, Planning Committee, Internal ; external disaster coverage, Plan availability in every dept, Hazard ; Risk profile coverage, Agreement with other hospitals in territory
2 Command and Control Commander In charge, Incident command and control centre, Chain of command and channel of communication, SOPS and Standing rules.

3 Communication Responsibility of Plan activation, Communication systems to be used during Disasters, Alternative communication systems, Data Backup systems, Power outage and communications systems- Alert, Standby, Call out, Stand out. Plan activation specification, Notification to Hospital Staff.

4 Safety and Security Point of entry / exit of people and transport / ambulance service. traffic control, patient and relatives identification protocol, personal protective equipments, registration process for staff and outside workers for safety and security with quality patient care
5 Key Areas Selection Identification of Staff Reporting area, Assembly Point, Body holding area, Command control room, Volunteer reporting area, Press area, Triage and Treatment area, Decontamination area, Area of Ventilation systems.

6 Key staff selection and staff tasking Key Staff – Incident Commander, Public Information officer/ media, safety and security officer, Logistics chief, Medical care director, Nursing care manager, Finance and planning chief. Formation of Team, Duty Cards developed for positions.

7 Infrastructure and Equipments Stockpiling of drugs and equipments during Disasters, PPE, Catering and Laundry services, Clinical equipment, Evaluation of supply and equipments levels during normal times.

8 Training and Education Responsible for Training and Education, Familiarization of staff roles with training , Workshops for staff awareness
9 Monitoring and Evaluation Process and Monitoring measures for Disaster Preparedness. Evacuation Drills, Tabletop exercises. Involvement of other organizations, any other specific aspects
10 Response Internal disasters, Large influx of patients, Equipments supply and personnel, SOPS, Triage, Patient registration, Treatment, Provision of emergency cases, admissions and surgery, accommodation of extra patients / Extra beds/ additional staff. Volunteers. Safekeeping of items removed from casualties, Evacuation procedure.

11 Post Disaster Recovery Support for patients in Critical Incident debriefing, Employee assistance, Counselling for individual or group, family support program
Table 7 represents item wise 11 components of DM Plan and its respective contents.

4.8.6 The scheme of scoring for DM Plan Checklist: The score allotted to hospital was based on situation prevailing in the hospital and based on above components and their subcomponents. For each hospital under the study, component wise score is obtained. This score was converted to percentage, which was further graded as follows.

Score 1 to 25% = Poor; 26 to 50% = Good; 51 to 75%= V. Good; 76 to 100%= Excellent
4.8.7 Tool 2: Hospital infrastructure checklist. (Attached in Appendix B)
Total 15 components were included in infrastructure checklist as mentioned below having 10 score for each:
Regulatory and Statutory compliance in hospital related to disaster preparedness.

Activation of onsite guidelines and emergency codes
Presence of functional disaster management committee
Mitigation strategy
Fire safety committee in place / Fire safety officer with control room
Emergency medicine and medical gases and equipment availability
Emergency catering and laundry facility
External coordination and networking communication
Evacuation Mock drill and table top exercises
Functioning of fire safety equipments
Emergency exit signage’s and access control
Emergency staircase
Availability of transport and ambulance services in hospital
Morgue facility / Dead body management
Casualty infrastructure
Maximum possible score Total 15 * 10 = 150
4.8.8 Tool 2 – Scheme of scoring: The points were allotted to hospital based on infrastructure for disaster preparedness prevailing in the hospital. This is categorized into above 15 components and their subcomponents. For each hospital under study, component wise score is obtained and presented in chapter on Data analysis. Total score is obtained for each hospital separately. The score obtained was converted from frequency number to percentage. Percentage was further graded as follows:
Score 1 to 25% = Poor; 26 to 50% = Good; 51 to75% = V. Good; 76 to100% = Excellent
Table 8: Component wise Hospital Infrastructure checklist content
Item No. Component and content
1 1. Regulatory / Statutory documents and compliance in place
i. Hospital Disaster Management Written Plan in Place for External & Internal Disasters:
ii.Hospital Management and Employees Familiar with DM Plan Content:
iii.Statutory Compliance and its amendment by Management from time to time :
Other related documents are: (MPCB Certificate, Arms Act, 1950 for Weapon Security Guards, Bio Medical Handling 1998, Environment Protection act, 1986, Explosives Act 1884, Fatal Accidents act 1855, Maharashtra Medical Registration Renewal for All doctors, Disposal of Radioactive Waste Rules 1987. etc)
iv. Authority In- charge for chain of command / communication channel for plan specified: (Capability to take decisions static and dynamic: When a disaster strikes, authorized individuals are called to declare a ‘Doctor Major’; only the CEO/medical director/director of nursing/senior physician in the emergency room, is authorized to activate the disaster plan)
v. Plan Specifies the Roles and responsibility of DM Team
vi. Availability of media liaison officer, NGO representative, availability of good speaker conducting DM awareness and demonstration training cum drills.
2 Activation of Onsite guidelines for Emergency Codes
Receiving & registration of casualties with emergency manpower Triage and tagging, Emergency care coding, Patient safe transportation to various hospital departments , Maintenance of Emergency documents and patients records
3 Functional Disaster Management Committee in place
Presence of Commander in Chief, heading committee
Roles and responsibilities of each committee member in written format
Committee meeting at least once in 3 Months.
Availability of Agenda and Minutes of the meeting documented
Work out on Budget, financial aspects of preparedness & mitigation measures.
4 Fire Safety Committee in place – Mitigation strategies
Hazard Vulnerability Assessment for external disasters, HVA for Internal disasters
Hospital safety committee, (comprise of Doctors, Security staff, trained in Fire Fighting / Defense/ Para Military/ civil defense) in place –Fire Safety Arrangement with First Aid Team Composition with volunteers trained in First Aid Team
5 Fire Safety officer with control room available / Fire Safety Audit done
Fire Safety Audit conducted in Hospital – Mandatory six monthly –
Allocation of Fire Safety Control Station with monitoring of Fire Alarm system detection and extinguishing techniques
Liveliness of system and proper detection of alarms with appropriate actions
6 Emergency Medicine and Medical Equipment’s, Gases availability
Adequate supply of medicines,
Adequate supply of equipment during emergency
Supply of oxygen and other gases during emergency
Maintenance staff availability in house 24* 7
7 Emergency Catering and Laundry Facility
Adequate buffer stock of supply for emergency catering services
laundry facility available
8 External Ordination and communication
With other hospitals and pharmacy, medical stores in territory
Police and Bomb Detection Squad networking with contact details available
Fire brigade contact Details available
Tehsil / Collectors office contact details for administrative support
9 DM Evacuation Mock Drills and table top exercises held in hospital
Mock Drill conducted in the Hospital based on frequency – mandatory frequency quarterly
Training program conducted on specific interval with demonstration
Mock drill and table top exercise conducted
Documentation available for the yearly training with attendance
10 Fire Safety ; other electrical Systems for emergency preparedness in place
Fire extinguishers in live mode, refilling done, Sprinkler, hoses, hooter in working conditions
Electrical audit done, Public announcement systems in working conditions
Functioning of another Emergency system and casualty management
11 Emergency Exit Signage’s and Access
Emergency Exit signage’s well illuminated erected on vintage points in local language
Exit door under direct access without lock and key
12 Emergency Staircase
Clutter free safety staircase
Illuminated Exit Access with Exit Direction Boards
fire safety lift exclusively available for emergency
13 Availability of transport / ambulance services in hospital
Dedicated Ambulance available in-house hospital services
Round the clock outsource ambulance services available
Stretcher and life support fitted
Drivers trained n stretcher, drills and Basic Life Support
14 Availability of morgue facility in hospital / Dead body management
Mortuary available in hospital in house with cooling facility
Mortuary available with ; 4 bodies capacity holding with cooling facility
Mortuary available with ; 4 bodies capacity holding without cooling facility
Mortuary with HEARSE Facility available with separate vehicle for dead bodies
Mortuary with Post-mortem facility
Dead body Storage and Handing over systems to relatives / Disposal facility
15 Casualty Infrastructure
Road Access to casualty – 20 feet wide road
Road Access to casualty – 15 feet wide road
Road Access to casualty – 10 feet wide road
Disable friendly arrangements at entry point
Availability of Disable friendly ramp way
Availability of Disable friendly toilets and trolley at the reception point of casualty
Table 8 represents Hospital Infrastructure checklist each component wise contents Score 15 component * 10 score = 150 total score.

4.9. Tool 3: Self -reporting Questionnaire: response to questionnaire were categorized into 3 Point Likert Scale for Knowledge, Attitude and Practices Score – Pre and Post-tests: (attached in Appendix C)
The researcher collected quantitative and qualitative data with both closed and open ended questions. Same tool was used in Pre-test as well in Post-test. Questionnaire was divided into four sections as follows.

4.9.1 Section 1 – Demographics Questions number 1- 6 = total 6 questions related to hospital staff under the study regarding their gender, age, duty station, current position in hospital, work experience and level of education. Demographic statistics is presented in data analysis chapter.

4.9.2 Section 2 – Disaster Knowledge, Awareness and Experience questions: question no. 7 to 15 = 9 questions, (combination of open and close ended questions as follows).

Are you aware of any disasters that have occurred in your hospital area during last 5 years?
To your knowledge, which of the following disasters are likely to occur in your area?
Are you aware of the role of hospitals and staff members during disaster?
Does your hospital have a disaster plan?
Are you familiar with the contents of hospital disaster plan?
Are you aware of the major components / issues that must be included in hospital disaster plan?
Have you attended any workshops or training related to disaster preparedness?
What topics were covered in the training, what was the duration of training?
How would you rate your current knowledge regarding the disaster management situations for sudden influx of large number of patients?
4.9.3 The scheme of scoring for knowledge parameter: It was a combination of open and close ended questions, responses were obtained in 3 point likert scale. Answers were coded as Yes = 1 score, No = 0 score: Do not know = 0 score.
Total score of pre-test – (intervention) – after 1 month- post-test 1, thereafter interval of 2 month – post-test 2, thereafter intervals of 6 month for post-test 3, was obtained. These frequencies were converted to percentage. The percentages were graded as follows.
Score Grading:
Score 1 to 25 = Poor; 26 to 50 = Fair; 51 to75= Good; 76 to 100= Excellent
4.9.4 Section 3 – The scheme of scoring for Attitude for duty during disasters parameter: question no. 16 – 25 = 10 questions, (questions based on how hospital staff feels about disaster preparedness in their hospital, the questions were as follows)
Is your hospital adequately prepared to manage any type of disaster with sudden influx of patients?
Hospital should have disaster management plan?
The hospital is unlikely to be affected by disasters?
Only doctors and nurses, administrative staff needs to know about the disaster plan?
I do / do not need to know about the disaster plan?
Disaster planning is only for the hospitals administrative staff and heads of the departments?
Hospital staff needs training and education on how to manage disaster situations?
Hospital has adequate staff to deal with a sudden influx of patients?
Hospital should conduct regular drills and exercises to mange disasters?
Does hospital provide personal protective equipments?
4.9.5 The scheme of scoring for attitude parameter: It was a combination of open and close ended questions. Participants answers were coded as Yes = 1 score, No = 0 score: Do not know = 0 score. Total score of pre-test, after intervention 1 month- post-test 1, thereafter interval of 2 month for post-test 2, thereafter intervals of 6 month for post-test 3, were obtained. These frequencies were converted to percentage. Percentages were graded as follows on arbitral basis as follows.
Score Grading:
Percentage ;= 50% = Positive attitude; Percentage ;= 50% Negative attitude
4.9.6 Section 4 – Practices: to assess disaster preparedness practices at hospitals: Question no. 26 –30= 5 questions. It was a combination of open and close ended questions to assess disaster preparedness practices at the hospital. (3 point likert scale – Yes / No/ Do not Know). Participants answers were coded as Yes = 1 score, No = 0 score: Do not know = 0 score. The questions were e.g.
Does the hospital conduct disaster management training , mock drill regarding disaster preparedness?
Have you participated in developing or reviewing the disaster plan?
Have you ever involved in disaster victim care?
Do you have any comment on hospital disaster preparedness?
Would you like to receive information regarding disasters and role of hospital and its staff in disasters?
4.9.7 Scheme of scoring for practices parameter – Score Grading:
The scheme of scoring is as under: Total score of pre-test, after intervention 1 month- post-test 1, thereafter interval of 2 month for post-test 2, thereafter intervals of 6 month for post-test 3, was obtained. These frequencies were converted to percentage. Percentages were graded as follows.

Score 1 to 25 = Poor; 26 to 50 = Fair; 51 to75 = Good; 76 to100 Excellent
4.9.8 Validity of the tool:
Tool was prepared and given to experts in the field from the disaster management. One expert from disaster control management unit of greater Mumbai has suggested adding in few questions related to savior of women; child and old age patient in ICU rescue during disaster situations. One expert suggested to shortening of some of the question to the point. The necessary modification and suggested changes were made and tool was given to validation at MGM Tool Validation committee. Final Changes were incorporated as suggested by MGM Tool Validation committee.
4.9.9 Reliability:
The reliability of co-efficient of the instrument ranges from 0 – (non reliable) to 1 (perfect reliable).
Reliability Result
Tool 1 : The reliability for hospitals DM Plan Checklist was established using the Cronbach’ Alpha co relation coefficient. The reliability was found to be 0.833.

Tool 2 : The reliability for Hospital Infrastructure Checklist was established using the Cronbach’ Alpha co relation coefficient. The reliability was found to be 0.961.

Tool 3: The reliability for knowledge, attitude and practices questions was established using the Cronbach’ Alpha co relation coefficient. The reliability was found to be 0.968.

4.9.10 Pre-Testing of Tool – Pre-Testing of validated tool was done at MGM Hospital Kalamboli on 27th and 28th December, 2016. This hospital is a maternity and pediatric hospital with 130 beds. Intervention training program was conducted with help of Disaster Control unit of greater Mumbai.
Following subjects were covered during the training, Disaster types, Dos and don’ts during disaster, basics of fire, types of stretcher, lifting and carrying of patients during emergency, actual evacuation drill, fire safety live demonstration etc. This program was appreciated by the hospital management and staffs. Feedback of all hospital staff was collected for the training session. In the feedback forms majority of the participants mentioned about increasing the frequency of such training programs in near future for disaster preparedness.

During the pre-test tool was administered to 15 participants who fulfilled the sampling criteria. It was conducted in a similar way as final data collection questionnaire. Participants took 25 – 40 minutes to complete the questionnaire. The tool was found to be practical and feasible. The data was collected and then analyzed by using descriptive and interferential statistics. The result revealed that the objective of the study could be fulfilled. Based on pre-tested study conducted, the researcher received the permission from the guide to proceed with the actual data collection for the main study.

4.10 Data Collection:
4.10.1 Official Permission from concern authorities and participants: Formal Official permission for administering the pre-validating questionnaire was taken from 10 hospitals under study located in Navi Mumbai region.
In this study those participants who were allotted by hospital administration and among them those who were present on duty are considered as samples. They were informed about the date of administering the questionnaire and the training program. Participants were explained about the purpose of the study. Their willingness to participate in the study was obtained before the study. Participants were informed about the importance of the subject and purpose of the training, their involvement and the period of the training and requested them to be available during the subsequent sessions.
Interview of participants has been done by the researcher in person after obtaining their willingness to participate in study. Researcher herself administered the semi structured questionnaire for the pre-test and post-tests. Their doubts have been cleared and they have been given assurance for maintaining the confidentiality of the information provided. Informed consent has been taken from the participants detailing them about the purpose of the study.

4.10.2 Period Data collection and training:
For selected 10 hospitals of Navi Mumbai the data collection was done as follows;
Start date – December 2016 : End date – March 2018 = 16 months period.
After receiving of ethical approval on15.04.2015, researcher started approaching all the hospitals in Navi Mumbai for participation in study. For government and teaching hospitals longer time has been consumed for getting the permission from hospitals for participation. As these hospitals were initially not ready for the participation in the study.
Hence researcher had contacted Navi Mumbai Health Department senior officials for the necessary escalation and requesting them for looking into the matter seriously.
After getting the official permission from NMMC Health Department, again these hospitals were been approached and accordingly received the participation and permission for the study. However the process has taken longer time. Accordingly each hospital has taken their own time at their will and convenience for training and data collection. Researcher started collecting the training session and data from December 2016 from government hospitals. Approximately six months time frame was taken for collecting the data of every category of hospitals. Each hospital training and data collection has been done with prior appointment as per the availability slot given by the concerned hospitals. End of data collection was for teaching hospitals in March 2018.

Approximate 4 hours time has been invested every visit for training and data collection per visit. Time taken by the hospital staff to fill the intervention tool was as follows;
1. DM Plan check sheet – 11 components – 96 marks – approximately 25-30 minutes.
2. Infrastructure check sheet- 15 components -150 marks- approximately 40-45 minutes.

3. Hospital staff KAP Score questionnaire – 30 questions – 15-25 minutes.

4.10.3 Informed Consent: Pre-test was conducted after taking official permission from hospital administrative department and informed consent from the participated hospitals staff as participants. DM Plan checklist and hospital infrastructure checklist and Self structured questionnaire were given to participants who have been allotted by hospital management.

4.10.4 Administration of the Training: DM training with demonstration, after the pre-test participants were given training on disaster management with live demonstration on fire safety.

4.10.5 Teaching Module: Training interactive session with demonstration
Disaster Preparedness interactive session for hospital staff with live demonstration was conducted by researcher in English as well as in Marathi with the help of Disaster Management Unit Municipal Corporation of Greater Mumbai Region. The language was kept as simple as possible. The training program imparted topic like basic concept of disasters, causes, types, effects of disasters, do’s and don’ts during disasters, disaster management plan and lifesaving skills (First Aid), fire safety live demonstration etc.

4.10.6 Training and Workshop: Modus Operandi.

Date of the training was communicated to hospital in advance. All the participants were asked to gather at one place allotted by the hospital. Welcome note, introduction and purpose of the training, objectives were defined by the researcher along with trainer from Mumbai Disaster Management control unit. Power point slide show presentation were given on the subjects like Disaster meaning, definition, types of disasters, LPG cylinders and safety, evacuation drill, hospital disaster management plan, life saving skills, first aid, making immediate stretchers during emergency using various easy methods, Dos and don’ts, fire fighting actual demonstration with extinguishers were the content of the subjects covered. Sessions were conducted in mixed language as understood and requested by participants preferred language. (English Hindi and Marathi ). Question answer session was carried out at the end to solve the participant’s queries’ for more guidance on the subject by the experts from Disaster management unit, Mumbai.
4.10.7 Training Schedules
Schedules were intimated in advance so that respondent hospital staff should be made available at work in day shift on the day of training and data collection. The data was collected during the day shifts of the hospital, targeting day duty staff.
4.10.8 Post-test: Tool 1, Tool 2, Tool 3.

1. Hospital DM Plan Checklist – Post-test inspection was conducted after 6 months of pre-test and the training on the same date.

2. Hospital Infrastructure Checklist – Post test inspection was conducted after 6 months of pre-test and the training on the same date.

3. Participants KAP score – Post-test was conducted after pre-test and training on the same date after interval of 1 month, 2 month and thereafter wide gap of 6 months duration. This was done to check the memory retention level of the participants.
Same self structured questionnaire was administered to the participants to obtain the KAP score
4.11 Data Analysis Plan
Hospital Disaster Management Plan and Hospital Infrastructure score obtained by each hospital were scored separately. These scores were compared with each other within in the group and thereafter between the groups of hospital.
The individual participant in the study were scored self reported questionnaire on 3 sections as knowledge, attitude and practices score adopted on 3 point likert scale and compared with in a particular group of hospitals, and thereafter between the group, (such as corporate hospitals, private teaching hospital and municipal hospital) for comparison in order to understand the specific reason, if any for the difference.

4.11.1 SPSS Statistical Techniques software version 21 was used to quantify the results.

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