Identifying flood response experiences in Iranian health system: A qualitative study

One of the most essential purposes of the health system is to ensure that people affected by various disastrous events, such as floods, have access timely to basic health services. Therefore, enhancing the preparedness and response plans for such events should be a national priority. Because of the complexity and devastating impacts of floods on public health, it is a crucial to understand the various aspects of flood experience in the country. The experiences of managers and operational staff from various units of the Iranian health system are a valuable source for understanding flood complexities. These experiences were explored using 19 semi‐structured interviews with people who had firsthand experience of this phenomenon. Based on the results, in order to provide a flood response plan, it is necessary to adhere to the principles and foundations that can meet the needs arising from the flood. Our study showed that the health system's response to flooding can be divided into two categories: initial and specific functions. A comprehensive response requires an initial function to prevent flood impacts, and specific functions are needed to prevent and treat flood‐related diseases. These results could form the basis for the health system's response to future floods.


| INTRODUCTION
Floods are the biggest threat to community's health and have direct effects on mortality and morbidity (Austin et al., 2015(Austin et al., , 2019;;Khan et al., 2008;Mohajervatan et al., 2021;Watts et al., 2015).Floods were the most common natural disasters in 2019, accounting for 43% of all disaster deaths (Crunch, 2019).It is expected that as time passes, increased rainfall and floods will also have more effects on the infrastructure (Mahmood et al., 2017).According to the findings of research, floods have far-reaching health impacts.These effects occur in the short, medium, and long periods following the flood.The most significant effects include drowning; trauma; skin infections; illnesses caused by water entering the respiratory system; gastrointestinal problems; infectious diseases; diseases caused by insect bites; and mental disorders (Alderman et al., 2012;Doocy et al., 2013;Menne et al., 2014;Paterson et al., 2018).So health sector needs to be prepared and, disaster risk management principles must be applied to prevent and mitigate, prepare, respond, and recover the affected people from flood's complications (Ghazanfarpour et al., 2019;Malalgoda et al., 2011).Relevant organizations should improve their systems and response to these events as a national priority (Aitsi-Selmi & Murray, 2015).This is especially important in Iran, which has had numerous flooding events in cities and villages recently (Memarian Khalil Abad et al., 2018).The Mohajervatan study also showed the severity of these events.They recorded that 514 floods occurred in 106 cases of rainfall in Golestan province in northern Iran between 1991 and 2013, causing significant damage and loss to public health services (Mohajervatan et al., 2017).Mirhaghi's findings show that flood management in Bampur (an Iranian city) was ineffective, leading financial losses (Mirhagi et al., 2010).According to a report by the Iranian Red Crescent society, heavy rains and flash floods affected 10 million people in Iran in 2019, resulting in 78 deaths and 8 billion dollars in economic damage and losses (IRC, 2019;Yadollahie, 2019).Such similar impacts on public health reflect weak preparation and insufficient management of implementing new response methods, effective systems, and a lack of a strong theoretical foundation for responding to these events (Nojavan et al., 2016).While health professionals can take numerous measures to protect the health of affected populations, Fitzgerald declared that in most floods, illness and mortality can be prevented by education and training, proper floodplain control, and early warning systems (Du et al., 2010).The magnitude of such events' physical and human costs can be decreased if appropriate emergency prevention, readiness, response, and recovery measures are implemented in a sustainable and timely way.Health systems that are resilient and proactive in anticipating requirements and problems are more likely to respond successfully during emergencies, saving lives and easing human suffering (WHO, 2019).Prior planning, the ability to efficiently mobilize resources, continuous training, the elimination of gaps, and effective response are all required to be successful in this field (Pilon, 2002).WHO have been developed a series of fact sheets and documents, targeted at ministries of health; national, regional, and local health authorities; and medical and public health professionals.These fact sheets and documents describe in short what to do in case of a flood (WHO, 2019).In Iran, the health sector has a national emergency response plan for all hazard which the flood experience of 2019 showed that this plan could not meet all the needs (IRC, 2019;Yadollahie, 2019).So, because of the characteristics of floods, influencing factors in creating consequences and the full variety of their health impacts require special planning (Ardalan, 2015;Mirzaei et al., 2021;Mohajervatan et al., 2017;WHO, 2019).Using prior flood events' experiences to create a response plan might be beneficial.Other studies show that knowledge about flooding and how to respond to it increases with repeated experiences of flooding (Hansson et al., 1982).Ten Brinke contends that this is because flood events allow the system to go through the learning cycles repeatedly in order to reduce vulnerability to similar events in the future (ten Brinke et al., 2008).Zevenbergen contends that learning from previous flood experiences contributes to the development of effective flood resilience approaches (Zevenbergen et al., 2008).However, when it comes to public health service, we must be cautious of the lessons learned from global research because floods vary greatly in terms of the features, scale, and vulnerability of the population affected (Ahern et al., 2005).Since emergency managers and operational staff are the key informant persons who involved in disaster response field, this qualitative study was aimed to identify the experiences of managers and operational personnel from various units of the health system who responded to recent Iran's flood occurrences in order to adjust these experiences into the Iranian national health disaster and emergency response operation plan.

| MATERIALS AND METHODS
This was a qualitative content analysis study that was carried out in Iran in 2020 and 2021.The study participants have been selected purposefully from all managers and operations staff from various health sectors involved in the response to recent floods in Iran (Table 1).Study participants were included experts from the university, environmental health, disease control, pre-hospital, nursing office, hospital director, EOC director, disaster risk reduction office, and support unit, were invited to be interviewed to provide related experiences.The inclusion criteria were having more than 2 years of job experience in flood management in the health sector.Due to geographic, cultural, social, and technological differences between provinces, we attempted to select study participants from six regions to achieve greater diversity within the sample.They were taken from Golestan, Fars, Kuzestan, Lorestan, Kerman, Sistan, and Baluchistan, mainly based on historical flood records.A semistructured interview guide with four general questions was used to collect data in this study.We limited our scope of experience of managers and staff in flood response activities to four areas.(1) the impact of flooding on their communities; (2) the health needs of floodaffected people in their communities; (3) measures taken to meet these needs; and (4) operational units Individual interviews lasted anywhere from 15 to 45 min.Every interview was recorded with the individuals' prior approval.The data were interpreted using the Framework Analysis method, which is based on the building of a conceptual structure.The data familiarity step happened after turning the interviews to text, reviewing the transcripts, and listening to the recorded interviews again for this purpose.The familiarization step's repeating themes were recorded independently.
For data indexing, the MAXQDA 10 software was used.The data were then organized into tables in the next stage.The original theme was developed by assigning comparable codes to the same categories (Gale et al., 2013).The members of the study team evaluated all of the tables at the conclusion, and their theoretical framework was considered and agreed.To ensure the trustworthiness of finding, the following criteria were used: credibility, transferability, consistency, dependability, and confirmability.To verify the credibility of the results, prolong engagement and triangulation with adequate time for data collection, have been considered.Besides, the peer check and expert check were used.All stages of data analysis are recorded to ensure consistency and confirm ability.For confirmability, the texts of the interviews were given to another researcher (one of the project collaborators) as well as an external observer who had no relation to the study, and the results were compared to their findings.The study's results were discussed several times within the research team to ensure a uniform understanding of the data.
3.1 | Themes 1: Principles and components of the response plan (Table 2)

| Sub-themes 1: Basic features of plan
The study participants believe that the most important principle in a disaster response plan is to emphasize the functions of the health system.Giving attention to upstream documents, legal and executive criteria, and the description of the Ministry of Health's expected duties are also considered planning principles by some interviewees.P (7): "My experience is that we have to write an Emergency Operation Plan.Something other than the EOP is not executable."

| Sub-themes 2: Risk assessment
According to the interviews, the core principle of a response plan is risk assessment in order to categorize probable event scenarios.According to the interviewees, the needs relating to people's health should be extracted in order to deliver a solution based on those needs.P (8): "The most critical aspect of the plan should be that it is T A B L E 2 Concepts identified in interviews.

Themes Sub-themes Category Example
Principles and foundations of plan

Basic features of plan
Function of health sector Efforts to meet health-care needs/Activities facilitate health services.

Duties of various health unit
During floods, each unit should be aware of its job descriptions.
Health National Documents Refer to the national response plan.

Executive requirements
The plan is operated by experienced and skilled individuals.

Risk management Based on risk assessment
The plan is based on risk analysis/Include the country's flood risk zoning in the plan.

According to the ranking flood
Determine the level of participation of organizations based on flood levels.
Comprehensiveness Type of flood The response can be distinguished according to the type of flood.
User friendly Simple and usable.
Related to preparedness Link preparation activities to the response plan.
Covering all the health needs Meet all the needs of the accident/Include from the beginning to the end of the response process.
Consistent with the context.In accordance with our country's disease and population composition conditions.

Prioritizing
The sequence of interventions It is not necessary to activate all functions together.

Two-step response
Connect the plan to the early warning system/ Have plans and pre-plans.

Scheduling
The timing The activity of the units varies over time/Needs change over time after the flood.

Foresight
The plan will give us a prognosis regarding flood health needs.

Response actions Initial function
Leadership Establish a single command in the health system/Specify the hierarchy and authority at the time of response/Establish incident command post in the field.
Protection of live and facility Restrict areas to prevent population access to danger areas/Evacuation of public health centers/evacuation of EMS center/evacuation of endangered hospitals.

Partner coordination
Coordination with military forces/municipality (in waste collection)/waste organization (for waste disposal)/Veterinary Organization/ crisis management organization/Meeting with the Red Crescent/water and sewage department /Drilling companies to use pumps/coordination between health units.

Active emergency operation plan
Develop a plan based on needs and problems/ Develop an action plan to address the needs created by the flood.

Information management
Compare pre-and post-accident information/ Attention to psychological security in the dissemination of information/Information link with the electronic file of the household and information related to the affected families.
(Continues) compliant with the risk assessment; that is, the flood risk assessment would be the foundation for activating the plan."

| Sub-themes 3: Comprehensiveness of the plan
All of the participants believed that the response plan should address all flood-related health concerns.They thought that a comprehensive plan would handle all flood-related health issues.P( 12): "The nature and extent of the flood determines the response.For example, many people require assistance during floods that last for 3-4 h.However, floods in AqQala lasted 45 days, and the health demands were significantly different."

| Sub-themes 4: Prioritizing
The study's findings indicated that the severity of flooding determines the priority of intervention.P (19): "I think the flood reaction is different from the other hazards, this is because floods have a longer warning period than other hazards and give people a chance to react accordingly.The warning and notification must be included as part of the response.We need to prioritize a pre-response and a response activity".

| Sub-themes 5: Scheduling
According to the study participants, the flood's response needs time bond planning base on the risk assessment to meet affected people needs and predict their upcoming problems.P ( 16): "The early days of sheltering or supplying essential needs of life, such as heating equipment, became a problem.It took some time for our medical teams to realize that they required additional supplies or more specialized services for various populations".According to all interviewees, there are three-time categories for the flood's consequences: short-term, medium-term, and long-term, each with a set of needs that must be addressed.

| Themes 2: Response actions (Table 2)
Flood response is a combination of steps done to address the needs caused by flooding while adhering to the legal obligations and responsibilities of the health system.When coping with flood dangers, all interviewees believed that having a pre-determined plan is beneficial.
"If we have a particular flood plan and have already prepared and performed in various exercises, we will no longer have the anomalies and confusions that we had previously," says interviewee 6.Our findings show that, in addition to feeling that this plan is advantageous, some respondents believe it is more efficient than other hazard response plans, such as earthquakes.P (8): "I believe that this plan is more successful than the earthquake response plan because the flood has a long-term early warning".Our findings showed that an effective flood response plan consists of two types of functions: (1) Initial function and (2) Specific function.

| Sub-themes 1: Initial function
Our findings indicate that some response actions occur before and during a flood in order to avoid and reduce the severity of flood impacts prior to any health intervention.These actions have been classified as "initial functions."The initial functions in the Iranian health system involve six types of activities: 1. Leadership. 2. Protection.3. Partner coordination.4. Active emergency operation plan. 5. Information management.6. Operations support and logistics.

Leadership
Operational manager and staff involved in the response believe that establishing a unified command for the health sector and installing unified incident management posts on field will double the effectiveness of the response.P (10): "When an organization tries to meet its obligations, it cannot cope with a disaster.This response could be a parallel operation or service outage".

Protection
Our findings indicate that the priority for flood response in the health sector should be to protect both people's lives and healthcare facilities.To ensure the safety of the impacted individuals, camps might also be thoroughly overseen and assessed for fire and protection threats.P(3): The health system may be harmed as a result of the flood; for example, our generator was submerged during the AqQala' flood.We had cold chain freezers that were distinct from conventional freezers.Due to a problem at the vaccination center, we had to adjust our vaccine position.As a result, people who were unaware of the facilities or did not have access to them were denied entrance.During the flooding, we had to travel by boat to deliver certain necessary health services, which was "perilous."

Partner coordination
Floods have several impacts, necessitating coordination and collaboration with various relief agencies.P (10) "with regard to the closure of the route from AqQala to Gorgan, from which 700 to 800 tons of rubbish were delivered daily, this amount of waste was diverted to the east of the province in conjunction with the waste organization".

Active emergency operation plan
One of the most critical flood response actions is developing a plan of action based on EOP for the incident at the time of the occurrence.P (7): "At the time of the incident, write down your tactical plan based on the conditions of the occurrence, which we call the incident action plan (IAP).You must update the IAPs and determine which functions to employ and which to demobilize".

Information management
The majority of interviewees believe that acquiring information quickly and comparing data before and after an occurrence in the impacted region allows for an accurate reaction.Our findings reveal that good information management will reduce mortality and give high-risk populations, such as pregnant women, enough time to avoid high-risk regions.P(4): "Collecting information in the field is critical, and integrating electronic registry data on family health and relating it to new flood-based factors will help better monitor the disasters."

Operations support and logistics
The majority of interviewees believed that operational teams' requirements for support and logistics services were clear.This section covers a broad variety of activities, from supplying energy to health centers and hospitals, calculating damages for insurance agencies, providing access for workers, restoring care for persons in need of services, managing volunteers, recruiting volunteers, and providing equipment and manpower, recovery and motivation for human resources, Providing logistics such as using tractors instead of ambulances and auxiliary vehicles, long chassis, off-road vehicles, using naval boats, providing boots and waterproof clothes, providing pumping to drain water.P(6): "In a flood, we must have a good workforce and the necessary equipment, as well as the appropriate boots and clothing, or decontamination equipment, which is very critical, particularly in places that could need disinfection."

| Sub-themes 2: Specific function
According to this study, much of the flood response is consistent with the legal responsibility of Iran's health system.These activities have been assigned specific functions.The specific functions of the health system in flood response plan includes into three categories: 1. Emergency care.2. Continuity of health care.3. Public health services.

Emergency care
Many interviewees believe that the first few minutes after a flood are critical for health care.They thought that floods (especially flash floods) need immediate action and emergency medical services, such as evacuation, relief, trauma treatment, and injuries, as well as care for drowning victims in impacted regions.P ( 16): "where flooding has occurred the activities of each unit must be clearly specified.Arrival and care of those in need of assistance ranging from drowning to injured people and those in pre-hospital emergency units."

Continuity of health care
Most people surveyed said that effective continuity of health care is necessary.One of the key elements of the flood response plan is the continuity of care services.Collecting a list of chronic patients in affected areas and continuing mental health treatment, paying attention to the chronic unmet health needs of the affected population, providing chronic patients' access to drugs, taking timely care of drug use in chronic patients in camp, caring for heart patients, diabetics, special patients, and even chronic infectious patients such as tuberculosis are some of the actions that must be taken despite flooding.P(4): "Some services are provided regularly.We have a diabetic patient who is unable to take his medication or inject insulin on his own.We had to go to the patients' homes by boat or transport them to health centers.The care that chronic patients need of us is one of the services that get people into trouble.It's a really serious situation.These could be overwhelmed by more basic requirements."

Public health services
According to our findings, post-flood situations disrupt health-monitoring frameworks.These services are related to a wide variety of healthcare units and agencies, including occupational health, oral health, pharmaceutical services, medical and outpatient services, laboratory services, disease management, high-risk group services, mental health services, environmental health, family health, nutrition, housing, education, and vaccination.P(10): "The first step we take after a flood is to form rapid response teams so that we can control water resources and replace water resources.The second issue is food control after an accident.On the other hand, if a camp was established, we had to check the health of the food that got there.Where food is cooked, control the food transfer process.The next issue is the area's sewage.During the latest flood, many wastewater wells were filled in homes and also wastewater wells were filled in camps that could be used.Another concern about contamination in flood-prone locations that I'd want to raise with you is that garbage collection and waste generated by field hospitals should be considered".

| DISCUSSION
According to the results of our study, managers and staff of operational units considered responding to the needs generated by flooding a priority and one of the key functions of the health system.They believed that the flood also had many impacts on the affected population, which should be considered.So having a pre-determined flood response plan, in their opinion, is beneficial.They believe that, despite the existing national response plan to disasters (Ardalan, 2015) in the Iranian health system, a specific flood response plan is also needed.The reason is that flooding in the affected communities creates a variety of health-related needs after occurrence.Therefore, appropriate knowledge and skills are needed for a comprehensive response.According to our findings, risk assessment to determine future disaster scenarios is a basic and first principle in developing a response plan.Knowing what could happen allows you to determine the resources you will need and establish flood-response plans and procedures.Other studies confirm that paying attention to the consequences of past floods by reviewing experiences can increase our prognosis for future floods (Alderman et al., 2012;Doocy et al., 2013;Menne et al., 2014;Paterson et al., 2018).One of the most important findings of this study is the assignment of the functions to the flood response plan.Based on our findings, the interviewees described two categories of functions as the key components of the health system's flood response plan: (1) Initial function: These are the functions that must be performed by the incident management system (IMS) from the time the flood is certain.The implementation of these functions, while preventing an increase in the consequences of flooding on the community, also prevents secondary events.These functions may also be performed in other hazards, but their standard operating procedures are different in other hazards.(2) Specific function: These are functions that are the responsibility of the health system.These functions are carried out by different units of the health sectors based on national standards to respond to the demand created by floods.

| Initial function
The first few minutes after a flood are important for taking action so that it not only saves lives, but also provides accurate information to management and decisionmaking to mobilize troops and resources.Prolonging flood warning times will improve the efficacy of these interventions.Six categories of activities are extracted from the interviewees.These activities included: leadership, protection, partner coordination, emergency operation planning, information management, operations support, and logistics.These findings are consistent with the critical functions for emergency response under the incident management system (IMS) presented in the World Health Organization Emergency Response Framework (WHO, 2017).Other studies have also confirmed these actions as part of the flood response plan (Cvetkovi c et al., 2018;JICA, 2014;WHO, 2019).Also, the Ardalan study, which examined disaster response functions in a flash flood, validates these findings (Dizaji et al., 2019).According to our results, intra and interorganizational information exchange is very important during information management activities.The results of Claire Bayntun's et al.'s study confirm these findings.They realized that health care agencies must be able to work with other organizations, collaborate with other countries, efficiently communicate with people, interact with the community, and create flexibility and effective recovery (Bayntun et al., 2012).According to participants' point of view, the use of electronic family health records in response to the needs of the 2019 flooding seems to be a successful example of information management in disaster response in Iran.But the use of new technology in information management was given less consideration.According to the Tavakoli study, the use of new technologies such as patient tracking and victim registration improves disaster relief (Tavakoli et al., 2017b).In another study, Tavakoli discusses the problems of disaster management in Iran, such as the lack of communication and management infrastructure (Tavakoli et al., 2017a).Communication challenges, according to the operating departments' experiences in our study, must be properly considered in the flood response plan.

| Specific function
According to our findings, the activities that various health sectors should conduct after a flood are divided into three categories: 1. Emergency function.2. Continuity of health-care function.

Public-health services function.
This result is consistent with the proposed activities by WHO to respond to flood risks in the European Union (WHO, 2019), as well as the Iranian health system's national response plan (Ardalan, 2015).The World Health Organization's plan focuses on flood management across the four phases of disaster management, and the response section relates with the functions of our research (WHO, 2019).The response plan for Iran's health system lists specialized functions based on different operational units separately, whereas the dimensions extracted in our study had a strategic level, and this is the most significant difference between Iran's health system plan and our findings, because it allows all operational units to develop regional and local plans (Ardalan, 2015).However, depending on the context of the event, these actions may not be performed or they may be repeated at various stages of the response.This is because the emergency response to events is a dynamic process.In this regard, we recommend that each specific function and task defined in this section be carried out in compliance with the national guidelines, procedures, and standards of each country.

| Emergency function
The most significant reason for people to go to the health sector in the flood is emergency care needs.In the event of a flood, medical services, particularly surgeries and referral systems, may be unavailable due to building destruction, road closures, or a lack of specialist personnel, which causes them to be unable to meet people's emergency care needs.Similar conditions occur in most floods (Abaya et al., 2009).Timely and effective emergency services seem capable of saving many affected people's lives, and this is a requirement of a flood response plan.Other study substantiate our findings (Van Minh et al., 2014).Also, in the Iranian health system's national response plan, this function is classified as pre-hospital services (Ardalan, 2015).

| Continuity of health care function
According to the findings of our study, one of the key components of the response plan is post-flood health care for affected people.Several studies have shown that flooding has a significant impact on chronic disease conditions.Services will be cut off due to the lack of access to health centers and the volume of physical work associated with cleaning and rebuilding the centers (McKinney et al., 2011;Ng et al., 2011;Paterson et al., 2018;Robinson et al., 2011;Ryan et al., 2015).As a result, we believe that continuity of care should be taken seriously at all levels.This result is consistent with the proposed activities by WHO to respond to flood risks in the European Union (WHO, 2019).Kanittha's study, which investigated at hospital employee experiences, found that maintaining the function of care provision is an important component of flood preparedness measures (Rattanakanlaya et al., 2018).But this function is not included in the Iranian health system's national response plan, which is written with the approach of all hazards (Ardalan, 2015).

| Public-health services function
Our study's results revealed that floods have many consequences for the community's living environment and destroy many service delivery systems.Our findings showed that the scope of these effects is so broad that interviewees believed that they included a wide range of services, i.e., occupational health, oral health, pharmacy services, emergency and outpatient services, laboratory services, illness control, high-risk group services, mental health, environmental health, family health, nutrition, shelter, education, and vaccination.The World Health Organization's guide to floods confirms these findings (WHO, 2019;World Health Organization, 2014).Each of these tasks is viewed as a specific function in Iranian health system's national response plan, which is consistent with our findings (Ardalan, 2015).These services are critical because studies show that lack of access to health and social care services is a risk factor for psychological disorders among people who used to access these services but now their homes are flooded (Carroll et al., 2010;Waite et al., 2017).As a result, individuals involved in response and rehabilitation should prioritize the restoration of these facilities.Other studies emphasize the importance of identifying the most vulnerable groups in society in terms of gender, socioeconomic status, and health needs, in addition to integrating health elements into each aspect of risk management (Matsuyama et al., 2020).As a result, the flood response plan should include the services that each group requires to ensure the health of the community after a flood.

| CONCLUSION
According to the findings of our research, a flood response plan should be designed based on concepts and principles that cover all of the needs that may occur as a consequence of the occurrence of that hazard.We believe that the first step in responding to the risk of flooding should include primary or initial functions that will avoid the impacts of floods on public health from worsening.These functions encompass a variety of actions, the most significant of which are: leadership, protection, partner coordination, active emergency operation plan, information management, operations support, and logistics.These functions must be carried out before and during a flood.We also found that the specific functions of the health system include emergency care, continuity of health care, and public health services.Each of these dimensions addresses a different part of flood-affected society's needs.These findings allow for a re-definition of health duties in the face of flood risk, as well as recommendations for more effective services.The limitations include the following: there were no similar studies discovered in the research literature, and most existing research focus on the health impacts of floods.The recommendation is as follows: creating a framework to respond to the flood risk in the health system is an important topic for future research; this study presents components and elements of flood response plan.
General characteristics of the interviewees.