Health Disaster Management Guidelines for Evaluation and Research in the Upstein Style A Short...

Task Force for Quality Control of Disaster Medicine (TFQCDM) / World Association for Disaster and Emergency Medicine (WADEM/)Global Health 2002

Health Disaster Management: Guidelines for Evaluation and Research in theUtstein Style: A Short Introduction

A report byKnut Ole Sundnes, MD; Marvin L. Birnbaum, MD, PhD.

President of World Association for Disaster and Emergency Medicine; Editor-in-Chief of Prehospital andDisaster Medicine.

The objective of this presentation is to draw attention to newly developed disaster research strategies that in their

wake, are likely to result in shifts of currently accepted policies and paradigms. Such shifts will have relevance for

health-care personnel, bureaucrats, politicians, and the industry of health-care and public health.

The Problem

Disasters are described as a mismatch between resources and tasks, whether caused by unavoidable natural events or

by avoidable, man-made events. Disability, loss of human lives, crops, fertile land, seeds, production equipment,

infrastructure, and intangible losses all contribute to the short- and long-term consequences of disasters. Overall, for

every person killed in a disaster, ≥750 are affected. During the natural a disasters from 1966–1990, 975-billion

people were affected: 1.35 million were killed. For complex emergencies, the figures are worse. In Rwanda during

1993-94), >800,000 were killed.

The total damage resulting from similar events, differs significantly between the developing and the

developed world, as does the ratio between the numbers of those affected and killed. This inequity has the potential

to help to reveal some of the unknowns as pertinent questions arise and are researched systematically.

Unfortunately, such research has not been recognized in an institutionalized fashion, partly as it has been considered

to be an unethical competitor for scarce resources and partly because appropriate techniques have not been

legitimized medically. Consequently, much of the work has been based on intuition, not necessarily rooted in

understanding and knowledge. The lack of needed techniques has been appreciated for decades and is mirrored in

disaster documents: reports from the last 3-4 years focus on the same mistakes and shortcomings as did reports from

20–30 years ago.1,2

Solution

To meet the demands for structured disaster research, the TFQCDM developed mechanisms for evaluating

interventions applied during disasters, but also for prevention of future disasters and/or mitigation of the damage

from future events. They suggest how the effects of interventions can be evaluated including their efficiency,

benefits derived, and costs. Although the prime focus has been the health aspects of disasters, generic guidelines

were created that can be applied to development and long-term assistance.


These structured mechanisms (Guidelines and Templates) have been designed to improve

external validity of the findings through identification of similar findings from multiple studies,

and comprise four “pillars” of the “table” of research:

1. Conceptual framework;

2. Template with defined chronological phases and functions;

3. Application of scientific methods;

4. Tools for developing and maintaining baseline inventories.

Pillar 1. Conceptual Framework

Newer definitions have been proposed because of confusion created by the broad use of older definitions. The

evolution of a common language across the multiple disciplines associated with disasters will enhance

communication and help prevent duplication of efforts by parties.

A generic formula has been devised to facilitate the distinction between risk, hazard,

vulnerability, mitigation, and management:

PD = ƒ (RH)(Hman + Hnat)( Vnat + a1+a2 + b1 + b2)

Where:

PD=the probability that an event will inflict damage on a ociety at risk; H=hazard; ƒ=a function of the relationship

between all of the variables; RH=risk that an event that may result in damage; Hman= human component responsible

for the hazard; Hnat= natural hazard;

Vnat=natural vulnerability; a1=vulnerability augmentation; a2=vulnerability mitigation; b1=counter-productive

management; and b2=productive management or alleviation.

The ultimate objective of disaster management is to bring probability that damage will occur as close to zero as is

possible. This can be achieved by bringing the net value of any of the brackets to zero. As part of the development

of a society, man-made hazards are imposed on the society, but are accepted because the risk associated with the

hazard is perceived to be very small (e.g., nuclear power plants. hydroelectric dams). The probability of damage

occurring will be zero if the facilities are not built; or approaches zero if effective preventive measures are

mandated. However, the main focus has been aimed at reduction of vulnerability by increasing preparedness and/or

the absorbing capacity for when the hazard becomes an event. This can be achieved by implementing mitigating

measures (a2) or through productive management (b2). Thus, use of this formula facilitates identification of those

interventions that will be most effective in reducing the probability that damage will happen: it provides a rough,

pathophysiologic framework for evaluation.


The Templates

Three Templates (A, B and C) contain the structure for the study of disasters (Figure 1). The first Template (A)

relates to Pillar 2. The second provides structure and guidelines for the conduct of such studies, and the third

structure and guidelines for their design. Templates B and C comprise Pillar 3.

Pillar 2. Template A: Disaster Elements

For analysis purposes, it is essential to partition a disaster into simple, recognizable, and well-

defined phases that together comprise an algorithm defined by the properties of the respective

phase and not by time (hours, days, etc.) For example, some of the elements included in Phase 2

(Event) of an earthquake can be compared to those in Phase 2 of a drought, even when the

drought lasted for years and the earthquake for 20–90 seconds.

1. Pre-Event Status—the Point of Reference and serves as the baseline to identify damage to the society affected.

It also is necessary for evaluation of the effectiveness of responses, since the endpoint for management of a

disaster is when the pre-event situation for the societal function(s) being evaluated has been reconstructed.

2. Event—the release of uncontrolled energy described by type, onset, intensity, magnitude, duration, and the area

and population impacted, using standardized, universally accepted indicators. These descriptors are essential for

comparing the effects of similar events on the same or different regions and/or societies.

3. Insult (Damage Assessment)—comprehensive inventory of the functional status of each societal function must

be conducted as soon after and during events regardless of rate of onset and duration, using the same indicators

as used for the pre-event inventory. Identification of factors that render the damage caused by similar events or

similar magnitude is essential for understanding disasters.

4. Disturbances in Health Status— This phase focuses on the changes resulting specifically in the medical care and

public health functions, and generically can be adapted to study the damage to other specific functions as well.

5. Needs Assessments—The structure provided should facilitate the further development of validated,

standardized, needs assessment tools. Performance of needs assessments are complicated by confusion between

real needs, perceived needs, assessed needs, and demands.3 However, it is not possible to evaluate any

intervention without first knowing the need(s) that the intervention addressed. Needs Assessment must not be

confused with Damage Assessments.

6. Responses—include not only immediate responses during the acute phase of a sudden onset event, but all aid

and assistance provided until the disaster ends—the Disaster Critical Control Point (DCCP) is the time at

which the available supplies balance all of the needs of the function or sub-function being evaluated.

Identification of DCCP depends on correct, ongoing needs assessment, and is crucial to avoid oversupply. Aid

always is significant: response that is not needed is counter-productive.

7. Changes in Health Status—the outcome from the intervention(s) being studied, and are defined by comparing

the current health status of the affected population with that before the intervention being studied was

implemented. Changes could be documented by a change in a disaster health severity score or by changes in the

elements of health. Since a society never is static, the concept of what the “Best Outcome Without Assistance


“ (BOWA) should be included when assessing the effects of any intervention. Thus, not only must the pre-

event baseline be assessed, but also the direction the status was going prior to the event. As the use of these

Guideline evolve, ways to incorporate BOWA will be identified. Currently, the points of reference still will be

the immediate pre-event inventory.

8. Restoration of Health Status — When the pre-event status has been attained for the aspect of health being

studied, that aspect of the disaster for the affected population is terminated. Improvement beyond the Pre-event

status is development.

Pillar 3. Scientific methods: Templates B and C:

Disaster science cannot provide randomized, controlled, experimental trials. However, adaptation of techniques used

in the study of the social sciences has expanded the capabilities for learning about disasters. Templates B and C

outline the steps for the performance of studies related to situations that do not lend themselves to use of

experimental techniques. Template B consists of eight sections: A) Identification of the Problem(s); B) Design

Research Project; C) Data Collection; D) Analysis of the Data; E) Comparisons; F) Conclusions; G)

Recommendations; and H) Feedback. Section B, Design of a Project, is detailed in Template C: 1) Formulation of

the question(s)/hypotheses; 2) Validation of the question(s); 3) Identification of what needs to be evaluated; 4)

Selection of indicators; 5) Determining the most appropriate methodology; 6) Identification or construction of data

collection instruments; 7) Validation of data collection instruments; 8) Plan for data collection; 9) Organizing and

training the research team; 10) Construction of the sampling plan; 11) Selection of methods for analysis; and 12)

Implementation.

Pillar 4. Inventory: Basic Societal Functions

The Guidelines and their Templates are dependent upon inventories of Societal Elements of Function. Such

inventories, in addition to serving as baselines from which to judge change, provide valuable information about

vulnerability and preparedness, and information for formulation of external responses. Fourteen Basic Societal

Functions (BSF) have been identified, all linked together by Coordination and Control function provided by the

respective governments based on the triangle of responsibility: Mandate, Power, and Resources (Figure 2): 1)

Medical; 2) Public health; 3) Sanitation and water supplies; 4) Shelter and clothing; 5) Food; 6) Energy supplies; 7)

Search and rescue; 8) Public works and engineering; 9) Environment; 10) Logistics and transport; 11) Security; 12)

Communications; 13) Economy; and 14) Education. The format emphasizes the interdependence of all societal

functions upon one another. Failure to recognize this interdependence often results in unrealistic approaches to

disaster. Each functional element contains many sub-elements. To describe changes in a BSF indicators for each of

the societal functions and their respective sub-functions must be developed. Indicators may be numerically or

qualitatively described. The concept of functional and critical thresholds has been developed. Thresholds have utility

in defining the functional status of a BSF, and require selection and use of the most appropriate indicators of

function.


Future

The Guidelines a dynamic document, and will be refined into a working methodology and operational manual..

Decisions as to modifications and refinement of the Guidelines should be the responsibility of the TFQCDM

through consensus congresses conducted at intervals of no longer than five years.

Conclusions

The overall objective for the use of the Guidelines and Templates is to attenuate or eliminate the

damage from disasters through institutionalized, evidence-based competence building. This

could result from the elimination of hazards, decreasing the risks for the actuation of the hazard,

augmenting the absorbing capacity of the society and environment at risk, and proper and

effective disaster management, depending on which combination of activities prove more

feasible or/and more cost-beneficial to the society at risk. The Guidelines open for comparison of

otherwise quite dissimilar events. They provide a conceptual framework to address the need for

standardized definitions, descriptors, and indicators, provide a structure for conducting and

reporting disaster research, and summarize techniques that can be applied to the study of

disasters. They provide the first referral standard for the evaluation and research into medical

efforts that are part of disasters.

The full document will be available as a Supplement to PDM. See also <http//:pdm.medicine.wisc.edu> and

<http//:wadem.medicine.wisc.edu>

Acknowledgement

This work was supported in part by grants from the Laerdal Foundation for Acute Medicine, the Royal Norwegian

Ministry of Foreign Affairs, , the Swedish National Board on Health and Welfare; the Swedish International

Development Agency (SIDA); and the Nordic Council. This work would not have been possible without the indirect

support of the Joint Medical Command of the Norwegian Defense Forces.

References

1. Pan American Health Organization/World health organization: Evaluation ofPreparedness and Response to hurricanes George and Mitch: Conclusions andRecommendations. Prehosp Disast Med 1999;12:53-65.

2. HRH Prince Sadruddin Aga Khan: Improving the Disaster Management Capability of theUnited Nations. United Nations Management & Decision-Making Project UNA-USAUnited Nations Association of the United States of America, January 1987

3. Rubin M, Heuvelmans JHA, Tomic-Cica A, Birnbaum ML: Health-related relief in the former Yugoslavia:Needs, demands, and supplies. Prehospital and Disaster Medicine 2000; 15(1):1-11.


A: Medical Elements in a Disaster B: Evaluation/Research C: Project Design

1. Pre-event Health Status Prospective

A. Identification of Question(s) 1. Formulate Question/Hypothesis

2. Event 2. Validate Question

B. Design Research Project 3. Identify What Needs to Be Evaluated

3. Insult 4. Choose Indicators andDamage= (H nat+Hman)(Vnat+a1+a2+b1+b2) Retrospective Measures of Effectiveness

5. Determine Most Appropriate MethodologyC. Data Collection

4. Disturbances in Health Status 6. Identify/ConstructDamage Data Collection Instruments

I. Change D. Analysis of Data 7. Validate Collection Instruments

5. Needs Assessments8. Plan for Data Collection

E. Comparisons 9. Organize/Train Research Teams6. Responses

10. Construct Sampling Plan

F. Conclusions 11. Select Methods for Data Analysis7. Changes in Health Status

12. Do It

G. Recommendations8. Restored Health Status

H. Feedback

Figure 1—Templates for the Evaluation and Research on Responses to Disasters

A. Identification of a problem

Sundnes/Birnbaum- Utstein Disaster Research Templates/TFQCDM/WADEM/ of 7

Figure 2—Basic elements of societal functions linked by Coordination and Control

Coordination and Control

Resources Power

Culture/Language Geography/Climate

Mandate

Education Medical Public Health

Sanitation/Water

Shelter/C

lothingFood

Energy

Search & RescuePublic WorksEnvironm

ental

Logi

stics

/Tra

nspo

rtS

ecur

ityCo

mm

unica

tions

Econom

y

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