Australasian Emergency Nursing Journal (2015) 18, 165172

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RESEARCH PAPER

Impact of disaster on women in Iran and

implication for emergency nurses
volunteering to provide urgent
humanitarian aid relief: A qualitative study
a
Maryam Nakhaei, PhD
b,c,
Hamid Reza Khankeh, PhD
d
Gholam Reza Masoumi
b
Mohammad Ali Hosseini
e
Zohreh Parsa-Yekta
c
Lisa Kurland
c
Maaret Castren
a
Birjand Health Qualitative Research Center, Birjand University of Medical Sciences, Birjand,
b
Iran University of Social Welfare & Rehabilitation Sciences, Tehran, Iran
c
Department of Clinical Science and Education, Karolinska Institute, Stockholm,
d
Sweden Iran University of Medical Sciences, Tehran, Iran
e
Tehran University of Medical Sciences, Tehran, Iran

Received 12 June 2014; received in revised form 7 February 2015; accepted 20 February 2015

KEYWORDS Summary
Background: Men and women are equally affected by disasters, but they experience disaster
Disaster;
Special groups; in different ways.
To provide new knowledge and promote womens involvement in all phases of the disas-ter
Women
management, we decided to capture the perspectives and experiences of the women
themselves; and to explore the conditions affecting Iranian women after recent earthquake
disasters.

Corresponding author at: University of Social welfare and Rehabilitation Sciences, Koodakyar Alley, Daneshjoo BlV., Evin Street,
Tehran, Iran. Tel.: +98 21 22180160/Department of Clinical Science and Education, Karolinska Institute, Sdersjukhuset (KI SS),
Sjukhusbacken 10, 118 83 Stockholm, Sweden. Tel.: +46 70 408 52 05; fax: +46 8 616 2933.
E-mail addresses: Maryamnakhaee.mn@gmail.com (M. Nakhaei), hamid.khankeh@ki.se (H.R. Khankeh), masoomi-gh@health.gov.ir
(G.R. Masoumi), Mahmaimy@yahoo.com (M.A. Hosseini), ZPARSA@sina.tums.ac.ir, zparsa@tums.ac.ir (Z. Parsa-Yekta),
lisa.kurland@ki.se (L. Kurland), maaret.castren@sodersjukhuset.se (M. Castren).

http://dx.doi.org/10.1016/j.aenj.2015.02.002
1574-6267/ 2015 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
166 M. Nakhaei et al.

Methods: The study was designed as a qualitative content analysis. Twenty individuals were
selected by purposeful sampling and data collected by in-depth, semi-structured interviews
analysed qualitatively.
Results: Three main themes were evident reflecting womens status after disaster: individual
impacts of disaster, women and family, and women in the community. Participants
experienced the emotional impact of loss, disorganisation of livelihood and challenges due to
physical injuries. Women experienced changes in family function due to separation and
conflicts which created challenges and needed to be managed after the disaster. Their most
urgent request was to be settled in their own permanent home. This motivated the women to
help reconstruction efforts. Conclusions: Clarification of womens need after a disaster can
help to mainstream gender-sensitive approaches in planning response and recovery efforts.
2015 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights
reserved.

women. Historically, women are responsible for domestic

What is known
Individuals experience disasters in different ways.
Disasters can affect womens health directly or
indirectly, particularly in different settings and juris-
dictions where there are different cultural context. It
is important to come to understand the effect that
disas-ters have on women and their health at the
individual, community and population level for
disaster response and recovery.
What this paper adds?
This study provides a thorough understanding of the
perspectives and experiences of the women after a
disaster in an Iranian culture. Clarification of
womens individual need, womens problems in
family and community after disasters is important for
disaster recovery.
Introduction
Men and women are affected by disaster in different ways.
The gender differences of perception, experience and
behaviour of victims who are affected by stressful events
have been mentioned in several studies. 14 Regard-less of
whether men or women are more vulnerable in disastrous
events, there are obvious differences between them in
terms of socio-cultural and bio-psychological factors which
may result from differences in risk factors, man-ifest
reactions and recovery from traumatic events and
disasters.1,2,58
Women are often portrayed as the passive victims of
disasters, although this may not necessarily be true. 9,10
Disasters can affect womens health directly or indirectly
through socio-economic deprivation by destruction of
homes and businesses, and loss of employment
opportunities, which also affects men. Some reports
indicate gender igno-rance and violation of womens rights
in the aftermath of disasters.3,1113
In Iran as in other countries, there are differences in
activities, interest and social expectations between men and
chores, child rearing and caring for family members. The
social norms may put women in a more exposed and vulner-
able position with respect to some life-threatening events and
also following extreme physical injury, women were less
cared for and experienced worse situations with respect to
11,1417
family and social relations. It is important, therefore,
to take social gender into account as a reasonable category in
making up these differences. Womens specific needs dur-ing
a disaster in particular, in recovering from a disaster
have been less well researched.
Traditionally, emergency nurses have actively partici-
pated in disaster relief, in both the response to and recovery
from disaster that have affected health care delivery in local,
18,19
national and international contexts, but funda-mentals
that support nurses roles in disasters are not well
18
understood. Since having a disaster plan and being prepared
in the workplace, knowing about it and having practiced, may
influence in the participants decision to attend work during a
disaster, they need prerequisite knowl-edge in understanding
the complexities forced on health of a community during and
1921
after a disaster.
In the context of this paper, what shapes our knowl-
edge about women and disasters is based on studies that
included gender as a variable that sometimes compared
women to men.2224 Few studies have examined the situ-
ation of women after disasters, especially in the recovery
phase in Iran.
Since the roles and responsibilities of women stem from
cultural, political and economic conditions, it needs to be
understood the perspectives and experiences of women in
each culture. For this study, researchers decided to cap-ture
womens own accounts to better understand how their
everyday lives are shaped after a disaster, and to include this
knowledge in all phases of the disaster cycle. The aim of this
paper therefore is to explore this relatively unstudied area,
i.e., the status of Iranian women following disaster.
Method
This study was conducted to understand what happened
to women after disasters and how they experienced it.
Therefore a qualitative study design incorporating content
analysis, which is a suitable method when new areas are
to
Impact of disaster on women in Iran
be investigated in an explorative manner or if the area needs
to be explored from a new perspective,
25,26
was selected.
Recruitment
In qualitative studies, research is designed on key infor-
mants based on their experience; accordingly in this study,
participants were selected among those who were able to
communicate with the interviewer, had been affected by
disasters, and had experience of receiving or providing
health services in disasters, by purposeful sampling.26
As a first step, women who have experienced of receiving
health services in disasters were selected. In continue other
participants were chosen based on the needs of the study.
Study participants
Study participants were 20 individuals (16 women and 4
men) who had experienced disastrous events in Iran (Bam,
Zarand, Lorestan and the 2012 earthquake in Azerbaijan).
The par-ticipants ranged from 22 to 55 years of age with
three types of disaster experience (Table 1). In this study,
a rich picture of the topic and saturated emerged concepts
is constructed based on the contributions of a range of
participants; for example, data were collected from male
participants to develop concepts (sub concepts) related to
family and com-munity situations. Looking through the
eyes of men can add further insight into women and
disaster thereby providing a more comprehensive
understanding of this important issue. The sample size was
determined by saturation,26 that the researchers
concluded that collected data were repeated, new codes
were not developed or existing codes were not extended.
Data collection method
In-depth, semi-structured interviews were used for data
26,27
collection. Each interview individually organised but
usually began with an open question, e.g. Tell me about
what happened to you after the incident? What did you feel?
What did it mean to you? or Could you explain your expe- Ethical considerations
riences with respect to the health care after the incident?
What did you need? How were the needs met? Complemen-
tary probing questions were added when needed and could
relate to prior experiences of disaster, perceptions of health
Table 1 Number and positions of participants.
Code Position of participants in Number
experience of incident (women/men)
1 Health disaster manager or 3/1
specialist
2 Health care provider (nurse, 4/1
social worker)
3 Health service receiver 9/2
(victim, resident in disaster
area)
Total 16/4
167
care and individual needs. Interviews were guided by main
researcher, but each of them was checked and evaluated
for interview trend and subjects which need to be probed
by research team.
The interviews lasted between 45 and 60 min. Time and
place of interviews were determined by mutual agreement.
Data management and analysis
All interviews were transcribed verbatim and compared with
the original audio-recorded digital files for accuracy. Data
28
were analysed using qualitative (latent) content analysis.
The analysis started by identifying units of meaning that were
essential to the participants experiences and were extracted
from the statements/transcript. The codes were compared
based on differences and similarities and sorted into
categories and subcategories that were discussed within the
research team; appropriate themes were then extracted from
28
the data.
Data trustworthiness
Credibility was established through field notes and memos,
prolonged engagement with the participants, and revisions by
the participants using member check and peer check. The use
of a wide range of informants (male/female and in different
health positions) is one way of triangulating via data sources
25
that can help trustworthiness. Triangula-tion of researchers
in the research team helped to take into account different
perspectives when analysing the data. The findings and
interpretations of the study were reviewed by the research
team as an expert revision. Maximum variation of sampling
27
established the credibility of the data. As an additional
control for validity, a peer check on a sample of transcripts
was made by two faculty members who were not part of the
research team. In addition, to confirm the fitness of the
results, they were checked by a panel of experts in the field
of health and rehabilitation who did not participate in the
research.
The study received ethics approval from Birjand Health
Qualitative Research Center (BHQRC), Birjand University
of Medical Sciences (BUMS) in Iran.
The aim and process of the study were explained
verbally and in writing to the participants, after which
they gave written or verbal testament of informed consent
for partic-ipation in the study. Participants were informed
that they could decline participation at any time during
the study. Data collection, interview recordings and
presenting were given confidentially and made anonymous
by using code numbers.
Results
A total of 20 interviews were held between 2010 and 2012.
Three main themes were identified: (i) the impact of the
disaster on an individual level; (ii) women and the family; and
(iii) women in the community. Each theme is introduced,
168
described and supported by findings from the content
anal-ysis of the transcribed interviews.
Individual impact of disaster
Women who participated in this study indicated that the
loss of family members, and especially their children, was
the most stressful experience after a disaster. In all
phases after disastrous events, especially during the
rescue phase, women worry about their children. Even if
women are them-selves physically injured or have other
personal problems, they prioritise finding and evacuating
their own children above their own welfare.
Individual experiences were categorised according to
three concepts: emotional impact of loss, livelihood prob-
lems, and physical injuries and care needs.
Emotional impact of loss
Immediately after the incident, women were in shock
from the magnitude of the event, their injuries, and
witnessing injury/death. Victims tried to find and
evacuate their family members despite the lack of either
a plan or support service. They did not pay attention to
their own physical injuries but tried to save their loved
ones. Sometimes these reactions worsened their injuries.
Dead bodies were accumulated in the city and this was
a grievous scene. People wanted to bury their loved ones
as soon as possible and they were emotionally affected by
this horrible scene. As one mother (participant #14), a
spinal cord injury victim recalled:
My child was in my arms. I held him but I couldnt
save his life. . .. My back had been injured but I tried
to save him but I couldnt, I couldnt move, except
with my hands to move the bricks, then suddenly I felt
a sharp pain in my back. . .
Participants believed there were widespread problems
among women which were not fully considered. These
were the feelings of loneliness and fear of the future.
Emotional effects continued with assimilation and
memories of loved ones long after the disaster. A mother
who residence in disaster affected (participant #17) said:
Personally I do not like it; I really do not want to par-
ticipate in the wedding, even though it is my brothers
ceremony. If I go, Id rather sit and watch the others. . .
tears come to my eyes when I remember who should be
there but will not be at the ceremony.
Livelihood problems
There is a strong belief in Iranian culture that women are
a symbol of stability; according to the participants, they
always support the other members of their family. As par-
ticipant #19, a victim with amputated leg, expressed:
My mother worked too hard for me. My mother was
responsible for everything, especially at first I could
not even do my daily living activities. . . My mother did
everything, not only for me but also for my dad and
my sisters.
Despite what happened after the incident and physi-cal
and emotional injuries, women had to continue their
M. Nakhaei et al.
responsibilities in the family. They attempted to manage
their family even in tents or other temporary quarters.
Poor facilities and exposure made these efforts exhaust-
ing. Inadequate facilities for everyday duties increased
their suffering. Participant #13, a mother indicated:
Everything was miserable whatever I say I cant
express our situation. . .Living in tents was too hard
no facilities, no bathroom, hot water or shower.
Every-thing was a problem; even doing simple
household work was difficult. . .
Moreover, reproductive health, sanitary napkins and
pregnant womens needs were not sufficiently provided
for. The lack of sanitation, health services and privacy in
tem-porary facilities hindered reproductive health.
Reproductive health care services, including prenatal
care, delivery, and emergency obstetric care, were often
unavailable. This made young people more vulnerable.
Women had no access to family planning services,
exposing them to unwanted pregnancies under
disadvantageous or even perilous con-ditions. For example
a pregnant woman in disaster area (participant #16) said:
After my twins, I became pregnant with my third child.
When the disaster occurred, I sometimes had to ask my
neighbors to watch my children. . .I couldnt mobilize any
energy; one time in the tent when I moved supplies, I fell
down but nothing bad happened, thank God. . .
Physical injuries and care needs
Physically injured women had need of health care which
could only be provided in tents and temporary residences.
Some of the injured women were dependent on their chil-
dren and husband to accomplish their household duties.
This made them uncomfortable especially when this
affected their personal hygiene.
A spinal cord injured (Participant #10) recalled:
I had my husband, but my mother was dead, also my
sister and her children. I lost my brother and his wife.
Only my husband helped me. . . sometimes I couldnt
ask him to do some things. It was embarrassing, and
some-times I was ashamed. . .
Because of their physical condition, they needed more
health care and medical equipment which the family
some-times could not afford. In many cases, women
received improper care and there were some adverse
consequences such as bed sores and even in some cases
women became completely immobilised.
The caring problems for family members obligated
them to put some of the physically injured women in
nursing cen-tres. Since the governmental centres were not
completely equipped to admit and provide high quality
health care for this group, they had to go to the nursing
centres and come-back to their tents. This long, exhausting
process increased the suffering of the family and caused
the injured women to feel guilt, in part, inflicted by their
own family mem-bers. Moreover, the centres were often
far from the family dwelling, which could emotionally
affect them negatively, as participant #14 expressed:
Impact of disaster on women in Iran
After I was injured, I lost everything and I had to go
to the nursing center for a year, because there was no
bathroom in the tents and our house was ruined. . .,
there was nobody with me, no mother, and no sister. I
was away one year from my home and my life. . .In
nursing center they tried to do their best but there is
no place better than home.
Women and the family
After disaster strikes, multiple changes happen that affect
all aspects of family functioning. Culturally, because of
the important role of women as the centre of the family,
their situation can endanger family cohesiveness. Family
separation could occur due to death, hospitalisation and
psy-chological impacts. For example a victim with spinal
cord injury (participant #11) stated:
When I was injured I was very upset, I didnt like to
see my husband at all. . . When my husband came
home, I said, Get out! What do you want here?. . . I
hated him.
Marital conflicts
Family conflicts occurred due to couples emotional break-
down, addiction or remarriage. Because of the central role of
women in the family, physical injuries to them can create
problems for the whole family. The results in this sample
showed that men felt ashamed of their wives disability,
especially permanent disabilities such as spinal cord injury.
Consequently, husbands with disabled wives, and who
wanted to keep their children for themselves, often
became interested in remarriage. But among the women,
remarriage created a feeling of lack of support and
belonging. These conflicts led to family disintegration and
the formation of new family structures accompanied by
new expectations and relationships:
Participant #15, a 62 years woman had lost her children
in disaster said:
Now my husband remarried to have his own children. . .
At home I have a great sorrow because of the co-wife and
my husbands behavior. I just come to work and finish the
day . . . I want to have a home for myself to be indepen-
dent, I like to have a party, I want to have a peaceful life
and be happy without any conflicts.
Iranian women have a pivotal role in the family, so
according to the participants, their physical and emotional
well-being has more impact on the children than does the
father of the family.
Women in the community
In this theme, there are two categories: community
behaviour and compensatory activation.
Community behaviour
Study participants indicated that women who participated
in peer groups achieved positive experiences such as peer
learning, satisfaction and establishing social networks. For
example participant #17 recalled:
169
Earlier I came here just for fun. After a while, I learned
useful and practical things. I found good friends; although
four years have passed, we are still friends. . .
we are very happy when we see each other. They
helped me very much.
On the other hand, some participants mentioned that
the community had a negative attitude towards the
victims, especially those physically injured. For example,
unaffected people could consider the disability of the
injured victims as a punishment. As participant #18
(Victim with amputated leg) expressed:
I think this disability is not our main concern.
Acquaintances, family, clan or tribe are more annoying.
. .Peoples view of disabilities is really bad. . . for
example, we hear families asking why their kids were
disabled in the earthquake but our children werent
even injured.
Furthermore, improper public constructs caused limita-
tions in social and also family activities, which could result
in extended social isolation.
Compensatory activation
Reconstruction was often delayed due to administra-tive
bureaucracy and the lack of organisational planning. Because
of difficult living conditions in tents or temporary housing,
the womens most urgent request was to be settled in their
own permanent home. This all encouraged women to help
other family members in the reconstruction process such as
giving aid and offering loans, and so on.
Participants indicated that after the event, women
con-sidered more job opportunities. Participants stated
that their employment, resulting in earning their own
income, helped them to gain independence and
confidence in their future.
Participant# 13 said:
When I came to work my mood improved . . . Paid work
made me financially independent, it helped me so
much. I could stand on my own two feet. . .
Discussion
Womens ability to recover after disasters depends to a great
extent on how well disaster planners and health providers
2932
take womens concerns into account. Therefore there is
a need for a thorough understanding of the post-disaster
situation of women in each culture. The goal of this study was
to capture and systematise the experiences of women, to
understand their situation after disasters. It can help health
care providers especially nurses with a more longitu-dinal
perspective of their role beyond the clinical
18
to plan
response and recovery efforts to ensure that their needs are
adequately addressed. Having an opportunity for emer-gency
nurses, who will be on the frontlines of any disaster response,
are well situated to reassure women health care in disaster
situations therefore understanding the complexities of women
disaster relief can help to respond effectively and contribute
31,33,34
to the specific needs of survivors is critical.
170
The results of this study show, in spite of the harsh
post-disaster conditions, women have the potential to
help not only themselves but also other family members.
The key elements explored in this study were the
impact of disaster on women and their efforts to
overcome them. Three main themes became evident in
the current study; individual impacts of disaster, women
and the family, and women in the community.
Individual impacts caused by disaster consisted of
emotional effects, disorganised livelihood situations and
challenges due to physical injuries. In the acute medical
response and evacuation phase, women do not escape the
emotional impacts of health and security for children or that
1,7,1113
of losing their property or belongings. According to
the literature, gender differences undoubtedly persist in the
1,2,58
possible reactions to traumatic events. Although
diagnostic criteria of psychiatric disorders are beyond the
scope of this paper, the results show that women tended to
show more emotion-based behaviours immediately after the
incident and could not perform rationally.
Participants exhibited consequences of both short- and
long-term psychological illness that needed to be addressed.
According to the results, survivors presented a lack of help-
seeking behaviours to resolve these conditions. Other studies
have also described predictors of outcomes and dropout
3538
which may be affected by gender differences. It is
imperative, therefore, to provide psychological reha-bilitative
care and local counselling, especially as part of the acute
medical response in addition to active screening and incentive
strategies. Since emergency nurses are usu-ally involved early
in disaster management, and are highly skilled, they could
play a greater role in providing compre-hensive care that
involved psychological and well as physical support. By
expanding the emergency nurses role they would be better
able to provide and support comprehensive disas-ter
18
management and rehabilitation care for women.
The results indicate that living in camps with unsafe
con-ditions, lack of privacy, without supplies and facilities
for bathing and cooking and without the possibility of
maintain-ing other care giving responsibilities and
mothering tasks added to womens workload. There was
an inadequate pro-vision of reproductive health care and
supplies necessary for hygiene. 11,23 These shortages are
also documented in other disasters 12,29,39 have been shown
to affect womens mental and general health, 13,30 which
nurses may need prepared-ness to provide care in extreme
conditions when resources may be scarce.31
Since family members played an important role in help-ing
patient care, physical injuries imposed an excessive workload.
In line with other studies, participants mentioned problems in
the limited accessibility and cost of medi-cal care which
11,13,16,40
hindered their seeking/acquiring medical care. The
adverse consequences were permanent or longstanding
11,17,4042
disability and an impaired recovery.
Increasing physical demands and the inability of family
members to cope with the workload and conditions forced
them to take some of the injured women to nursing centres.
Being admitted to these centres, however, had paradox-ical
effects. It drew women away from the family, thus disrupting
family unity. On the other hand, it provided the opportunity
for peer group network building and peer learn-ing. In other
contexts such as those observed in Pakistan,
M. Nakhaei et al.
the separation of women from the family increased the
risk for mental health problems.13
This study indicated that family separation could result in
hospitalisation, death, and psychological problems. Injury or
separation of women from their family can endanger the
family union, since, as is widely suggested, it is the women
11,43,44
who hold their families together after a disaster.
Results showed that husbands felt ashamed of their
wives injuries and disabilities, especially permanent dis-
abilities such as spinal cord injury. As a consequence,
ignorance and lack of knowledge concerning the physical
injury, its limitations and their wives limited capabilities
caused adverse effects on the relationship. This could lead
to separation, divorce and remarriage. The reverse situa-
tion (when men were injured or disabled) was not
observed; wives did not leave their husbands. Marital
conflicts led to women feeling a lack of support from their
husbands and a lack of the sense of belonging.
Other studies have shown that disasters affect the mar-ital
4548
and other relationships in different ways. In the
aftermath of a disaster, family consultation and commu-
nication skills must be considered in the rehabilitation
services. The interventions that are recommended in other
studies
4851
should be considered as possible means to
enhance family functions in order to better promote health.
Participants were unsatisfied with the lack of social
acceptance (social sympathy) towards victims. Social iso-
lation and limitation of mobility were expressed as part of
the public construct, especially for spinal cord injuries.
Since social structure and peer group network formation
are important in social integration,5254 eliminating these
social and physical barriers must be considered.
The results of this study showed that survivors tried to
rebuild their homes and acquire economic stability, as
vital prerequisites for sustained and holistic
recovery.53,55,56 The role of women in aiding (to activate
or accelerate) the reconstruction process helped women
to be empowered, become familiar with social processes
and establish a pres-ence in the community. As the
participants mentioned, women who are employed are
independent and productive. Recovery and rehabilitation
programmes should therefore include opportunities for
women to participate and be empowered.43,44
While the notion of a disaster health place progressing in
terms of the programmes, the women issues although under
developed, and there is a need to simultaneously strengthen
both the theory and practice of gender approach in disasters.
Since womens health care is always an impor-tant element of
nursing mission, exploration of womens experiences should
enhance emergency nurses awareness of the realities of
service delivering before, during and after disaster and the
application them in preparedness planning.
Limitations
Because of unpredictable nature of disasters, the partici-
pants in the study have experience in different time span
and different recall ability, but in this study researchers
focused to capture their deep experience. Additionally,
although generalisation is not within the scope of the
qualitative
Impact of disaster on women in Iran
studies, findings should be interpreted cautiously because
of different characteristics of contexts.
Conclusion
In short, this study explored womens needs and experi-
ences after disaster at the individual, familial and societal
levels. Clarification of womens need after a disaster can
help to mainstream gender-sensitive approaches in plan-
ning response and recovery efforts. It can also make for
better resource allocation and more accurate service pro-
vision to ensure that the needs of women and girls are
adequately addressed. Because womens lives after disas-
ter were the main concern of this study and because this is
a process; the researchers strongly recommend further
investigation to explore the process by means of a
grounded theory approach.
Authors contributions
MN & HRKh conceived the study, designed and obtained
data. GhRM assisted in the conduct of the study and data
collection. MAH & ZPY participated in data collection and
analysis. LK & MC provided advices on analysis and revised
the manuscript. All authors participated in data analysis
and interpretation. MN drafted the manuscript and all
authors contributed to its revision. All authors take
responsibility for the paper as a whole.
Provenance and conflict of interest
The authors declare that they have no competing interests.
This paper was not commissioned.
Funding
The authors declare that they have no funding.
Acknowledgments
The authors wish to thank all participants for their support
and involvement in this study. We express our deep appre-
ciation to the people in recently earthquake affected
areas including Bam, Zarand, Lorestan and Azerbaijan for
their contributions to this study.
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