Article ID: 24-00049
Disasters are becoming more common, and their types are more varied. This study investigated the extent to which medical students would like to be engaged in different types of disasters to help recruit personnel for future disaster medicine based on a web-based survey. The study was conducted using existing data. The results revealed that students’ intention to engage in chemical, biological, radiological, nuclear, and explosive (CBRNE) disasters was lower than that for natural and human-made disasters. Further, differences in the intention to engage and perceptions of disasters were observed. We hypothesized that the low intention to engage in CBRNE disasters was due, in part, to the fear of unknown hazards and the belief that disaster response was not part of the university’s mission. Thus, each university should train healthcare professionals to imagine the social needs of risk and educate students about their intention to engage. This can be done by showing them how to respond to disasters in the social context of societal demands in case of future crises.
Disasters have become increasingly frequent worldwide1). Japan experienced the Great Hanshin-Awaji Earthquake in 1995, the Great East Japan Earthquake in 2011, and, most recently, the Noto Peninsula Earthquake in January 2024, all with numerous fatalities2,3). Additionally, human-made disasters, such as plane and train accidents, have been frequently experienced worldwide, including the Japan Airlines plane crash in 1985, the Fukuchiyama train derailment in 2005, and the Haneda Airport plane explosion in 2024. Recently, natural and human-made disasters, as well as chemical, biological, radiological, nuclear, and explosive (CBRNE) disasters, have attracted attention, requiring crisis response planning and expertise at the national level4). Japan experienced a chemical disaster in 1995 due to a sarin gas attack on the subway5), and the Great East Japan Earthquake of 2011 was the first time in human history that a natural disaster was combined with a radiation disaster6). Further, the COVID-19 pandemic was a biological disaster7). Globally, rampant terrorism, Russia’s invasion of Ukraine, and the Israel–Palestine war have increased the risk of disasters8).
Therefore, securing medical personnel to work during disasters and conduct disaster response activities quickly and accurately is essential. However, previous studies on healthcare workers and firefighters have found that they are less willing to engage in CBRNE disasters than in natural and human-made disasters9,10,11). A survey found that Japanese nursing students were less willing than Korean nursing students to participate in disaster relief activities outside their domestic residential areas or overseas12). A survey of Japanese Disaster Medical Assistance Team (DMAT) members found that their intention to engage in CBRNE disasters was significantly lower than that for natural or human-made disasters9). However, the factors that improved DMAT personnel’s intention to engage were incentives and confidence in disaster response11) and having a personal acceptable dose standard for protection13). Factors influencing firefighters’ intent to engage included confidence, family understanding, and incentives to respond to disasters, whereas factors influencing fire academy students’ intent to engage included information about radiation10). These previous studies have suggested that social factors such as incentives, confidence in the disaster response, and family understanding may be important for healthcare professionals, whereas knowledge or education is likely to influence students’ intention to engage.
However, research on medical students who are likely to serve as leaders in disaster medical responses is limited. Despite studies on fire academy and nursing students9,10,11), no study has explored medical students’ intentions to engage in disasters. Moreover, the characteristics of medical students’ intentions to engage in disasters in medical schools in Japan might be established based on the diverse social roles of medical schools: for example, universities may be national, prefectural, or private, and may have a specific purpose of training doctors. We believe that the task of managing large-scale natural, human-made, and CBRNE disasters is not limited to emergency physicians, DMAT, and other front-line professionals; all medical professionals need to be involved. Therefore, it is crucial to educate medical students about disaster medicine so that they can decide on a career path to secure future personnel for disaster medicine.
Thus, the purpose of this study was to use this existing data to understand the current status of engagement intentions of Japanese medical students with different backgrounds toward various types of disasters and examine these intentions from an academic perspective.
We designed this research as a cross-sectional study. Existing data from medical students at five universities who attended lectures on radiation disaster medicine between September 2023 and April 2024 were included in the survey (Table 1). Specifically, we used data obtained from post-lecture surveys conducted in April 2024 for University A, October 2023 for University B, September 2023 for University C, December 2023 for University D, and November 2023 for University E. The breakdown of the participants at each university is presented in Table 2. Although the content of the lectures on disaster medicine at each university differed, the lectures on radiation disaster medicine conducted by a Fukushima Medical University faculty member, lecture content, and course materials were generally the same at all universities. The content covered the 2011 Great East Japan Earthquake and Fukushima Daiichi Nuclear Power Plant accident, Fukushima Medical University’s subsequent response, radiation emergency medicine, and CBRNE disasters. After the lecture, a questionnaire-based web survey was administered to consenting students. An example survey item was: “Will you actively engage in activities during the event of a natural, human-made, chemical, biological, radiological/nuclear, or explosive disaster?” The respondents selected a score from 0 to 100 (0 = not at all willing to engage, 100 = actively willing to engage, in increments of 4 points) by manipulating icons on the smartphone screen. Table 3 summarizes the characteristics of the various disaster types described above. The curriculum of each university and lecture materials on radiation disaster medicine are shown in Supplemental Data 1 and 2.
The dates when the questionnaire was administered at each university and the characteristics of the university curricula
Indicates the students who agreed to and participated in the study at each university
Characterize natural disasters, human-made disasters, and CBRNE disasters
The statistical analysis software used was IBM SPSS®︎ Statistics Ver. 28.0 Chicago IL USA. Microsoft®︎ Excel Ver. 16.86 Redmond, WA, USA, was used to create the figures. We summarized the scores of the intention to engage in each disaster. The overall median and interquartile range by university were calculated. For each university, the Friedman test and Wilcoxon’s signed rank sum test with Bonferroni correction were performed to gauge the strength of the association between the intention to engage scores across each disaster. A hierarchical cluster analysis was also performed to visualize the closeness of each university’s intention to engage in each disaster. In other words, a dendrogram was created for each university to ascertain how students differentiate between natural, human-made, and CBRNE disasters. Statistical significance was set at p < 0.05.
Participants were informed in advance that the survey would be conducted anonymously and that their responses would be aggregated and analyzed. Only those who provided their consent proceeded with the survey. This study was approved by the Fukushima Medical University Ethics Review Committee (approval date: April 15, 2024; reference number: REC2024-003). Information about the use of existing data for academic research is publicly disclosed. Participants were permitted to opt out of the study at any time.
In total, 512 medical students agreed to participate in the study (Table 2). As noted in Supplemental Data 1, students of universities A, B, and C attended a lecture on radiation disaster medicine before attending a lecture on general disaster medicine. University D simultaneously conducted lectures on radiation disaster and general disaster medicine. University E was surveyed after a complete lecture on general disaster medicine, CBRNE disasters (including radiation disaster medicine), and war injury medicine, followed by practical training in radiation disaster medicine.
The distribution of the engagement intention scores is shown as box-and-whisker diagrams in Fig. 1-A. The mean scores for natural and human-made disasters for all universities ranged from 31 to 61; for CBRNE disasters, all universities had scores ranging from 19 to 53. Furthermore, Universities A, B, and C had a larger percentage of students who reported 0 scores compared with Universities D and E. The bottom 25 percentile of the scores for Universities A, B, and C meant that the intention to engage was 0 for all disasters. In particular, the median score was 0 for biological and explosive disasters at University B and for chemical, biological, radiological/nuclear, and explosive disasters at University C.
The relationship with university engagement intention is shown in Fig. 1-B. The numbers in the figure represent the average score of the rank order of intention to engage with the six types of disasters for that university. The blue lines indicate combinations that differed with statistical significance on the intention to engage score for each pair of disasters after Bonferroni correction. Based on the results of multiple comparisons, universities A, B, C, D, and E possessed 7, 6, 5, 8, and 5 pairs, respectively, demonstrating a statistically significant difference in the engagement intention scores for each disaster. For example, at University A, significant differences were obtained between natural disasters and chemical, biological, radiological/nuclear, and explosive disasters. At University B, significant differences were found between natural disasters and chemical, biological, radiological/nuclear, and explosive disasters. At University E, only biological disasters significantly differed from natural disasters. None of the universities exhibited a statistically significant difference between natural and human-made disasters.
Fig. 2 shows the results of the hierarchical cluster analysis of the intention to engage scores. All universities involved in this survey exhibited a Euclidean distance of 15 or less and were associated with two categories of disaster recognition. At universities A, B, and C, disasters were classified into two groups: “natural/human-made disasters” and “CBRNE disasters.” At universities D and E, disasters were classified into two groups: “natural, human-made, and radiation/nuclear disasters” and “chemical, biological, and explosive disasters.” In other words, at universities D and E, radiation/nuclear disasters were grouped with natural and human-made disasters.
The intention to engage scores for each type of disaster at each university are shown in the box-and-whisker diagram. The vertical axis is the intention to engage score. × marks the average value.
Natural: natural disaster, Human Made: human-made disaster; Chemical: chemical disaster; Biological: biological disaster; Radiological/Nuclear: radiological/nuclear disaster; Explosive: explosive disaster.
The results of multiple comparisons of the intent to engage scores at each university using Wilcoxon’s signed rank sum test are visually illustrated in the figure. The blue line indicates combinations that were statistically significantly different after Bonferroni correction. The number for each disaster type indicates the mean rank of the intention to engage. The mean rank is the average of all participants’ rankings of the intent to engage scores for the six disasters.
The results of the analysis of the intention to engage scores at each university are shown using stratified cluster analysis for each disaster. The horizontal axis denotes the Euclidean distance; the closer the distance, the more similar the scoring trends of that university, visually indicating that they perceive it as a similar type of disaster.
This study surveyed medical students by institution to determine the extent to which they intended to engage in disaster-related activities to raise awareness and improve systems for disaster education, and help secure future personnel to engage in disaster medicine. The results revealed differences in awareness and intention to engage in various types of disasters depending on the university curriculum and social context.
Student scores for CBRNE disasters were lower than those for natural and human-made disasters at all institutions. This is consistent with previous studies of fire academy students, firefighters, and DMAT9,10,11). For DMAT, the factors that made them unwilling to engage in CBRNE disasters were a “lack of knowledge and skills, anxiety, and fear” for chemical, biological, radiation/nuclear disasters and a “lack of safety guarantees for second or third explosions” for explosive disasters14). Compared with natural and human-made disasters, CBRNE disasters are more difficult to imagine, which may lead to more anxiety and fear among students. However, as in this study, the responses were collected immediately following the lectures, they could also be interpreted as a result of a strong awareness of the danger of special disasters during class. According to Slovic15), the perception of risk is composed of two components: dread and unknown risk factors. We hypothesized that the high prevalence of these two factors in CBRNE disasters contributed to a lower intention to engage compared with natural and human-made disasters.
The overall aggregate results for all participants indicated that the bottom 25% of students did not want to engage in any disaster (Fig. 1-A). The results indicated that many medical students were reluctant to engage with not only CBRNE disasters but also natural and human-made disasters. We believe it is important for medical students, who will lead the next generation, to learn from the past or at least imagine what would happen if they did not. The next generation of medical students must learn the history of the disaster or imagine what would happen if they did not engage in the disaster activities16). Moreover, to confront fear and the unknown as a healthcare professional, it is necessary to enhance one’s imagination by recognizing the specific activities required in the social context of each institution and the social needs of the risks faced. Imagination implies thinking; for example, a student at University C, where occupational medicine is a major part of the curriculum, could also be in charge of logistical support and prevention medicine during a disaster17). Imagination is important for dealing with unexpected events that may occur in daily practice on the medical scene. Therefore, in formulating the curriculum for medical students, it is necessary to consider enhancing the imagination of medical students. Specifically, it is necessary to regularly expose them to a variety of information and provide them with real-life experiences. In the field of education, concepts like these are recognized as forms of social practice approaches18). Educators should also inform medical students that engaging in disaster medicine does not only imply confronting hazards on the front lines but also making various contributions according to the social roles of medical personnel.
The influence of COVID-19 on the intention to engage in biohazardous activities should be considered. The students surveyed were second- to fifth-year medical students who had spent most of their high school and college years during the COVID-19 pandemic. We considered that the unfounded discrimination against healthcare workers who confronted the pandemic was reported in the media and that the hardships they witnessed were one of the reasons for the students’ low intent to engage19). COVID-19 is currently one of the most common infectious diseases, and individuals with COVID-19 are no longer discriminated against. We believed it was important to provide lectures that enable students to “actively obtain and evaluate reliable information and consider acceptable risks on their own,” not only for emerging infectious diseases but also for other disasters.
Comparisons among institutions revealed a distinctive trend in the distribution of scores for intent to engage. Students from Universities A, B, and C accounted for more than 25 percent of all students who indicated that they did not want to engage in any disasters. However, relatively fewer students from University E indicated that they did not want to engage in any disaster. We attributed this to the fact that University E is engaged in a social mission to train medical personnel in responding to various crises and disasters20). This may also be influenced by the fact that of the five universities surveyed, University E had conducted the second-highest number of lectures on disasters, and lectures on radiation, chemistry, and various lectures organized on various hazards in special situations (war and terrorism). It is possible that by the time this survey was conducted, the students of universities D and E had taken several disaster medicine courses and were able to envision specifically what it would be like to work during a disaster. Conversely, students of universities A, B, and C may have lower intentions to engage because they have not learned enough through their lectures on CBRNE disasters or even natural and human-made disasters.
In the hierarchical cluster analysis of University B, the Euclidean distance between “chemical/biological disasters” and “radiation/nuclear disasters” was close, whereas the distance between “explosives disasters” was a little farther. This was considered to be the case because the area where University B is located experienced the atomic bombing, and therefore, the university provides atomic bomb education21). Universities D and E included “radiation/nuclear disaster” in the framework of “natural and human-made disasters.” University D is located in an area affected by the Great East Japan Earthquake of 2011, and one of its missions is to train doctors who can respond to disasters22). The Great East Japan Earthquake was a combination of an earthquake, tsunami, and radiation; thus, the university may have considered that the radiation/nuclear disaster occurred as an extension of the natural disaster23). By contrast, University E students were educated to cope with all types of disasters and already had an understanding of the social needs of radiation risks. This may have led them to view radiation disasters as a more familiar disaster framework, similar to natural and human-made disasters, compared with chemical, biological, and explosive disasters. However, University A, which also experienced the Great East Japan Earthquake, may have positioned radiation disaster medicine as an element of CBRNE disasters and educated its students using a different framework than University D, suggesting that University A may have regarded radiation/nuclear disasters and natural/human-made disasters from different frameworks (Fig. 2). Additionally, University A offers a curriculum that enables students to relive the experiences of those who have experienced a disaster24). They were able to relive not only natural disasters such as the tsunami but also the radiation problems caused by the accident at the Fukushima Daiichi Nuclear Power Plant. It can be argued that radiation/nuclear disasters were relatively more familiar topics than hazards such as chemical, explosive, and biological disasters, influencing students’ disaster perceptions25).
This study showed that even in a survey conducted immediately following the same class, differences in perception and intention to engage in various disasters were caused by differences in university curriculums and social backgrounds. A person’s role in disaster medical activities can change according to their social role. Disaster medical care does not only consist of going to the disaster site; logistical support also plays an important role26,27). Therefore, it is necessary to train medical personnel to engage in disaster medical care according to the social context. Based on the results of this study and a previous study, we recommend that educators should take into consideration the social backgrounds of students and provide information that includes concrete suggestions that students can consider as their own, as well as develop education curricula that allow students to relive the actual experiences about disasters of the educators18). We believe that this will reduce the fear of unknown hazards, establish a realistic view of risk, and ultimately contribute to the improvement of the medical students’ intention to engage in relief efforts for crises and disasters.
This study has several limitations because it is based on existing data. First, this study did not investigate the direct reasons for the low intention to engage. Therefore, it is not clear whether these are the same reasons as in previous studies or whether there are student-specific reasons. Although we narrowed down the questions to increase the response rate, we believe that further consideration of survey items is required. Another limitation is the lack of data to support the present results due to the scarcity of previous studies. Third, the validity of the survey administered to students after only a one-hour lecture is unclear. Fourth, the generalizability of the survey conducted at different stages of disaster medicine courses at each university is debatable. We believe that future research can overcome these limitations by examining the reasons for medical students’ low intention to engage, by conducting pre- and post-lecture comparative studies to infer the impact of lectures, and/or conducting studies with first- and sixth-year students.
Differences were observed in awareness and intention to engage in various types of disasters because of differences in university curricula and social backgrounds. We believe that training medical personnel to meet the diverse demands of disasters based on the recognition of these social backgrounds could help ensure the availability of personnel to engage in disasters.
We would like to thank the University of Occupational and Environmental Health, Tohoku Medical and Pharmaceutical University, Nagasaki University, Fukushima Medical University, and the National Defense Medical College for their cooperation.
The authors declare no conflict of interest.
