Natural and man-made disasters are unpredictable and inevitable events that take a devastating toll on the health, economy, and society of people and governments.Reference Abbasabadi-Arab, Mosadeghrad and Asgari 1 In 2021, about 432 natural disasters, including earthquakes, volcanoes, floods, landslides, droughts, and fires, were reported across the globe which claimed 10 492 lives, affected 101.8 million people, and resulted in economic losses approaching $252 billion. 2
High-risk occupations, such as those involving health care workers who provide emergency rescue services (i.e., “first responders”), are often associated with significant mental and physical stress. Emergency health care rescue workers frequently encounter potentially traumatic events as part of their job. They triage thousands of victims, and negotiate destroyed buildings and devastated communities, while working with limited resources Reference Al Harthi, Al Thobaity and Al Ahmari 3. As a result of these repeated and upsetting exposures, health care first responders are at high risk of developing stress-related mental health issues such as anxiety disorders (e.g., cute Stress Disorder; ASD and Post-Traumatic Stress Disorder; PTSD), depressive disorders, and other mental health problems, some of which may become chronic.Reference Mao, Loke and Fung 4 In some reports, mental health problems in first responders have rendered them passive victims of their occupations and ineffective in their work.Reference Choi 5 , Reference Garbern, Ebbeling and Bartels 6
However, all is not bleak when it comes to the work of health care first responders. A recent qualitative survey of these health care providers found that some rescuers actually experienced positive feelings after completing disaster missions. These positive outcomes were described as greater “personal maturation, “self-confidence,” and “altruism.”Reference Khankeh, Alizadeh, Nouri, Bidaki and Azizi 7 According to social science research, first responders with positive outcomes may be those who apply certain effective coping strategies when dealing with disasters. This group of rescuers who use effective ways of coping are reported as less likely to experience negative psychological outcomes following a rescue event.Reference Azizi, Bidaki and Ebadi 8 For example, they use approaches such as supportive strategies (e.g., psychological, social, and equipment support), on-stage strategies (e.g., deviation of thought, use of knowledge and experience, and adherence to moral-religious principles), and reconstruction strategies (e.g., psychological arrangements, self-soothing skills, and reassessment) which have been shown to be helpful and promote a level of resilience in rescuers who respond to disasters.
The phenomenon of “resilience” is understood as a hallmark of positive psychology. It is described as the ability of a person to cope well, manage, and maintain a sense of control, well-being, and life satisfaction without negative psychological symptoms in the face of adversity.Reference Henshall, Davey and Jackson 9 Resilience can also be thought of as a person’s ability to bounce back following hardships and life’s inevitable difficulties. It has been empirically investigated and is considered to be a protective factor against professional burnout in health care.Reference Zanatta, Maffoni and Giardini 10 Further, resilience has been reported to play an important role in reducing or even preventing mental distress such as PTSD and depression.Reference Kim, Park and Kim 11 Thus, resilience in health care first responders is critical to the health and well-being of both rescuers and impacts the survivors for whom they are providing emergency services.Reference Kašpárková, Vaculík and Procházka 12 As a result, researchers in the area of resilience have suggested a need for the development of interventions to help health care first responders increase their resilience by integrating known resilience protective factors such as social support and other coping strategies into training and selection processes.Reference Connor and Davidson 13 , Reference Southwick and Charney 14
The Connor-Davidson Resilience Scale (CD-RISC)15 and the Resilience ScaleReference Chang and Taormina 16 are currently available non-specific assessment instruments, based on the general population, which could be used to measure first responders’ resilience in disasters.
A valid and reliable tool for measuring the resilience of emergency health care rescuers could help rescue organizations better identify and recruit health care first responders who are most likely to be successful in their jobs. Moreover, a psychometrically sound resilience assessment tool also could identify current first responders who might benefit from additional support and subsequently provide interventions specifically targeted to increase their resilience.Reference Mao, Loke and Hu 17
Because there was no readily available scale to measure the resilience of health care rescuers, Mao et al. designed an instrument specific to this group. The scale included a variety of dimensions including, optimism, altruism, disaster preparedness, social support, perceived control, self-efficacy, coping strategies, and positive growth.Reference Mao, Loke and Hu 17
After a number of iterations and psychometric re-evaluations of this tool, it was condensed to 4 dimensions including, self-efficacy, altruism, positive growth, and social support.Reference Mao, Chen and Hu 18 Considering the social and psychological vulnerability of health care rescuers in Iran and the lack of a specific scale to measure their resilience, the present study aimed to translate and validate a Persian language version of the Disaster Resilience Measuring Tool (DRMT-C19) for health care first responders in Iran.
Methods
This was a methodological psychometric study, to evaluate of the validity and reliability of the DRMT-C19 for health care rescuers as translated into the Persian language (Figure 1). The Institutional Review Board (IRB) of Aja University of Medical Sciences (AjaUMS) evaluated and approved the research protocol.
A summary of steps for determining reliability and validity of the Persian DRMT-C19 for health care rescuers.
Sample and Sample Size Calculation
To evaluate the final version of the questionnaire, 483 individuals (n = 253 for Exploratory factor analysis, n = 230 for Confirmatory factor analysis) were identified using a consecutive sampling method. This strategy entailed selecting all health care rescuers who consented to participate and satisfied inclusion criteria, up until the target number of participants was obtained. All participants signed an informed consent in accordance with the updated Declaration of Helsinki (2013). Participants were health care rescuers who had been referred to the Red Crescent Society of Tehran, a Non-Governmental Organization in Iran known for responding to natural disasters.
Criteria for the Inclusion and Exclusion of Disaster Health Care Rescuers
The inclusion criteria for the study were: current health care rescuers, 18 years or older, who have provided rescue services at the scenes of accidents and disasters for 3 years or more; have a university education; and are approved by the Ministry of Health of Iran. Retired or cognitively impaired participants were excluded.
The Measuring Instruments
DRMT-C19 for Health Care Rescuers
The DRMT-C19 contains 19 items among 4 subscales: self-efficacy, social support, positive growth, and altruism. Each item is scored on a Likert Scale of 1 to 4 (where strongly disagree = 1, disagree = 2, agree = 3, and totally agree = 4). The DRMT-C19 demonstrated adequate internal consistency (Cronbach’s alpha = 0.84) and stability over the 2-week study period with an interclass correlation coefficient = 0.85. The cut-off discriminative point of the DRMT-C19 was a score of 61 that differentiated between high and low levels of disaster resilience. Higher total scores on the DRMT-C19 indicate greater resilience in the health care worker.
Concurrent Validity
The CD-RISC was used to assess concurrent validity of the DMRT-C19. The psychometric properties of the CD-RISC have been evaluated across 6 different groups including, primary care patients, psychiatric outpatients, patients with generalized anxiety disorder, and 2 groups of patients with post-traumatic stress disorder. The developers of the CD-RISC report that this questionnaire can identify resilient people from non-resilient people in both clinical and non-clinical groups and that it can be used in research as well as clinical situations (Mohammadi, 2002). The CD-RISC has 25 items and uses a Likert scale where 0 means “completely false” and 5 means “always true.”
Data Collection Procedure
The current researchers reached a use agreement with the corresponding author of the study who first described the development of the DRMT-C19 (Mao, et al. 2021) to translate the questionnaire into Persian. Standard translation processes from English to Persian were followed. This involved independent translation into Persian by 2 writers who are proficient in English (i.e., forward translation). A third translator then reviewed their translations. The questions were then translated back into English (i.e., backward translation) and again evaluated by 2 English-fluent translators. The English and Persian version of the DRMT-C19 was thought to be comparable. A final comparison of the translations, along with handling the discrepancies, yielded a final Persian version of the DRMT-C19 for health care rescuers to be psychometrically evaluated.
The face validity and content validity were approved by 10 professors (4 faculty members of the School of Nursing and 6 faculty members of the School of Health). Ten health care rescuers also evaluated face validity of the translated questionnaire. Most of the rescuers and experts were uncertain about 7 items, thus researchers added some examples to help clarify (see Appendix 1). All questionnaires were completed online.
Data Analysis
Means (with SDs) were used to represent continuous variables, while percentages were used to summarize categorical variables. Cronbach’s alpha, ICC, and Pearson product-moment correlation coefficients (r) were used to evaluate the questionnaires’ internal consistency, test-retest (temporal) reliability, and convergent and concurrent validity. SPSS 22 and Jamovi 2.3.28 were the statistical program used for the analysis.
Results
The results describe the demographic characteristics of the participants, the item analysis, and the validity and reliability of the Persian version of the DRMT-C19.
Characteristics of the Participants
In this study, 483 health care rescuers participated and completed the questionnaires. The mean age was 32.99 (SD = 7.46) years. Table 1 shows the demographic and baseline characteristics of the participants.
Characteristics of the participants
* 253 people
** 230 people
Validity
Content validity
The content validity using the Scale’s Content Validity Ratio (S-CVR) = 0.92 and the Scale’s Content Validity Index (S-CVI) = 0.93. The comprehensiveness of the tool = 0.875.
Construct validity
The Kaiser-Meyer-Olkin (KMO) sampling index = 0.89 which indicates that the data were suitable for factor analysis. Also, Bartlett’s sphericity test was significant (P ≤ 0.0001) and indicated there was sufficient correlation between the variables to perform factor analysis.
A scree plot of the eigenvalues of factors was used to determine the number of factors to retain in an exploratory factor analysis and to identify the principal components to keep in a principal component analysis (Figure 2).
Screen plot of the principal axis factor analysis of the DRMT-C19.
A factor extraction method was used to form uncorrelated linear combinations of the observed variables. The first component has maximum variance are in Table 2. Exploratory factor analysis determined 4 factors which accounted for more than 58.54% of the variance among the items. The varimax method was utilized for rotation, with a maximum iteration for convergence of 25 times. A correlation matrix analysis based on an Eigenvalue larger than 1 was used for extraction. On the other hand, using confirmatory factor analysis method, the compatibility of the desired model to evaluate the factors affecting the resilience of health care rescuers, which was formulated in the questionnaire, was done with the relevant data and the fit of the model was checked. Because the strength of the relationship between the factor (hidden variable) and the observable variable (questionnaire questions) is shown by the factor load, this value should be between -1 and 1 and the value higher than 0.4 or lower than -0. 4 was acceptable (Figure 3).
Factor extraction method to form uncorrelated linear combinations of the observed variables
Extraction Method: Principal Component Analysis
Modified model of second-order confirmatory factor analysis according to standardized coefficients.
In addition, the modified model of first-order confirmatory factor analysis according to standardized coefficients is available in the attached file (Appendix 2). The fit test of the second-order confirmatory factor analysis model using different fit indices showed that before correcting, the model included a P value less than 0.05 (for chi-square), comparative fit index (CFI) = 0.80 (which should be more than 0.9), and root mean square error of approximation (RMSEA) = 0.11 (should be less than 0.1). After correcting the model, it included a P value more than 0.05 (for chi-square), CFI = 0.91 (more than 0.9), and RMSEA = 0.09 (less than 0.1).
Furthermore, item discriminant validity and item convergent validity were tested for the level of divergence between an individual item and other scales, excluding its own scale (see Table 3).
Item discriminant validity and item convergent validity with each question
Colored columns indicate item convergent validity and uncolored columns represent item discriminant validity for each factor.
Criterion-Related Validity
Criterion-related validity was determined using Pearson product-moment correlation coefficient. There was a strong, positive relationship between the 2 measures (i.e., DRMT-C19 and CD-RISC), r = 0.604 (P ≤ 0.0001).
Reliability
Internal consistency was evaluated using Cronbach’s alpha. For the overall DMRT-C19, Cronbach’s α = 0.89, with 4 factors ranging from 0.70 to 0.84, indicating satisfactory internal consistency for the resilience measure. Test re-test reliability was assessed using the interclass correlation coefficient (ICC) and 48 health care emergency rescuers. The ICCs were all higher than 0.7 (ranging from 0.68-0.92), suggesting that DRMT-C19 had adequate stability. The final questionnaires (Persian version and backward translation) are in Appendix 3 and 4.
Discussion
The present study aimed to investigate the psychometric characteristics of a Persian version of the DMRT-C19 to assess the resilience of health care workers responding to disasters in Iran. This resilience tool has 4 subscales: altruism, social support, self-efficacy, and positive growth. For the face and content validity, the rescuers and experts found that some items need examples to be understood and they added them to 7 items. Some research cited that to understand the words and terms in the target language, the items or questions can be modified, if the original meaning does not change.Reference Kalfoss 19 , Reference Shabany, Nasrabadi and Rahimi-Movaghar 20
This scale analyzed a technical focus which is knowledge application and tool use. It was a special and valuable scale for evaluating disaster resilience in health care rescuers. To validate the 4 constructs, exploratory factor analysis was performed. From the factor analysis, 4 main and significant factors were extracted. The percentage of variance explained for altruism was 6.48%, social support was 7.83%, self-efficacy was 37.13%, and the positive growth factor was 7.11%. Exploratory factor analysis confirmed that 4 factors adequately explained 58.54% of the total variance. No factor was deleted because all the factors’ loadings were higher than 0.40 with an eigenvalue higher than 1. The results of factor analysis in this study were consistent with those from a recent study by Mao et al. They found that the first factor (self-efficacy) explained 20.89% of the variance with 7 items. Then, social support explained 15.93% of the variance with 4 items. Next, positive growth explained 15.72% of the variance with 5 items, and finally, altruism explained 13.39% of the variance with 5 items. All of them had an eigenvalue higher than 1. In total, the 4 factors explained 65.93% of the cumulative variance.Reference Mao, Chen and Hu 18
In addition, confirmatory factor analysis was performed for construct validity. It determined 12 factors which showed a highly satisfactory goodness fit for the 4-factor model. This result was similar to study of Mao et al.Reference Mao, Chen and Hu 18
In the current study, the validity indicators of the resilience scale show alignment of this study with previous ones.Reference Mao, Chen and Hu 18 The newly translated tool has demonstrated good theoretical and experimental validity and the results are aligned with the psychometric characteristics of most of the research reported in this field.Reference Polit, Beck and Owen 21 ‒Reference Mohammadbeigi, Mohammadsalehi and Aligol 23
The CD-RISC-25 was used to test the criterion-related validity of the DRMT-C19 on measuring psychological resilience. There was a significant and moderate correlation between the 2 instruments, indicating a good criterion-related validity of the DRMT-C 19. The CD-RISC-25 was also used as a criterion in Mao et al.’s study and the results were similar.Reference Mao, Chen and Hu 18 , Reference Mao, Wang, Hu and Loke 24
The Alpha coefficients were adequate and expressed the good internal consistency of the entire tool and its 4 subscales. The results were similar to Mao et al.’s study. They showed that the Cronbach’s alpha for the whole tool (DRMT-C) was 0.92 and 4 factors ranging from 0.84-0.87, suggesting that DRMT-C has good internal consistency in the population of health care rescue workers in China.Reference Mao, Chen and Hu 18
The ICCs in the 48 Iranian health care emergency rescuers were all higher than 0.7, suggesting that the Persian version of the DRMT-C19 had adequate stability. This result was similar to Mao et al.’s study. They did the test-retest among the 27 health care rescuers. The ICC of the scale was higher than 0.85 (ranging from 0.85-0.95), indicating that the DRMT-C19 has adequate stability.Reference Mao, Loke and Hu 17 ‒Reference Mao, Chen and Hu 18
Aid workers with high resilience can show less vulnerability when faced with stressful events. In fact, there are numerous reviews that report that those with resilience seem to better deal with life’s problems and are less affected by daily events. These resilient people try harder when facing difficulties and even when managing successes.Reference Mao, Wang, Hu and Loke 24 , Reference Mao, Fung and Hu 25 Therefore, examining the psychometric properties of a comprehensive scale to assess the resilience of health care first responders across different dimensions can open the way to provide better services to this group of health care rescuers and to potentially improve services provided to disaster victims.
The findings of this study can be more widely applied to investigate the resilience of other health care workers dealing with disasters. Recognizing the 4 characteristics of resilience allows a more comprehensive view of the resilience construct and can be a framework for studying resilience as a multidimensional construct that is likely related to other variables of interest. In addition, integrating these 4 factors into the general knowledge of relief organizations can help managers more clearly conceptualize how to support health care providers faced with disaster care, as well as stressful work demands. It is suggested that other rescue groups in different organizations be investigated in future research to add to the overall knowledge base.
Limitations
This study had 2 potential limitations. Firstly, the only available questionnaires were online, so only those who had access to a smartphone or computer could participate in the research.
Secondly, the researchers acknowledge the potential impact of age as a confounding factor in this study. Due to the small sample sizes within different age groups, stratified sampling was not done specific to age groups in this study.
Conclusion
The validity and internal consistency of the Persian-translated DRMT-C19 show that this questionnaire, comprised of 4 factors, has satisfactory psychometric properties. It is a valid, reliable, and useful tool for assessing resilience in dealing with disasters in Iran’s health care first responders. The translated scale fits within the Iranian culture and is appropriately aligned with social characteristics and values. The tool had acceptable validity and reliability for Iranian health care rescuers and it can be used to inform psychiatrists, counselors, emergency managers, and supervisors about health care providers’ level of resilience, examine their coping abilities, and identify areas in which extra support might be needed.
Data availability statement
The data that support the findings of this study are available from corresponding author, Mohammad Imanipour, upon reasonable request.
Acknowledgements
The authors thank health care rescuers for participating in this study.
Author contribution
Study design: M.Sh; Manuscript writing: M.Sh, M.A, M.I, Sh.D.P, Z.S; Data Collection: M.I, Z.S; Data Analysis: M.Sh; Study Supervision: M.Sh; Critical revisions for important intellectual content: M.Sh, M.A, M.I, Sh.D.P, Z.S. Reviewing the final article draft: M.Sh, M.A, M.I, Sh.D.P, Z.S.
Aja University of Medical Sciences, Faculty of Nursing (Dr Maryam Shabany, Dr Maryam Azizi, Mr Mohammad Imanipour). Kerman University Medical Science, School of Nursing and Midwifery (Miss Zahra Salajegheh). Behavioral Science Integration Kaiser Permanente (Dr Sheri D. Pruitt).
Funding statement
This Article has emanated from research conducted with the financial support of Aja University of Medical Sciences under Grant number IR.AJAUMS.REC.1401.158.
Competing interest
None declared.
Ethical standard
This research was approved by the ethics committee of Aja University of Medical Sciences with the code (IR.AJAUMS.REC.1401.158). Full informed consent (both verbal and written) to participate and to publish was obtained from all participants.
Appendix 1 Modified items in Persian version of the DRMT-C19
Appendix 2 Modified model of first-order confirmatory factor analysis according to standardized coefficients
Appendix 3 Persian version of the DRMT-C19
Appendix 4 Backward translation of the Persian version of the DRMT-C19
