Education

Development and evaluation of disaster

preparedness educational programme for
pregnant women
inr_919

335..340

T. Yasunari1 RN, RNM, MNSc, M. Nozawa4 RN, RNM, PhD,

R. Nishio2 RN, RNM, MNSc, A. Yamamoto3 RN, RNM, PhD &
Y. Takami5 RN, RNM, MNSc
1 Assistant Professor, 2 Former Instructor, College of Nursing Art and Science, 3 Professor and Executive Director of the
Research Institute of Nursing Care for People and Community, College of Nursing Art and Science, University of Hyogo,
Hyogo, 4 Professor, Department of Nursing, School of Health Sciences, Tokyo University of Technology, Tokyo, 5 Midwife,
Kakogawa Municipal Hospital, Kakogawa, Japan

YASUNARI T., NOZAWA M., NISHIO R., YAMAMOTO A. & TAKAMI Y. (2011) Development and evaluation of
disaster preparedness educational programme for pregnant women. International Nursing Review 58, 335340
Purpose: The objective of this study is the development and evaluation of the usability of an educational
programme that teaches disaster preparedness to pregnant women.
Methods: This intervention study examined an intervention group that attended an educational programme
and a control group that did not. The subjects were pregnant women in their second trimester. The
programme was developed with prior studies and evaluated by self-administered questionnaires that asked
about disaster preparedness. The questionnaire was administered twice to the participants in both groups: to
the intervention group just before the childbirth class and 1 month after the class, and to the control group at
the time of their maternity examination and 1 month afterwards. Two hundred twenty-six members of the
intervention group and 262 members of the control group responded to both questionnaires. Of these, 99 of
the intervention group and 104 of the control group were primiparous without disaster experience, and the
programme was evaluated by comparing these two groups. Effects due to the disaster experience were also
analysed within the intervention group.
Results: Among primiparous without disaster experience, an intervention effect was found in items
concerning awareness modification (five of six items) and behaviour modification (three of seven items). The
intervention effect was particularly pronounced in a comparison of primiparous without disaster experience.
Conclusions: An intervention effect was found among the pregnant women who took the programme. In
particular, it was statistically significant among primiparous without disaster experience, which suggests that
the programme should be shaped to reflect this subject demographic.
Keywords: Disaster Preparedness, Educational Programme, Intervention Study, Japan, Pregnant Woman

Introduction
Recently, a large number of natural disasters have been occurring
throughout the world, and their frequency and number of
Correspondence address: Tomoko Yasunari, 13-71 Kitaoji-cho Akashi Hyogo
673-8588, Japan; Tel: +81-78-925-9424; Fax: +81-78-925-9424; E-mail:
tomoko_yasunari@cnas.u-hyogo.ac.jp.

human casualties has risen (Robinson 2010). Self-reliance and

cooperation play an important role in preparing for natural
disasters (Cabinet office, government of Japan 2008). An important topic for Japan an earthquake country and other
nations is how to instill awareness of disaster preparedness in
each person and link this to actual disaster preparedness. The
International Council of Nurses also sees disaster preparedness

2011 The Authors. International Nursing Review 2011 International Council of Nurses

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T.Yasunari et al.

as a critical issue and has stated the importance of nurses

involvement in care for invalids, children, women, the elderly
and other vulnerable persons (Minami 2007).
Pregnant women are usually vulnerable when disaster occurs,
and they are seen as people in need of support during such
occasions (Cabinet office, government of Japan 2006). As a
result, it is difficult for them to take appropriate action with the
information that is provided, and they need support. They are
also one of the groups that are most at risk during a disaster
(Ohara & Sakai 2007). Pregnancy is the time when families and
pregnant women prepare to greet the newborn. Therefore, this
period is seen as the most effective time to offer disaster instruction to such pregnant women. Future mothers who are bringing
new life into the world want to protect themselves and their
families from disasters. This is the time when it is easiest to
motivate them to become aware of disaster preparedness and to
put their knowledge into action.
Earlier research found community intervention for disaster education but did not find programmes that encourage pregnant
women to prepare for disasters (Okuno et al. 2006; University of
Hyogo, Graduate School of Nursing Art and Science and Research
Institute of Nursing Care for People and Community (RINCPC)
2005). DeWald & Fountain (2006) also found that disaster instructions taught at birth preparation classes were not a universal standard and emphasized their importance. Accordingly, a programme
called, Disaster Preparedness: An Educational Program for Pregnant Women was developed. The aim of this research is to develop
and evaluate the usability of this educational programme.

Methods
Research design

This is an intervention study about disaster preparedness that

clarifies the effectiveness of an educational programme on
awareness and behaviour modification that is directed to pregnant women. The study is of an intervention group that attended
an educational programme and a control group that did not. A
two-stage design was employed to compare pre- and postintervention data on disaster preparedness awareness and behaviour. The intervention and control groups consisted of pregnant
women from different facilities, and the subjects were women in
their second trimester of pregnancy. The second trimester was
judged as appropriate because the pregnancy is stable and the
facilities cooperating with this research usually recommend
childbirth preparation during this period.
In this study, awareness modification is specifically defined as
starting to think about disaster preparedness and as increased
knowledge and memory of essential information because of participation in the programme. Behaviour modification is defined

in this study as transforming memories and knowledge about

disaster preparedness into concrete action.
The educational programme

The goals of our educational programme were increased awareness of disaster preparedness and transformation of this awareness into action. The educational programme was developed
from information obtained from our earlier research (University
of Hyogo, Graduate School of Nursing Art and Science and
RINCPC 2005, 2006).
The contents of this programme were (1) the importance of
preparedness, (2) contact methods with families in times of
disaster, (3) receiving medical examination in times of disaster,
(4) evacuation sites and routes in times of disaster, (5) items to
prepare in case of emergency, and (6) preparing for safety inside
a home. The six topics were organized to awaken interest in
disaster preparedness after presenting important information.
First, to emphasize the importance of preparedness, nurses
asked, Right now, if an earthquake occurred nearby, how would
you contact your family? How would you go home?
In the second session, contact methods with their families in
times of a disaster were also discussed. During a disaster, when
people cannot confirm the safety of their families, they experience
psychological instability (University of Hyogo, Graduate School
of Nursing Art and Science and RINCPC 2005). Therefore, the
importance of prior discussion of emergency contact methods so
that they would immediately find out family contact methods at
the time of disaster was emphasized. Information was provided
about the Disaster Emergency Message Dial 171 that Nippon
Telegraph and Telephone Corporation (NTT) developed learning
from the 1995 Kobe earthquake and the Cellular Phone Disaster
Message Board managed by the cellular phone industry.
In the third session, receiving a medical examination in times
of disaster was discussed. Several problems trouble pregnant
women; they cannot contact their maternity hospital/clinic
(Hyogo Society of Obstetrics and Gynecology 1996); traffic is
disrupted; and hospitals may not be able to function (Kobe University School of Medicine 1995). Therefore, information about
maternity hospitals/clinics and access to them during a disaster
was provided. Anxiety is lowered by knowing neighbourhood
hospitals in addition to ones own maternity hospital/clinic,
contact addresses, alternate routes and various advice centres.
There was information that medical facility examinations are
possible even if one does not have a letter of introduction or a
Maternal and Child Health Handbook, and that it is important
to know ones current health status and medical care.
In the fourth session, evacuation sites and routes in times of
disaster were discussed. As there were cases in which it was difficult to evacuate with impassable roads and not knowing the

2011 The Authors. International Nursing Review 2011 International Council of Nurses

Disaster preparedness programme

location of evacuation sites, pregnant women were encouraged

to learn about evacuation sites and escape routes and to look at
hazard maps for dangerous areas on the roads near their homes.
In the fifth session, items to prepare in case of emergency were
discussed. During disasters, relief supplies of specialized items
such as powdered milk and disposable diapers are often inadequate (Ono 1998). Therefore, pregnant and post-partum women
should prepare evacuation bags that contain items appropriate for
their condition in addition to their regular evacuation supplies.
In the last session, preparing for safety inside the home was
discussed. Disaster preparation within the home saves lives.
Some instructions about life-saving provisions such as sleeping
in a safe place, preventing overturned furniture and falling
objects and preventing shattered glass were provided.
Evacuation bags and residential hazard maps were used as educational materials that would give pregnant women without disaster experience a visual image of how to prepare. The results from
earlier research to prepare the primary educational tool were used
in the form of a pamphlet called Be Prepared Before a Disaster
Strikes Disaster Preparedness For Pregnant Women, ChildRearing Mothers and Their Families (Yamamoto et al. 2006).
The nurses who aided this research at each maternity hospital/
clinic implemented this programme as a 15-min lecture in a
pre-existing childbirth education class.
Prior to implementation, there was concern about programme
uniformity. Specifically, prior to the programme, the researchers
instructed nurses at each hospital on how to implement the
programme. In addition, researchers were present when the programme was presented and gave feedback on whether programme implementation had gone according to plan.

Questionnaires for programme evaluation

The questionnaires were developed by the researchers and were

administered twice using the same content. The questionnaire
consisted of a face sheet to ascertain participant demographics
and 13 questionnaire items. To ascertain the state of subject
preparedness in this programme, these items are broken down
into six questions on awareness modification and seven questions on behaviour modification.
The six items on awareness modification asked whether
respondents knew about the Disaster Emergency Message Dial
171, the Cellular Phone Disaster Message Board, residential
hazard maps, maternity hospitals/clinics other than the womans
own, evacuation sites and whether the respondent could explain
the current status of her pregnancy and medical examinations.
The seven items on behaviour modification asked about the
respondents prior discussion of emergency contact methods
among families; the presence or absence of a plan for preventing

337

overturned furniture, falling objects and shattering glass, a safe

place to sleep and the preparation of an evacuation bag.
Responses to the 13 questionnaire items were requested as
dichotomous questions that ask for a yes/no answer.Yes affirmed
disaster preparedness and meant know, have or can do.
Subjects

The intervention group consisted of 226 women who had participated in both surveys, out of 993 women in their second trimester
who had attended the childbirth education classes included in this
educational programme (a return rate of 22.8%).
The instruction was conducted at nine maternity hospitals/
clinics with which the university has educational and research
connections. Five of the nine facilities were in Hyogo Prefecture.
The control group consisted of 1010 women in their second
trimester of pregnancy who had not attended this educational
programme. They were from 12 maternity hospitals/clinics that
have educational and research connections with the university.
Four of the 12 facilities were in Hyogo Prefecture. Two hundred
sixty-two women participated in both surveys for a return rate of
25.9%.
Collecting data from the intervention group

After receiving instruction from the researchers, nurses at cooperating maternity hospitals/clinics explained the study at childbirth classes for pregnant women in their second trimester and
asked for their participation. The request form written by the
researchers was used for the explanation, and ethical considerations such as respect for the voluntary participation of research
subjects and the protection of privacy were stated. Both selfadministered questionnaires for programme evaluation were
distributed simultaneously and time was provided to answer the
first questionnaire before the start of the childbirth class. After
the conclusion of the childbirth class, the responses to questionnaire 1 were placed in a classroom collection box using the placement method. Pregnant women who had not consented to
participating in the study had the choice of not returning the
questionnaire or returning a blank questionnaire.
The pregnant women were asked to put the second questionnaire into the envelope addressed to the researchers and either
bring it back or mail it in about 1 month after the classes. To
remind the pregnant women to return the second survey, posters
were put up where they would be seen during a subsequent
pregnancy examination.
Collecting data from the control group

Nurses in the outpatient area of cooperating maternity hospitals/

clinics gave the pregnant women in their second trimester
who had visited a doctor an envelope with a request form, two

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T.Yasunari et al.

The return of questionnaires from pregnant women in both the

intervention and control groups was viewed as consent for
research participation, and this was handled statistically. To
protect the pregnant womens personal information, the nurses
at the maternity hospitals/clinics did not know whether they had
or had not consented to participate. The voluntary participation
of research subjects was respected and their privacy protected.
This research was conducted with the approval of the Research
Ethics Committee of the university.

intervention effect was analysed and the resulting primiparous

without disaster experience became the object of analysis.
Supporting Information Figs S1 and S2 show the results for the
two successive questionnaires given to the 99 women in the intervention group (average age 31.4 4.3 years, gestational week
22.9 3.8 weeks) and the 104 women in the control group
(30.7 4.6 years, 24.7 5.8 weeks). The numerical values in the
figure show the percentage of people who repliedyes. In Supporting Information Fig. S1, of the six items that asked about awareness modification, five items were statistically significant only for
the intervention group: Know about NTTs Disaster Emergency
Message Dial 171 (P = 0.030), Know about the Cellular Phone
Disaster Message Board (P = 0.020), Know several neighborhood
maternity hospitals/clinics (P = 0.020), Know the evacuation site
in the residential area (P = 0.040) and Can explain current status
of pregnancy and medical examinations (P = 0.010). In Supporting Information Fig. S2, of the seven items about behaviour
modification, three showed significant differences before and
after the educational programme: Prior discussion of emergency
contact methods among families (P = 0.000), Can immediately
find out family contact methods (P = 0.001) and Preventing
overturned furniture (P = 0.030). Meanwhile, there were no significant increases that appeared only for control group items.
Further analysis of the primipara in the intervention group
who attended the educational programme found that the intervention effect varied according to the primiparas experience of
disaster. The intervention group contained 99 primiparas without
disaster experience and 100 primiparas (31.4 5.0 years,
25.2 5.7 weeks) with disaster experience. When their responses
were compared, six items with statistically significant increases
appeared in the second questionnaire only for the former group.
Three of these items showed awareness modification. Know
several neighborhood maternity hospitals/clinics increased from
52.5 to 68.7% (P = 0.020). Know the evacuation site in the residential area increased from 47.5 to 67.7% (P = 0.004), and Can
explain current status of pregnancy and medical examinations
increased from 86.9 to 97.0% (P = 0.009). Three items showed
behaviour modification for preparedness: Can immediately find
out family contact methods increased from 46.5 to 70.7%
(P = 0.000). Preventing overturned furniture increased from
33.3 to 48.5% (P = 0.030), and Preventing falling objects
increased from 20.2 to 34.3% (P = 0.025).

Results

Discussion

questionnaires and two return envelopes. On that occasion, the

nurses explained the research subject and process, and asked for
their participation in the research. The pregnant women were
asked to answer and mail the first questionnaire quickly, and to
answer the second questionnaire in the same manner about 1
month later. To remind the pregnant women in the control
group, posters were put up where they would be seen during a
pregnancy check-up at their medical facilities as well.
Data collection

Data were collected from July 2006 to May 2007.

Data analysis

The programme was evaluated first by examining the intervention

effects that appeared in a comparison of the intervention and
control groups. It was found that the intervention and control
groups lacked homogeneity in both their reproductive history and
in the presence or absence of disaster experience. Therefore, the
effect of the programme was evaluated using primiparous
without disaster experience as subjects. The subject of analysis
became the primiparous in both groups who lacked disaster
experience, which is to say: 99 women in the intervention group
and 104 women in the control group. This was followed by the
analysis of the effect of the presence or absence of disaster experience on members of the intervention group.
When the data were analysed, the number of yes answers was
totaled for each item answered by the intervention and control
groups, and preparedness awareness and behaviour changes were
evaluated by their increase or decrease. The chi-square test was used
to compare these variables, with a significance level of P < 0.05.
Ethical considerations

Respondent demographics are shown in Supporting Information Table S1. In both groups, subject demographics lacked
homogeneity. As such, comparisons using data from the entire
set of respondents were seen as inappropriate. Therefore, respondents were divided by their distinguishing characteristics, the

Intervention effects seen between the intervention and

control groups

Examination of the group primiparas without disaster experience showed a clear increase and an intervention effect only in

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Disaster preparedness programme

the intervention group for eight of 13 items about disaster

preparedness.
Five of these awareness modification items concerned preparedness on such topics as information for contacting family
members, information about maternity hospitals/clinics and
explanation of the current status of pregnancy and medical
examinations. Thus, pregnant women in the intervention group
learned new information, and the utility of this programmes
presentation of important disaster preparation information was
evaluated. Ewing et al. (2008) reports that it would be a great
help for pregnant women to learn information such as where
they could receive emergency medical treatment if they could not
go to their usual maternity hospital/clinic.
During the 1995 Kobe earthquake, one of the greatest concerns
was the unavailability of information (University of Hyogo, Graduate School of Nursing Art and Science and RINCPC 2005). The
recently developed programme discusses the Disaster Emergency
Message Dial 171 and the Cellular Phone Disaster Message Board,
which allow people to check family safety. Even if people are unfamiliar with the system, they will find it is easy to obtain and send
information once they access the sites. It is not a matter of just
knowing information but motivating people to apply it. It is important that these sites are easily available and helpful to everyone.
Change was seen in three of the seven questionnaire items on
behaviour modification. It was more difficult to change actual
behaviour than it was to increase knowledge and change awareness.
However, even in the disaster programme introduced by Mack et al.
(2006), it was suggested that evaluation be conducted based on the
presence or absence of an evacuation bag as behaviour modification.Gershon et al.(2009) report,Further research should focus on
whether training results in behavior modification. Thus, interventions that increase behaviour modification should be sought in the
future. In addition, as this study found that disaster prevention in
the same home may result in some actions that are easily performed
and others that are not easily performed, it is important to elucidate
the causes of behaviour difficulties and find more effective intervention methods for behaviour modification.
All the control group did was respond twice to the selfadministered questionnaire, but it is worthy of attention that
there was a statistically significant increase in people who said
they took preventative measures in the item Preventing falling
objects. Concern about a possible Hawthorne effect is raised by
a womans opinion that was reported by the Bureau of Social
Welfare and Public Health, Tokyo Metropolitan Government
(2007): Answering a questionnaire like this is a stimulus in its
own right and so it would be nice if such questionnaires are
offered in many places. Receipt of a questionnaire focuses the
respondents attention, and this may be all that it takes to
produce the desired behaviour.

339

Differing effectiveness in the intervention group because of

the presence or absence of disaster experience

Although the primiparas had attended the same intervention

programme, there were items that were statistically significant
only for women without disaster experience. Three of these items
fell under the awareness modification: Know several neighborhood maternity hospitals/clinics, Know the evacuation site in
the residential area and Can explain current status of pregnancy
and medical examinations, and three under behaviour modification: Can immediately find out family contact methods, Preventing overturned furniture and Preventing falling objects.
For pregnant women with disaster experience, the education
programme may have included some facts that they already knew
or actions that had already been taken. For programme participants
without disaster experience, learning new information may have
led to more awareness modification and behaviour modification.
At times, the way in which the intervention effect appears is
dependent on the subject. Therefore, developing an intervention
programme in the future that concerns subject demographics
should be considered.

Research limitations and future implications

The return rate was low for the second questionnaire. This suggests that the questionnaire may have been returned only by
subjects already interested in the topic and limits the wider applicability of these results. As a reminder to return the second
questionnaire, posters were placed in a prominent location in the
obstetrics outpatient area where they would be seen by pregnant
women. The cause of the low return rate was the fact that both
intervention and control groups were asked to return the second
questionnaire after a 1-month interval, and many women may
have forgotten. From a systemic perspective, there was the fact
that the people who distributed the first questionnaire to the
intervention and the control groups were unidentifiable, and that
because no address or personal information was gathered for the
second questionnaire to be distributed by mail, the result was a
limitation in information gathering. To increase data gathering,
it will be necessary to reconsider the questionnaires distribution
methods and time period.
Further, subjects in the control group who did not take the
education class already had the second questionnaire in their
possession, and it is thought that the very act of responding
modified the behaviour of the pregnant women; in other words,
the intervention produced a Hawthorne effect. In the future, it will
be necessary to find research methods that exclude this influence.

Conclusions
It was evident that the educational programme had an intervention effect for the pregnant participants and resulted in both

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T.Yasunari et al.

heightened awareness of the need to prepare and actual behaviour. In view of their busy schedules, it was not easy for the nurses
to take on the new field of teaching. In the future, it will be
necessary to continue to refine the programme structure and
education materials to make it easier for nurses to implement this programme at various facilities. It is also important
to strive to have nurses understand the need for preparedness
education.

Acknowledgements
We would like to express our sincere thanks to the pregnant
women who participated and to the nurses at each hospital who
cooperated with this research. This study is a part of the 21st
century Center of Excellence Program of the University of
Hyogo, funded by the Japanese Ministry of Education, Culture,
Sports, Science and Technology.

Author contributions
Study conception/design: T. Yasunari, M. Nozawa, R. Nishio,
A. Yamamoto, Y. Takami
Data collection/analysis: T. Yasunari, M. Nozawa, R. Nishio,
Y. Takami
Drafting of manuscript: T. Yasunari, M. Nozawa
Critical revisions for important intellectual content: T. Yasunari,
M. Nozawa, A. Yamamoto
Supervision: M. Nozawa, A. Yamamoto
Statistical expertise: M. Nozawa, Y. Takami
Administrative/technical/material support: T. Yasunari,
M. Nozawa

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Supporting information
Additional Supporting Information may be found in the online
version of this article:
Fig. S1 Differences between intervention and control groups
in awareness items (*P < 0.05, **P < 0.01).
Fig. S2 Differences between intervention and control groups
in behavioural items (*P < 0.05, **P < 0.01).
Table S1 Characteristics of the respondents.
Please note: Wiley-Blackwell are not responsible for the
content or functionality of any supporting materials supplied by
the authors. Any queries (other than missing material) should be
directed to the corresponding author for the article.

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