Original Article

Evaluation of Disaster Medicine Knowledge Level and Educational Approaches of Future Health Professionals

10.4274/nkmj.galenos.2021.51422

  • Nurcan BIÇAKÇI
  • Sercan BIÇAKÇI
  • Murat ÇETİN

Received Date: 02.09.2021 Accepted Date: 17.11.2021 Nam Kem Med J 2022;10(1):59-73

Aim:

This study aimed to determine the disaster medicine knowledge levels and educational approaches on disaster medicine of prospective healthcare students who are important factors of disaster response.

Materials and Methods:

This cross-sectional descriptive study was conducted with final year students from the nursing department, the Emergency Aid and Disaster Management (EADM) Department, and the Medical Faculty at Tekirdağ Namık Kemal University in Tekirdağ, Turkey. The data were collected through a face-to-face administered questionnaire.

Results:

Among the 159 study participants, 49% (n=78) of the participants had received disaster medicine education. The mean knowledge level of the EADM student group (78.96±10.56) was found to be higher than nurse (65.49±12.84) and medicine (72.33±10.56) student groups. Most of the students with high level of knowledge (n=56, 58.9%) participated in the disaster drill. Personal protective equipment (PPE) (n=30, 18.8%), decontamination (n=52, 32.7%) and triage (n=60, 37.7%) questions were respectively answered correctly with the lowest percentage. Students (n=82, 92.1%) who did not receive disaster medicine education stated that they wanted to receive disaster medicine education and most of students (n=115, 72.3%) preferred that disaster medicine courses be led by emergency medicine specialists.

Conclusion:

Disaster medicine classes that address some special subjects like the use of PPE and decontamination procedures and triage should be included in the basic curriculum of health professions, and students’ personal knowledge and competence perceptions on disaster medicine should be supported by reinforcing the learning outcomes with disaster drills.

Keywords: Disaster medicine, education, health profession students

INTRODUCTION

Today’s world has witnessed a steady increase in disasters, and greater populations of people are being directly or indirectly affected by these disasters1-3. This means, in effect, that there is a high possibility that at one point, other people will encounter disasters in their lifetime. Due to the random and unpredictable nature of most disasters, it is difficult to predetermine potential disaster victims and the teams that will be responsible for responding to disasters. Regardless of the professional field in which a doctor operates, they may be required to undertake an active role in patient care, field management, or incident command during disasters4,5. Students who are educated to be health professionals can also be assigned to provide health services in disasters as in various periods of history, or their voluntary participation in health service delivery can be encouraged as in the Coronavirus disease-2019 (COVID-19) pandemic process6-11. The American Medical Association, the Association of American Medical Colleges, and the World Association for Disaster and Emergency Medicine have all suggested that disaster medicine should be included in the medical education curriculum under various subjects12-14. Currently, disaster medicine is not at the desired level in global medical education curricula.

In examining medical education in Turkey in terms of disaster medicine training, it was found that the Undergraduate Medical Education National Core Education Program 2020 included only a few topics on disaster concepts under the title of Behavioral, Social, and Human Sciences Lists and that basic medical care practices included no courses on disaster medicine15. In other words, there is no standard disaster medicine education in medical faculties, and disaster medical care is not considered a professional medical field in Turkey. However, emergency medicine specialists receive education on the subject of disaster medicine as part of the “Emergency Medicine Education Core Curriculum”16. Like doctors, nurses also function as the foremost health care professionals responsible for providing healthcare services in disaster responses. Yet, despite the well-established, comprehensive content constituting the Nursing National Core Education Program in Turkey, the program lacks structured disaster medicine content17. The Emergency Aid and Disaster Management (EADM) program provides disaster management and undergraduate education on emergency situations in Turkey, as well as education on disaster medicine subjects and other fields of disaster. At the Tekirdağ Namık Kemal University, for students enrolled in the EADM department, the “Disaster Medicine I-II” course is mandatory; for nursing department students, the “Nursing Care During Disasters and First Aid” course is elective. There is, however, no structured disaster medicine course offered to students enrolled in the medical faculty.

The primary aim of this study is to determine the disaster medicine knowledge level and educational expectations for disaster medicine of prospective health practitioners, considering the important role they will play in the disaster responses of today and the future. The secondary aim of this study is to provide supporting evidence on the necessity of making disaster medicine education widespread in the curriculum of medicine and other health sciences by demonstrating how health practitioners’ disaster medicine knowledge level can increase through the provision of disaster medicine education.


MATERIALS AND METHODS

This cross-sectional descriptive study was carried out in the 2019-2020 academic year with sixth-year students of the medical faculty, fourth-year students of the Nursing Department, and fourth-year students of the EADM Department at Tekirdağ Namık Kemal University in Tekirdağ, Turkey. Only final-year students (n=217) from these programs were chosen because their vocational curriculum was about to be completed, meaning that these students would likely have an important advantage insofar as taking a more holistic approach to disasters. The whole universe was included in the study without choosing a sample, and a questionnaire was applied to a total of 159 students who could be reached.

The participating students were asked to fill out a questionnaire consisting of 38 questions arranged under three sections (Appendix 1). The first section of the questionnaire includes seven questions addressing the students’ demographics and education, such as their age, gender, department of study, disaster medicine education, and disaster drill experiences. The second section, disaster medicine knowledge level, includes 25 questions on topics such as basic disaster information, introduction to disaster medicine, fundamental principles of disaster management, decontamination, cardiopulmonary resuscitation, infectious diseases, public health, and mental health. The third section has six questions, four of which are multiple-choice and open-ended questions about the educational approach toward disaster medicine education, and two of which involve self-assessment of competence and knowledge levels, where the participants rated themselves from 0 to 10. The total possible value of the disaster medicine knowledge level questions is four points, and there is only one correct answer to each of the four multiple choice questions. Scores of 70 points and higher, which fall within the 75th percentile on the scale of 100, indicate a high level of knowledge about disaster medicine, while scores below 70 indicate a low level of knowledge of disaster medicine.

The questionnaire was developed by the researchers based on previous studies and data published by the Centers for Disease Control and Prevention Disaster Preparedness and Response: Complete Course Facilitator Guide and the Didactical Course of the European Master Program in Disaster Medicine18-23.

Prior to conducting the study, the participants were provided detailed information about its content and aim and they gave their written consent. This study was approved by the Tekirdağ Namık Kemal University Non-invasive Ethics Committee (decision date-no: 24.09.2019-2019.138.08.10).

Statistical Analysis

In this study, continuous data were analyzed as mean and plus/minus standard deviation, while categorical data were analyzed as a percentage (%). Normal distribution of the data was evaluated using the Shapiro-Wilk test, with normally distributed groups being compared using the one-way ANOVA in cases where the number of groups was three and higher. Results from the crosstab analysis performed were evaluated based on the Pearson chi-square test. All statistical analyses were carried out using the IBM Statistical Package for the Social Sciences (SPSS) Statistics 21.0 program (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, version 21.0. Armonk, NY: IBM Corp.). Statistical significance was accepted as p<0.05.


RESULTS

Of the 217 students constituting the population, 73.2% (n=159) filled out the questionnaire. Only those students who fully completed the questionnaires were included in the study.

Participants’ Demographic Data

Among the study participants, 45.9% (n=73) were studying in the medical faculty; 37.1% (n=59) in the nursing department; and 16.9% (n=27) in the EADM department. 64.5% (n=102) of the participants were female, 49% (n=78) reported that they had received education about disaster medicine, and 57.8% (n=92) reported that they had participated in a disaster drill before. Furthermore, only 3 of the participants (1.8%) reported that they were not interested in receiving disaster medicine education. Table 1 presents the participants’ demographic data.

Knowledge Level

Table 2 presents brief information about the questions used in the knowledge level evaluation and the students’ responses. The mean score was 72.33±10.56 (40.00-96.00) for the medical faculty students, 65.49±12.84 (24.00-84.00) for the nursing students, and 78.96±10.56 (56.00-96.00) for the EADM students. Of all the participants, 62 (38.9%) had a low knowledge level, and 97 (61%) had a high knowledge level. In terms of the student groups, it was found that 69.8% (n=51) of the medical faculty students, 40.6% (n=24) of the nursing department students, and 81.4% (n=22) of the EADM students had a high knowledge level. The results further showed that for all three student groups, higher disaster medicine knowledge levels corresponded to female gender and participation in a disaster drill. Moreover, having received disaster medicine education was associated with higher knowledge levels in students who were studying in the nursing department and those who were in the EADM department. However, there was no relationship between being a student in the medical faculty and high knowledge level. None of the participants answered all the questions correctly, nor was there one question answered correctly by all the participants. The question that was most correctly answered by the participants (n=152 95.5%) was Q1, about medical attention priority, while the question with the lowest correct answer rate (n=30 18.8%) was Q4, about the use of personal protective equipment (PPE), and Q1, Q2, and Q19 were correctly answered by all EADM students. The medical faculty students had lower correct answer rates on the questions related to the use of PPE, decontamination procedures, and triage.

Educational Approach Toward Disaster Medicine

Most of the students (58.4%) stated that education on disaster medicine should be carried out through “video conference.” The least (n=42) preferred (26.4%) method for receiving disaster medicine education was “online web-based courses.” One hundred-fifteen participants (72.3%) felt that disaster medicine education should be provided by “emergency medicine” specialists and that the duration of education should be “an academic year or a specifically designated period” (n=82) (Table 3). A student enrolled in the medical faculty stated, “the disaster medicine education should be provided during the sixth academic year in place of elective internships”. Another participant suggested, “disaster medical care education should be provided by categorizing disaster types and spreading them out across academic years”.

Table 4 shows the participants’ average knowledge level and competence level according to their own estimations. EADM students’ estimations of their personal knowledge level and competence level in all subjects were higher than those of students from other departments.

When participants were asked about the subject that they wished to receive disaster medicine education, “earthquakes” was the most (n=121, 76.1%) and “disaster epidemiology” was the least (n=40 25.1%) preferred response (Figure 1).


DISCUSSION

This study evaluated the disaster medicine knowledge levels and expectations for disaster medicine education of final-year students in the medical faculty, the nursing department, and the EADM department of Tekirdağ Namık Kemal University. Although this study was carried out with a lower number of participants compared to that seen in similar studies in the literature, it is unique in terms of the variety of the participants constituting the sample in Turkey18,20,24-26. This study found that most of the students who received disaster medicine education did so during their undergraduate years. Moreover, most of the students who reported that they had not received disaster medicine education during their undergraduate education were interested in receiving education on this subject. Similar to the study of Wunderlich et al.24, the participants stated that they wanted to receive training in disaster medicine. The fact that the participants who had not received disaster medicine education before wanted to receive this education is a promising indicator for that these future health practitioners are aware of the fact that they may have to work during disasters and in disaster environments, and they want to be prepared for this. Undergraduate education forms the backbone of health professionals’ occupational knowledge, skill acquisitions, their future in-service trainings, and lifelong learnings27,28. As Markenson et al.29 stated, healthcare students need to be trained so as to be capable of undertaking tasks during disasters, as these tasks are an integral part of their profession. A common national disaster medicine education curriculum that is structured based on up-to-date developments and needs, which supports interdisciplinary cooperation, and that can be adapted according to the competencies of disciplines can help future health professionals to be more safely and systematically prepared for disaster response roles30,31.

Contrary to the study of Arslan et al.26, the rate of participation in disaster drills of the students was high. Disaster drills provide unique opportunities for future health professionals to, at the very least, experience the chaotic environments of disasters and to be prepared for their tasks in disasters. Previous studies show that drills can serve to develop health professionals’ competence in practice-based subjects, such as incident command, triage, patient care, evacuation, and decontamination procedures31-35. Healthcare students should be given the opportunity to participate in disaster drills, and their participation should be encouraged. Conducting these drills with the simultaneous participation of multiple disciplines in undergraduate education would provide students the opportunity to experience the cooperative working environment and prepare them to quickly act together when necessary.

The participants’ disaster medicine knowledge levels varied between groups. The fact that participants who had participated in disaster drills had higher knowledge levels suggests that drills foster disaster awareness and familiarity with basic information about disasters. Contrary to expectations and the current literatures, the high level of disaster medicine knowledge seen in the medical students, despite the lack of a standard structured disaster medicine curriculum, could be attributed to the fact that this subject is scattered throughout the curriculum of different clinical branches18,24,25,36. In this context, it would be fairly easy to simply gather the existing disaster medicine subjects and additional related subjects under the title of “disaster medicine” and add this to the medical education curriculum. This would be an encouraging step for students, educators, and education content planners alike in terms of fostering disaster medicine education. At the same time, the authors also recognize that a national study may produce also different results. The low knowledge level results of the nursing students are worrying. It is likely that these results are a consequence of disaster medicine and nursing subjects being provided in a single academic term as an elective course. Making disaster medicine a mandatory course in the nursing curriculum could be motivating for both educators and students and lead to an increase in students’ knowledge levels and the confidence they have in their personal knowledge and competence.

The medical faculty students reported that their knowledge levels and self-competence levels were low, despite proving to have high knowledge levels. This lack of confidence could lead to setbacks in patient care, critical decision-making, and incident command stages, and thereby increase the mortality and morbidity of victims of disasters. Being provided a disaster medicine course could positively contribute to improving the confidence that medical students have in their personal knowledge and competence levels. The fact that the EADM students received disaster medicine education likely played a big role in their high knowledge levels and their higher self-perceptions of personal knowledge and competence on the subject, as compared to other student groups. The preparedness and competence of healthcare professionals in extraordinary events, such as disasters, are valuable insofar as these would enable them to assume a managerial role and perform their duties in a focused/professional manner when disasters occur in their communities28.

Knowledge about the use of PPE was low in all three groups. This is concerning considering how important it is that the personnel can efficiently use PPE to protect themselves and other patients in healthcare environments. It has been well established that with appropriate trainings, the inaccurate usage of PPE can be prevented37. A study related to the COVID-19 pandemic in Wuhan, China, which investigated the healthcare professionals responsible for the care of COVID-19 patients, demonstrated the importance of appropriate PPE usage, in that it found there to be no incidences of infection in the study participants despite the high exposure risks38.

Contrary to the study by Barrimah et al.21, this study revealed that participants preferred to receive disaster medicine training via videoconferencing during an academic year or during a certain period. Students were most interested in receiving education about how to respond to earthquakes, which is not surprising considering that much of Turkey’s geography lies on high-risk areas for earthquakes, and that earthquakes are a disaster type that causes the most loss of life and property in Turkey39. The students further indicated that they most preferred disaster medicine education to be provided by emergency medicine specialists. This preference likely stems from emergency medicine expertise being seen as a clinical branch that involves a holistic approach toward complex and extraordinary health issues, and from the ability of emergency medicine specialists to organize their clinics like a disaster manager during their routine emergency service operations. Considering these matters in the planning of content and methods for disaster medicine courses will provide key contributions to achieving educational goals.

Study Limitations

The main limitation of this study is that it was a single-center study. Including students from earlier academic years could yield different results. Secondly, the self-evaluations of the participants about their knowledge and competence levels may not be fully reliable. Studies carried out in multiple centers with broad sample sizes could provide more valuable data.


CONCLUSION

This study has revealed that future health professionals are interested in receiving disaster medicine education. It is recommended that disaster medicine courses be generalized with special emphasis on certain special subjects, such as the use of the PPE and decontamination procedures, in order to increase knowledge level and personal knowledge, and competence level perception and to reinforce those gains with disaster drills. The results from this study can contribute to the design of disaster medicine courses that should be added to the basic curricula of health professions.

Ethics

Ethics Committee Approval: This study was approved by the Tekirdağ Namık Kemal University Non-Interventional Research Ethics Committee on 28.09.2019 with the protocol number 2019.138.08.10 and decision number 10.

Informed Consent: Consent form was filled out by all participants.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Concept: N.B., S.B., M.Ç., Design: N.B., S.B., M.Ç., Data Collection or Processing: S.B., M.Ç., Analysis or Interpretation N.B., S.B., M.Ç., Literature Search: N.B., Writing: N.B., S.B.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.


Images

  1. Centre for Research on the Epidemiology of Disasters (CRED). 2018 315. Emerg Events Database. 2018: EM-DAT The International Disaster Database. Available from: https://www.emdat.be/
  2. Hossain S, Spurway K, Zwi AB, Huq NL, Mamun R, Islam R, Nowrin I, Ether S, Bonnitcha J, Dahal N, Adams AM. Urbanisation and Natural Disaster - A Systematic Review. 2017. Last Accessed Date: July 10, 2020. Available from: https://eppi.ioe.ac.uk/cms/Portals/0/PDFreviews andsummaries/Urbanisationandnaturaldisaster2017reportfinal.pdf?ver=2018-04-30-161140-207
  3. Centre for Research on the Epidemiology of Disasters (CRED). Disasters in Africa: 20 Year Review (2000-2019*). CRED Crunch. 2019;56:1-2. Available from: https://www.emdat.be/cred-crunch-56-disasters-africa-20-year-review-2000-2019
  4. Kumar A, Weibley E. Disaster management and physician preparedness. South Med J. 2013;106:17-20.
  5. Morin K, Higginson D, Goldrich M; Council on Ethical and Judicial Affairs American Medical Association. Physician obligation in disaster preparedness and response. Camb Q Healthc Ethics. 2006;15:417-31.
  6. Starr I. Influenza in 1918: recollections of the epidemic in Philadelphia. 1976. Ann Intern Med. 2006;145:138-40.
  7. Acharya S. A Medical Student’s Encounter with Disaster – International Emergency Medicine Education Project. Last Accessed Date: July 13, 2020. Available from: https://iem-student.org/2019/08/05/a-medical-students-encounter-with-disaster
  8. Reyes H. Students’ response to disaster: a lesson for health care professional schools. Ann Intern Med. 2010;153:658-60.
  9. Katz CL, Gluck N, Maurizio A, DeLisi LE. The medical student experience with disasters and disaster response. CNS Spectr. 2002;7:604-10.
  10. T.R. Higher Education Council Press and Public Relations Consultancy. Coronovirus (COVID-19) Information Note: 1 13 March 2020. Last Accessed Date: July 9, 2020. Available from: https://www.yok.gov.tr/Sayfalar/Haberler/2020/coronavirus_bilgilendirme_1.aspx
  11. Ladds E. What can I do? BMJ. 2010;340:c3137.
  12. American Medical Association (AMA). Report of The Council On Medical Education CME Repot 1-I-11. 2011. Last Accessed Date: September 14, 2020. Available from: https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/about-ama/councils/CouncilReports/council-on-medical-education/i11-cme-med-student-resident-disaster-medicine.pdf
  13. Colleges A of AM. Training Future Physicians about Weapons of Mass Destruction: Report of the Expert Panel on Bioterrorism Education for Medical Students. 2003. Last Accessed Date: September 14, 2020. Available from: http://libproxy.dundee.ac.uk/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=eric&AN=ED482377&authtype=shib&site=ehost-live&scope=site
  14. Archer F, Seynaeve G. International guidelines and standards for education and training to reduce the consequences of events that may threaten the health status of a community. A report of an Open International WADEM Meeting, Brussels, Belgium, 29-31 October, 2004. Prehosp Disaster Med. 2007;22:120-30.
  15. T.R. Council of Higher Education. National Core Education Program for Undergraduate Medical Education; 2020;2020. Available from: https://www.yok.gov.tr/Documents/Kurumsal/egitim_ogretim_dairesi/Ulusal-cekirdek-egitimi-programlari/mezuniyet-oncesi-tip-egitimi-cekirdek-egitimi-programi.pdf
  16. T.R. Ministry of Health Medical Specialization Board Curriculum Formation and Standard Setting System (TUKMOS). Emergency Medicine Specialization Education Core Curriculum. 2019. Available from: https://tuk.saglik.gov.tr/TR,50050/acil-tip.html
  17. T.R. Council of Higher Education. Nursing National Core Education Program (HUÇEP). Last Accessed Date: July 8, 2020. Available from: https://www.yok.gov.tr/Documents/Kurumsal/egitim_ogretim_dairesi/Ulusal-cekirdek-egitimi-programlari/hemsirelik_cekirdek_egitim_programi.pdf
  18. Mortelmans LJ, Bouman SJ, Gaakeer MI, Dieltiens G, Anseeuw K, Sabbe MB. Dutch senior medical students and disaster medicine: a national survey. Int J Emerg Med. 2015;8:77.
  19. Kaji AH, Coates W, Fung CC. A disaster medicine curriculum for medical students. Teach Learn Med. 2010;22:116-22.
  20. Su T, Han X, Chen F, Du Y, Zhang H, Yin J, et al. Knowledge levels and training needs of disaster medicine among health professionals, medical students, and local residents in Shanghai, China. PLoS One. 2013;8:e67041.
  21. Barrimah I, Adam I, Al-Mohaimeed A. Disaster medicine education for medical students: Is it a real need? Med Teach. 2016;38(Suppl 1):S60-5.
  22. Centers for Disease Control and Prevention (CDC). Disaster Preparedness and Response Training - Complete Course. Facilitator Guide. 2014. Available from: https://www.cdc.gov/nceh/hsb/disaster/Facilitator_Guide.pdf
  23. European Master Disaster Medicine (EMDM) Course Program XIX edition – 2020-2021. https://www.dismedmaster.com/course/#!/program-teachers. Accessed July 16, 2020.
  24. Wunderlich R, Ragazzoni L, Ingrassia PL, Corte FD, Grundgeiger J, Bickelmayer JW, et al. Self-Perception of Medical Students’ Knowledge and Interest in Disaster Medicine: Nine Years After the Approval of the Curriculum in German Universities. Prehosp Disaster Med. 2017;32:374-81.
  25. Mortelmans LJ, Dieltiens G, Anseeuw K, Sabbe MB. Belgian senior medical students and disaster medicine, a real disaster? Eur J Emerg Med. 2014;21:77-8.
  26. Arslan E, Sayhan MB, Salt Ö. Knowledge Attitude and Behaviorus of Medical School Students About Disaster and Education of Disater Medicine. Anatol J Emerg Med. 2018;1:5-10.
  27. Berkhout JJ, Helmich E, Teunissen PW, van der Vleuten CPM, Jaarsma ADC. Context matters when striving to promote active and lifelong learning in medical education. Med Educ. 2018;52:34-44.
  28. Naguwa GS, Sakai D. Professionalism in medical education. Hawaii Med J. 1999;58:7.
  29. Markenson D, Woolf S, Redlener I, Reilly M. Disaster medicine and public health preparedness of health professions students: a multidisciplinary assessment of knowledge, confidence, and attitudes. Disaster Med Public Health Prep. 2013;7:499-506.
  30. Silenas R, Akins R, Parrish AR, Edwards JC. Developing disaster preparedness competence: an experiential learning exercise for multiprofessional education. Teach Learn Med. 2008;20:62-8.
  31. Scott LA, Carson DS, Greenwell IB. Disaster 101: a novel approach to disaster medicine training for health professionals. J Emerg Med. 2010;39:220-6.
  32. Gable BD, Misra A, Doos DM, Hughes PG, Clayton LM, Ahmed RA. Disaster Day: A Simulation-Based Disaster Medicine Curriculum for Novice Learners. J Med Educ Curric Dev. 2021;8:23821205211020751.
  33. Alim S, Kawabata M, Nakazawa M. Evaluation of disaster preparedness training and disaster drill for nursing students. Nurse Educ Today. 2015;35:25-31.
  34. Wiesner L, Kappler S, Shuster A, DeLuca M, Ott J, Glasser E. Disaster Training in 24 Hours: Evaluation of a Novel Medical Student Curriculum in Disaster Medicine. J Emerg Med. 2018;54:348-53.
  35. Kim CH, Shin SD, Park JO, Kim SC, Coule PL. The effects of a community-based disaster drill of simulating Disaster Medical Assistance Team (DMAT) on the knowledge and attitudes. Ulus Travma Acil Cerrahi Derg. 2021;27:174-9.
  36. Mortelmans LJ, Lievers J, Dieltiens G, Sabbe MB. Are Belgian military students in medical sciences better educated in disaster medicine than their civilian colleagues? J R Army Med Corps. 2016;162:383-6.
  37. John A, Tomas ME, Cadnum JL, Mana TS, Jencson A, Shaikh A, et al. Are health care personnel trained in correct use of personal protective equipment? Am J Infect Control. 2016;44:840-2.
  38. Liu M, Cheng SZ, Xu KW, Yang Y, Zhu QT, Zhang H, et al. Use of personal protective equipment against coronavirus disease 2019 by healthcare professionals in Wuhan, China: cross sectional study. BMJ. 2020;369:m2195.
  39. AFAD. Disaster Management and Natural Disaster Statistics in Turkey. 2018. Available from: https://www.afad.gov.tr/kurumlar/afad.gov.tr/35429/xfiles/Turkiye_de_Afetler.pdf