Introduction
isasters have been the focus of human attention for centuries. Today, disasters account for a large portion of government resources and programs. Climate change, human manipulation of nature, and the rapid growth of technology have increased the vulnerability of people and the occurrence of disasters [1]. The number of reported disasters and the extent of their effects show that most disasters are inevitable and are associated with changes in the environment, resources, population, etc., and communities are severely affected by disasters [2, 3]. Some groups of people in the community are more vulnerable to disasters, including people with disabilities and their mortality is higher than the general population [4].
 The United Nations World Conference on Disaster Risk Reduction addresses the problems of people with disabilities, including neglect in decision-making processes, poor living conditions, inadequate infrastructure, unfair income or lack of income sources, limited access to services, especially education and information [5]. In addition, researchers believe that one of the reasons for the lack of preparedness of people with disabilities in the face of disasters compared with ordinary people is the limitation of access to basic training and their lack of knowledge and emphasis on the education of these people [8, 7, 6]. Also, the results of studies emphasize the lack of knowledge of people with physical disabilities in the areas of disaster prevention and reduction and response measures. Lack of knowledge in these areas along with mobility problems due to disability, especially in devastated areas, life and property are at greater risk and increases their vulnerability [9]. McClure et al. showed that the ability and emergency evacuation programs of people with spinal cord injuries who use wheelchairs in the event of a disaster indicate that they are unable to exit the emergency room due to mobility limitations and should be adequately trained about using related technologies and an emergency exit plan. Therefore, researchers have recommended training and empowerment of people with physical disabilities and identifying their educational needs [10].
 However, limited studies are available on the needs of people with disabilities (especially educational needs) at the international [11, 12] and national levels [13]. Therefore, due to the importance of education for people with disabilities, especially people with physical disabilities and because of their special conditions and mobility restrictions to escape the danger [14], and considering that these people 40% of the total population are people with physical disabilities in Iran [15], the present study was conducted as part of a larger study to identify the educational needs of people with physical disabilities and related groups from their perspectives of family, people, rescuers, and disaster managers.
Materials and Method
 This research was a qualitative study because, in qualitative studies, it is possible to identify the needs and investigate the causes of their formation, as well as to understand the human condition [16, 17, 18]. We used qualitative content analysis, which has been widely used in health-related studies in recent years, with a conventional approach [19].
 Participants were employed and non-employed people with physical disabilities, literate, and experienced in earthquake exposure, and were invited to study through purposive sampling [20, 21]. The participants were selected through face-to-face visits to the Rehabilitation Department of the Welfare Organization of Iran and welfare departments of the earthquake-stricken cities using the information of people with disabilities. Finally, 18 eligible individuals (seven females and 11 males) were enrolled.
 To collect data, semi-structured interviews considering the health system were done [22]. Through a review of the sources and objectives of the study, the interview guide was developed and the experts were guided to resolve the possible issues. To determine the reliability of the study data, four criteria of validity, transferability, confirmability, and stability were considered. To this end, measures, such as verification of interview data after implementation by participants, data integration, description of study data during the collection and reporting findings, recording all the details of the research, and taking notes in all stages of the research were taken [17, 23, 24]. Participants were asked questions, such as “Have you ever received special training in earthquake management? How do you see the impact of such training? What type of training and training method do you consider appropriate according to your circumstances?” According to the participants, the relevant groups included families, rescuers, people, and disaster managers, who answered the question, “Who do you recommend training other than yourself and why?” They identified and believed that educating these people could affect their health and quality of life. Thus, 18 interviews were conducted from January to September 2018 for 60-45 minutes. After each interview, the recorded interviews were transcripted verbatim and assigned a code. To analyze the data, the thematic analysis method was used by the six-step method of Brown and Clark [25]. Also, MAXQDA software version 10 was used to manage the data.
For the present study, the necessary permissions were obtained from the Ethics Committee of Iran University of Medical Sciences. For each participant, the research objectives and explanations were provided, including voluntary participation, compliance with the principle of confidentiality, and the right to withdraw from the investigation at any time. The approximate duration of the interview was explained to the participants in the research and the interview time was adjusted based on their physical, mental, and emotional state. A conscious consent form was also signed by the participants.
Results
Participants in the study considered education as essential to improving earthquake preparedness and commented on the two main categories of educational needs of people with disabilities and the educational needs of relevant groups, including families, people, rescuers, and disaster managers. Educational needs from the perspective of people with physical disabilities are listed in Table 1. 


Educational needs of relevant groups to people with physical disabilities
Due to the seismicity of the country and the problems and limitations of people with disabilities and the high probability of their mortality compared with healthy people, the participants considered it necessary to train in dealing with earthquakes appropriate to the type of disability. In addition to increasing performance and reducing pain, they emphasized the positive impact of such training on valuing people with disabilities as individuals in the community. They also mentioned the role of people with disabilities in demanding proper education from responsible organizations, such as the Welfare Organization, non-governmental rehabilitation-oriented organizations, and the Red Crescent Society.
Basic educational needs
Participants acknowledged their need for life-saving training and prevention of secondary disabilities in earthquake conditions as a basic need. They considered the reasons for the necessity of this training as mobility problems and inability to escape from dangerous situations, dependence on aids of others in mobility and movement, especially in critical situations, and inability to choose a safe place and shelter. In addition, participants discussed other educational topics they needed to acquire skills for maintaining composure, stress management, and decision-making. They believed that due to physical problems, fear of further harm, and dependence on others in critical situations, they were unable to control themselves and suffered from severe stress and inability to make decisions.
Empowerment educational needs
Participants believed that the training they received, in addition to saving their lives and self-control, should lead to an increase in their ability to adapt to disability in critical situations. Physical problems have caused most of these people to depend on others to do their jobs, which is a big problem for them during and after the earthquake. Hence, they wanted the training to increase their ability to cope with the earthquake so that they could cope despite their disabilities.
Participants also believed that if their abilities increase, they can help others and even pass on the training to other people with disabilities.
Educational needs of relevant groups with people with physical disabilities
Participants also mentioned the training needs of related groups, including families, people, relief workers, and disaster managers. They mentioned that if these people are trained about dealing with earthquakes, saving their lives and the lives of others, and providing services to people with disabilities, in addition to maintaining their health, they will be more effective in supporting people with disabilities.
General educational needs
 General educational needs include the educational needs of families and people. According to the participants, considering that people with disabilities alone are not able to take refuge and evacuate to insecure places to save their lives and need the help of other people, family members, as the closest people to them, can play effectively in this regard. Therefore, improving their knowledge on how to deal with earthquakes is very fruitful and its effects in addition to saving lives and preventing disability for the trainee can also save the person with disabilities.
Participants also stated that because the people of the community are the first to rush to the aid of the people under the rubble, training these people as the first responders not only can save their lives and prevent disability but also plays an important role in preserving the lives of the injured and preventing secondary disabilities. On the other hand, due to the limited number of rescuers and the need for many people to help in the event of a large-scale accident, training ordinary people to provide services can be very effective. Also, educating people to empower them to cope with critical situations can relieve the burden of the authorities.
 Another issue that was considered in the educational needs of the participants was the support and psychological support of people with disabilities. These people experience many difficulties in earthquake conditions due to physical problems, emotional and functional dependence on others, financial difficulties, and similar issues, and they need psychological support and companionship of others more than healthy people.
Specialized educational needs
These training needs, according to the participants, included the training needs of relief workers and disaster managers. Because rescuers have the specialized task of search and rescue, their additional training in topics, such as how to properly rescue people from to prevent disability or secondary disabilities, identifying people with disabilities and prioritizing rescue them, familiarity with how to transport these people according to their problems, and identifying the needs of different groups of people with disabilities to provide optimal services, is very effective. Therefore, the participants introduced this need as training special aid workers.
Another issue addressed by the participants was the training needs of disaster managers. People with disabilities, while emphasizing their problems in the field of economic issues, adaptation and urban furniture, transportation, employment, etc., acknowledged that with the occurrence of the earthquake, their difficulties multiplied and they lost their savings for many years. Therefore, the participants need that the managers to be informed about their needs and consider them when providing services in earthquake conditions and also provide suitable facilities for this group.
Discussion and Conclusion
 Participants in the study considered education as essential in improving preparedness while facing an earthquake and their educational needs were classified into two main themes: educational needs of people with physical disabilities and educational needs of relevant groups. The first main subtheme consisted of two subtheme: basic educational needs, including saving lives and preventing secondary disabilities, maintaining composure, stress control, and decision-making; and also empowerment training needs included coping with disabilities in critical situations, helping others if possible, and educating other people with disabilities. The second main theme had two subtheme: general educational needs of families and public, including, rescue people with disabilities, saving lives and preventing disabilities, providing proper assistance to people to prevent disabilities, and accompanying and Proper relief to public for prevention of disabilities, and specialized training needs related to rescuers and disaster managers, including assistance to people with disabilities, prevention of disability and injury while rescuing people, familiarity with different groups of people with disabilities and their needs, and considering the needs of people with disabilities in response measures.
Participants in the present study acknowledged that they had not yet received training about the earthquake. Kamali et al. mentioned this issue regarding the Rudbar and Kazerun earthquakes [26], which shows that in the interval between these two studies (14 years), no attention has been paid to educating people with disabilities. However, studies have shown that education is an effective intervention for people with disabilities that has lifelong benefits [27]. Morris and Jones showed that people with disabilities who were trained and experienced in dealing with disasters received higher scores in preparedness [28].
Participants also mentioned their need for life-saving training to prevent further injury, control mental health, and empowerment to improve earthquake preparedness. The United Nations Office for Disaster Risk Reduction also emphasizes comprehensive training for people with disabilities regarding harm reduction, adaptation, mitigation, disaster preparedness, evacuation, and early warnings like other people with the same quality, and appropriate training facilities in an environment free of violence [29], which is in line with the needs raised by our participants.
In addition, the participants considered family education as a necessity and linked the promotion of their knowledge to the preservation of life and health of people with disabilities. According to Juen et al., families of people with disabilities need to be trained in dealing with disasters to care for and interact with them [30]. Hipper et al. have considered education as an essential need for the families of people with disabilities because it leads to identifying local emergency sources, develop a family emergency plan focusing on the child’s specific needs, communicate with officials, and obtain information about local shelters [31].
Training the public as they are first available in the disaster scene to provide optimal services to others, including people with disabilities, was considered by the participants in the present study. In the studies conducted after the Rudbar, Kazerun, and Bam earthquakes, the need for public education to face the earthquake and understand the concept of rehabilitation, and training specialists to provide appropriate and timely services to people with disabilities and earthquake victims, has been emphasized [26, 32].
Another finding of the present study was the effective role of specialized training of paramedics in identifying the needs of people with disabilities and taking these needs into account in providing them with relief. Studies have shown that specialized training of paramedics on the needs of people with disabilities before disasters is essential and can increase their awareness, knowledge, and skills in providing services in the event of disasters [30, 33]. Rowland et al. also pointed out that the specific training of relief personnel, especially in the field of rehabilitation aids, using the consulting services of rehabilitation experts (physiotherapists, occupational therapists, and rehabilitation nurses) is effective in helping people with mobility disabilities [34].
In addition, according to the participants regarding the training of disaster managers, identifying the needs of people with disabilities and the services they need, makes managers pay special attention to this group and prioritize their services. Wolf-Fordham et al. acknowledged that emergency plans are usually designed for healthy people and managers and planners are not adequately trained about the needs of people with disabilities in critical situations. Trained respondents will be able to increase equal access to emergency services in disaster situations and remove barriers to the optimal response that increase the safety and well-being of people with disabilities [6]. Fox et al. also indicated the lack of knowledge of disability emergency management teams. Therefore, researchers recommend considering issues related to people with disabilities in the training program of managers [35].
Therefore, considering the educational needs of people with disabilities has increased their readiness in the face of earthquakes; however, the development of standard and practical training programs using their opinions and also implementation of these programs in conditions similar to disasters are needed. On the other hand, considering that no serious and principled action has been taken regarding educating people with disabilities so far, it is necessary for planners and policymakers to provide specialized training platforms for these people by formulating specialized policies appropriate to the country’s conditions. This measure can be effective in reducing mortality and improving the health of these people in disaster conditions. In addition, it is suggested that further studies be conducted to identify the needs of different groups of people with disabilities in other natural, technological and pandemic hazards, especially COVID-19.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the ethics committee from the Iran University of Medical Sciences. Also, All ethical principles are considered in this article. The participants were informed about the purpose of the research and its implementation stages. They were also assured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them.

Funding
This study is part of a research project with registration number 9221567202, which has been accepted and funded by Iran University of Medical Sciences.

Authors' contributions
Research, writing, correction: Shahrzad Pakjoui; Supervision: Aydin Arian Khasal; Methodology: Mohammad Kamali and Hesam Seyedin; Investigation, Writing – original draft, and Writing – review & editing:  Mohammad Heidari. 

Conflict of interest
The authors declared no conflict of interest.


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