Background
Earthquakes, as the second deadliest natural disaster, have always existed throughout the life of the planet. These are unpredictable and out-of-control, which can cause extensive destruction, threaten many lives [
1‐
4], and can leave profound and lasting effects on the minds and development of human beings [
5]. As reported by the World Health Organization (WHO), over the past century alone, 1150 fatal earthquakes have been happened in 75 countries worldwide [
6]. Although most natural disasters occur in developing countries, they are not sufficiently equipped with the necessary resources and structures to provide survivors with proper services [
7]. People in developed countries are less affected by mental problems associated with earthquakes due to the availability of social protection systems in these countries [
8]. Iran, as a developing country, records the severity of earthquakes with titanic magnitudes every four years, whereby 97 and 79% of rural and urban units are demolished, respectively. For instance, over 170 thousand people have lost their lives in major earthquakes that occurred in the Iranian cities such as Torbat-e Heydarieh, Kerman, Bam, Shirvan, Larijan, Rudbar, Tabas, Ahar, and Varzaghan [
9]. As another example, a 7.3-magnitude earthquake rocked the Kermanshah Province at 9:48 p.m. on Sunday, November 21, 2012, resulting in massive destruction and casualties. According to Iran’s Forensic Medicine Organization, the death toll stood at 620, as well as leaving 9388 injured and 70,000 homeless [
10].
Recent studies have shown that the damages caused by natural disasters are not equitable among different groups of people [
11]. In the events of natural disasters, the pre-existing hierarchies and inequalities in access to resources, capabilities, and opportunities, make the certain groups more vulnerable to more suffering [
12] Recent research has shown the unique effects of natural disasters and earthquakes on vulnerable groups such as women, children and ethnic minorities [
13,
14]. Moreover, the results of sociological and ethnographic research have also revealed that gender and social inequalities are exacerbated by natural disasters [
15].
One’s reaction to natural disasters is heavily influenced by his/her cultural, social, economic and political backgrounds [
16,
17]. Hence, natural disasters are perceived differently by men and women [
13,
18].
Not to mention, women, with more vulnerabilities and less access to resources [
19,
20], are often seen as the victims of natural disasters [
21].
The study of Anwar et al. (2011) and Demirchyan et al. (2014) on Pakistani women stricken by earthquakes concluded that those women had multiple health problems and notable danger of depression and anxiety [
4,
22]. Doris et al. (2016) explored that the female survivors of the Haiti earthquake experienced various physical and psychological problems and also a lot of violence from their husbands or boyfriends. However, 60–78% of women did not report any case of violence [
23]. The study of Chan and Zhang (2011) on women troubled by an earthquake in Sichuan, China, revealed that all kinds of domestic violence, ranging from sexual to physical, was on the rise between couples after the earthquake, thereby disturbing the mental and physical performance of victims [
24]. In a few studies conducted by Liu et al. (2012) and Qu et al. (2012) on rural women stricken by earthquakes in China, the results revealed that 52.2% of participants had psychiatric disorders, and widows and those who witnessed their loved ones dying had more psychiatric disorders. Besides, the women working outside villages experienced fewer psychiatric disorders than the unemployed women living in these villages [
25,
26]. Among women, rural women are the weakest groups because of the traditional social and cultural contexts that govern their villages, who can suffer from numerous physical and psychological damages as a result of natural disasters such as earthquakes.
Most studies conducted on earthquakes are quantitative and empirical, and a few previous studies have addressed the experiences of rural female survivors qualitatively. It should be noted that qualitative studies have a unique ability to understand phenomena and to describe life experiences, human interpretations and perceptions in the same cultural and social context [
27]. Hence, the qualitative study of rural women’s experiences of earthquakes can provide health workers and policymakers with extensive information and necessary knowledge to appropriately respond to earthquakes. Therefore, the present study aimed to investigate the experiences of rural women with damages resulting from an earthquake in Iran.
Methods
In this research, a qualitative approach and the conventional content analysis were employed to explain the experiences of rural women with damages resulting from an earthquake in Iran. Qualitative content analysis is one of the several research methods and a robust process that is used to analyze textual data and is intended to start the introductory meanings of the concept. It is also a systematic categorization and coding method. The main goal of this method is to satisfactorily understand the phenomenon being investigated [
28].
Moreover, the study population consisted of rural women residing in the earthquake-stricken areas of Sarpol-e Zahab and Salas-e Babajani counties in Kermanshah Province, Iran, who were there on the night that the earthquake rocked these two counties on November 12, 2017. Moreover, the inclusion criteria were consciousness, willingness to express their experiences of the earthquake, being female, residing in rural areas, ability to speak and willingness to participate in the research.
To commence the study, the required permits were obtained from the Vice Chancellery for the Department of Research and Technology at Kermanshah University of Medical Sciences. For data collection, semi-structured interviews were used. However, given that the researchers were natives to the earthquake-stricken areas and served there as volunteers, the observation method was also used. Furthermore, the interviews were commenced two months after the earthquake and lasted for four months. Besides, the interviews were conducted based on some general questions (Table
1). The interview guide was developed specifically for this study.
Table 1Interview questions
1 | Explain to us what happened after the earthquake? |
2 | What were your main problems after the earthquake? Please explain |
3 | Were your personality and behavior changed after the earthquake? Please Explain |
4 | What impact did the earthquake have on your family? Did it affect inter-family relationships? Please Explain. |
5 | Were your health needs met as a woman after the earthquake? Please Explain |
6 | How was the distribution of aid among the affected people? Were you satisfied with the services they provided for you? Please explain. |
7 | Could you easily access the services they provided for you? |
8 | How do you evaluate the overall status of different organizations in terms of the services they provided for you? What were the weaknesses of their services? Please explain. |
9 | How did you deal with the post-earthquake conditions? Please explain |
10 | Did any of your family die in the earthquake? If yes, please explain what you think of his death. |
11 | What were you doing to make it easier to cope with earthquake damages? |
After asking the general questions that were the same for all participants, the following questions were developed concerning the answers that they provided. Any new code that emerged in the interview was attempted to be asked as a question in the subsequent interviews to check the codes repeatedly to find out whether or not other interviewees have had such an experience so that researchers can gain richer concepts.
During the interviews, given that the researchers used local language of the interviewees, they were asked to speak in their local language to express their experiences comfortably, thereby creating a sense of trust and willingness to participate in the study. The time and place of the interviews were decided by the samples, which were mostly held in container homes and tents without anyone accompanying them since it was likely that other people would prevent them from communicating their experiences to the researchers smoothly. The average duration of the interviews was 37 min. After each interview, the researchers began to analyze and encode the data to use them as a kind of guidance in subsequent interviews. Moreover, sampling was purposeful, and theoretical saturation was achieved by conducting 22 interviews and the main and sub-categories were formed. In qualitative research, the sampling criterion is the theoretical saturation, and whenever there is no new code in interviews, it shows that saturation is reached and the researchers can interrupt the interview process and no longer need to increase the sample size [
29]. In fact, in an interview with the 18th participant, all the codes were repetitive and no new code was formed; however, the researchers performed four more interviews to make sure of this, and in the next four interviews, no new code was created, so the researchers concluded that continuing another interview is not necessary because they had reached the saturation and there was no new code.
In the present study, the data analysis process was performed according to the steps proposed by Graneheim and Lundman (2004). Additionally, the data analysis began simultaneous with data collection, and all interviews were recorded, and the contents were written verbatim. Besides, the entire material was reviewed several times to gain a correct understanding [
28]. At the data preparation stage, to get acquainted with the data, the entire text was read in full and the researchers immersed themselves in understanding the contents of interviews. Bedsides, the researchers took general notes of their ideas of the interviews. Next, at the defining semantic units’ stage, the semantic units were identified and the primary codes were extracted. Then, at the coding, the text and classifying and developing themes and subthemes stages the codes were merged and classified according to their similarities and named under different sub-categories. Then, at identifying the main themes stage, several sub-categories fell into one category based on at least one common feature, which was the basic part of content analysis. It was also tried to have the most homogeneity within the categories and the most heterogeneity between the categories.
Since qualitative research has slightly different paradigmatic principles than quantitative research, the methods of evaluating and generalizing results in qualitative research are different from quantitative research [
30]. Therefore, for the credibility and transferability of this study, the Guba and Lincoln criteria were used, which is one of the most common criteria for evaluating the quality and reviewing the principles and strategies of accreditation and generalizability in qualitative research [
31]. After encoding and data analyses, the data were given to some samples to confirm their accuracy and to correct them if it is necessary (member Check). In addition, some parts of the interview texts along with codes and categories were sent to some psychologists and social workers to verify the accuracy of the data analysis (Checking by experts). Moreover, maximum diversity was used in sampling to provide more comprehensive and complete information (Diversity in samples), and direct quotations were also used.
To observe the ethical considerations, the objectives of the present study were explained to the target subjects, and they were assured that their information would be kept confidential. They were also assured that their data would be encoded and published in such a way that they could not be identified by any means. Moreover, they were given the right to interrupt the interview at any time.
In this research, different to most existing studies, the problems and needs of rural women after the earthquake were examined qualitatively, which can provide unique information and give us the needs and problems of rural women after the earthquake to prepare the grounds for intervention to improve their health condition. Similarly, since some of the authors of the article were indigenous to the studied areas and were working as a social worker there, they could establish a close relationship with the participants, could gain a comprehensive familiarity with the research field, and could get more complete and hands-on information from the research field for readers and, therefore, pave the grounds for further researches.
Discussion
In addition to destroying houses, earthquakes can bring about massive destruction and threaten the lives of many people, especially rural women, as one of the most vulnerable groups in the event of earthquakes. It should be noted that women’s ability to come to terms with natural disasters such as earthquakes relies on how well their needs and concerns are understood by health planners and policymakers [
32]. Therefore, examining the needs of women in the context of society and culture is necessary [
31].
The results of the present study demonstrated that the health needs of women were neglected in the earthquake, which could endanger their health. When natural disasters occur in third world societies, some of the vital needs are neglected due to the lack of a proper supportive structure, and the same case goes for Kermanshah Province, too. For example, the health needs of women were neglected for months after the earthquake. Similarly, in studies conducted by Nakhaei et al. (2015), Hirth et al. (2013), and Rahmani Bilandi et al. (2015), the neglect of women’s health needs has been reported [
31,
33,
34]. Our findings, therefore, add to the already strong body ofevidence showing that for effective disaster response and recovery, there is a need for explicitconsideration of the health needs of women – ideally involving women themselves – at the planningstage.
The results of the present study indicated that earthquakes could cause tensions in families, and since the circumstances of families are extensively affected by earthquakes, it can lead to tensions in marital relationships and disruptions in family functioning [
19]. Chan et al. (2011) reported that family violence such as physical and psychological violence against women was increased as a result of earthquakes [
24]. Also, the results of a study done by Campbell et al. (2016) revealed that violence against women was increased after the occurrence of earthquakes [
23]. Research also has shown that women’s satisfaction with their sexual lives is dramatically decreased [
25]. The results of this study, in comparison with the results of previous studies, revealed that more attention should be paid to the family after natural disasters because family is the source of peace, otherwise it will turn into a source of stress and pressure increasing the post-earthquake problems.
Gender inequity in the provision of services and aid was one of the other categories in the present study. Women in rural areas did not have access to resources due to the lack of sufficient literacy and restrictive culture in the village. Additionally, because of the dominant patriarchal culture in these areas, women did not have the opportunity to receive aids. Therefore, the lack of access to vulnerable groups, such as women, to services can impose irreparable damages to them. Research has shown that, compared to men, women’s health is more at risk during disasters due to personal, social, and health-related factors. In other words, the vulnerabilities of women’s health in the events of natural disasters deteriorates because of inequality in facing disasters and access to resources and opportunities [
35]. Providing health services in the event of natural disasters based on gender is of prime importance since, in addition to the social and cultural limitations that women face in receiving health services, they have their own health needs, such as those during menstruation, pregnancy and breastfeeding their babies [
34].
Feeling insecure was another category in the present study. Since the presence of aid workers and volunteers changed the previous social atmosphere of villages, it created a kind of insecurity in rural women because of their unfamiliarity with the new situation, which made women decide not to go out. It should be noted that there was no report of sexual assault due to the specific cultural context of the target area and the sensitivities that exist in this respect among Kurds.
The results of the present research revealed that the ruling culture of the region had been ignored when the survivors of the earthquake were provided with services. For this reason, most of the delivered services were not used due to the incompatibility of the sent clothing and food with the native culture of the region. For example, many bathrooms were built in villages, but most women did not use them because of the cultural conditions governing their villages. It should be noted that providing services to earthquake victims should be community-based and based on the culture of the region so that the needs of certain groups such as children, women and the elderly to be taken into account [
36]. In addition, the values and norms governing the region should be considered in this respect.
Another result of the present research was about the rural women’s unmet needs, especially their health-related needs, due to concealing them for fear of stigmatization. Likewise, in a study done by Rahmani Bilandi et al. (2015), it was reported that indigenous beliefs and cultural taboos were the main reasons for earthquake-stricken women’s concealing their needs, thus exacerbating their health problems [
34]. The results of a study conducted by Bahman Jonbeh et al. (2018) revealed that women were reluctant to ask for any health care services such as sanitary pads because of cultural taboos and their shyness [
30]. The results of this study added to previous studies that much of the needs of rural women remain unaddressed due to the conditions prevailing in the village, thus considering the social and cultural conditions of the villages as well as providing appropriate opportunities, such as the use of female social workers to assess women’s needs can be a good way for women to express their needs easily.
The incoherent mourning was another category in the present study. Those who lose their relatives during an earthquake suffer from the loss of their loved ones for a long time because they cannot mourn their deaths properly.
One of the issues that matter after earthquakes is adaptability and coping with emergencies afterward. Some people have more adaptability and less vulnerability whereas there are some who cannot cope with this problem and are more exposed to damages. Adaptability and coping are the topics of interest to researchers who study the effects of natural disasters on communities [
37,
38]. Adaptability after such terrible disasters is affected by various factors, such as personal ability, religious beliefs and faith and external support [
39,
40]. Not to mention, women are more susceptible to disasters and their compatibility capacity is reduced under the effects of gender roles, norms and unequal access to power and resources [
41]. The findings demonstrates that the survivors were upset about the process of the funeral ceremony for their loved ones and they had a guilty conscience was found for the first time in this study; therefore, when authorities bury the dead after natural disasters, they have to maintain their dignity so that their families do not feel bad.
The results of the present study revealed that rural women’s reactions to earthquake fell into two categories: positive and negative interactions. In the former, they approached this phenomenon by getting closer to God, participating in group works, comparing their current circumstances with other worse conditions, sharing feelings and experiences, and heroizing the dead.
Getting closer to God through religious practices and prayers was one of the strategies that rural women adopted to come to terms with the earthquake, which created a kind of inner satisfaction in them. Likewise, the results of previous studies showed that religious practices were recognized as one of the strategies for coping with natural disasters [
42‐
44].
Participation in group works was another strategy adopted by rural women to come to terms with the earthquake and to make them too occupied with group works in the community to think about problems, thus having less stress.
Another category of positive interactions among earthquake-stricken women was comparing their own circumstances with others’ worse conditions. Since earthquakes can lead to loss of many lives, everyone is exposed to this problem, and the majority of victims compare their problems with those of others to relieve their pain and psychological burden.
Sharing of memories was another way whereby rural women could come to terms with the earthquake consequences. After the earthquake, rural women gathered around their tents and container homes and shared the memories of the night of the earthquake, thus encouraging them and reducing their post-earthquake stress [
45]. Similarly, the results of a study done by Ahmadi et al. (2018) revealed that sharing emotions and experiences with neighbors was one of the strategies to come to terms with the earthquake consequences [
42]. In fact, this strategy can be used as a kind of local social capital to play a positive role in compatibility with natural disasters [
45,
46].
One of the other ways that rural women came to terms with the death of their loved ones was to heroize them, and they were believing that their relatives would have God’s mercy on their souls because they lost their lives in the earthquake. On the other hand, having found themselves in tremendously difficult conditions, they supposed that the dead were finally relieved and adored by God too much to let them experience intolerable conditions. However, some rural women found it hard to come to terms with the consequences of earthquakes, and their reactions included annoyance at God, phobic display of a greater disaster, aggression towards the others, isolation, and death wish.
Since earthquake is seen as something that occurs with the will of the Almighty God, its occurrence in some cases changes the relationship between the survivors and God, and because the earthquakes are regarded as a punishment by God, they find it an annoyance.
The phobic display of a greater disaster was another issue that was obtained from the data. In the area under study, after the major earthquake, there were a lot of aftershocks that exposed people to high levels of mental pressure to the extent that the mental pressure of aftershocks was more irresistible than that of felt during the main earthquake itself. In the meantime, rural women fell victim to a variety of local, national and international propaganda and rumors, such as man-made earthquakes, due to insufficient media literacy. They also fell for rumors that there would be more destructive earthquakes at any time. Accordingly, they were obsessing over worse happenings. Consistent with the findings of the present study, previous studies revealed that worry and fear after a natural disaster were more common among female survivors than men [
47].
Aggression towards other people was another result of rural women’s negative interactions because they experienced a lot of stress after the earthquakes, thereby leading to aggression and violence. This finding was concurrent with the results of studies in which it was reported that aggression and violence were prevalent in the families after earthquakes [
19,
24].
Isolation was another alternative taken by rural women after the earthquakes, thereby excessively increasing their psychological burden and making it less likely to appear in community and to express in their desires and needs.
Death wish was another category in the present study. The earthquake that occurred in Kermanshah destroyed lots of residential buildings and the subsequent damages led to psychological problems and hopelessness in women. Furthermore, since rural women in this area had little knowledge to deal with critical conditions, they got distressed and desperate, and thought of death and suicide. For example, in a study conducted by Hyodo et al. (2010) on the victims of an earthquake in Japan, the tendency towards death and suicide was on the rise among women [
48]. Likewise, Yang et al. (2005) and Yip (2009) concluded the same finding among the earthquake survivors [
49,
50]. The findings of this study add this point to previous studies that, after the earthquake, some women deprived themselves from all the services they were provided with and this could worsen their condition. So, paying more attention to these women and providing conditions for them to be more present in society can be effective in improving their health faster.