Factors relating to anxiety among medical teams dispatched to the Fukushima nuclear power plant disaster

Journal Pre-proof Factors relating to anxiety among medical teams dispatched to the Fukushima nuclear power plant disaster Yoshiko Fukushima, Koji Yoshida, Makiko Orita, Noboru Takamura, Shunichi Yamashita PII:

S2212-4209(18)31444-4

DOI:

https://doi.org/10.1016/j.ijdrr.2019.101330

Reference:

IJDRR 101330

To appear in:

International Journal of Disaster Risk Reduction

Received Date: 20 December 2018 Revised Date:

6 September 2019

Accepted Date: 7 September 2019

Please cite this article as: Y. Fukushima, K. Yoshida, M. Orita, N. Takamura, S. Yamashita, Factors relating to anxiety among medical teams dispatched to the Fukushima nuclear power plant disaster, International Journal of Disaster Risk Reduction (2019), doi: https://doi.org/10.1016/j.ijdrr.2019.101330. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd.

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Factors relating to anxiety among medical teams dispatched to the Fukushima Nuclear Power Plant disaster

Yoshiko Fukushimaa,*,1, Koji Yoshidab, Makiko Oritac, Noboru Takamurac, Shunichi Yamashitad a

Facilities Department Safety Planning Division, National Research and Development Agency

National Institute of Radiological Sciences Research Infrastructure Center Safety b

Department of Health Sciences, Nagasaki University Graduate School of Biomedical Sciences,

Nagasaki, Japan c

Department of Global Health, Medicine, and Welfare, Atomic Bomb Disease Institute, Nagasaki

University, Japan d

Fukushima Medical University

*Corresponding author: Division of Nursing, Faculty of Nursing at Higashigaoka and Tachikawa, Tokyo Health Care University 2-5-1 Higashigaoka, Meguro-ku, Tokyo 152-8558 Tel: 03-5779-5031 Email: [email protected]

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Abstract At the time of the accident at Tokyo Electric Power Company’s Fukushima Dai-ichi Nuclear Power Plant, medical teams and radiation experts were solicited from all over Japan by the Japanese government to go to Fukushima Prefecture. While several reports on the incident and its management have been published, there have been no reports on the causes of anxiety felt by the volunteers or problems foreseen by organizations that declined to send volunteers. To identify the factors contributing to the anxiety levels of the dispatched personnel and to understand the difficulties faced while dispatching volunteers to the affected area, two different questionnaires were sent out to the recruited volunteers and recruiting organizations. Among the professionals sent to Fukushima Prefecture, we found that previous knowledge of radiation emergency or disaster medicine was inversely proportional to their anxiety levels (p < 0.001). Factors giving rise to apprehension depended on the professional’s occupation (p = 0.042). Possessing and sharing radiological information among team members helped alleviate anxiety once the professionals entered the hazardous area. It is thus desirable to establish systematic plans with guidelines for proactive education and training for each kind of professional and policies regarding the dispatch of volunteered professionals to alleviate anxiety levels prior to dispatch.

Keywords: nuclear power plant disaster, medical team, questionnaire survey, anxiety, Fukushima

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1. Introduction It is expected that personnel dispatched to disaster zones will experience high rates of negative health effects. Medical complaints were documented by 64% of the personnel who responded to a post-earthquake mission in Nepal, with gastrointestinal and respiratory symptoms being the most common [1]. Exposure to damp environments after water-related natural disasters is a concern due to excessive exposure to airborne microbes, which can cause novel or exacerbate existing symptoms in the airways, skin, mucous membranes, and internal organs [2]. Research suggests that the rate of injury and illness may be positively associated with the intensity of the disaster response [3]. Additionally, personnel dispatched to disaster zones may experience high levels of mental health symptoms, including post-traumatic stress disorder (PTSD), which is classified as an anxiety disorder, and general anxiety [4]. “Anxiety” is defined as “an emotion characterized by the subjective experience of activation of the autonomic nervous system – especially the sympathetic nervous system – and stress, as well as recognition of apprehension and worry” [5]. It also includes adaptations to avoid hazardous behaviors. For example, 17% of medical rescue personnel who responded to the Wenchuan earthquake in China in 2008 experienced symptoms of PTSD [6]. In addition, PTSD symptoms were higher among responders to the U.S. Oklahoma City Bombing who were very dissatisfied with the debriefing process [7]. Poor mental health among responders to Hurricane Katrina persisted for 18 months [8], and PTSD symptoms are more likely to occur in individuals who respond to multiple disaster situations [9]. Health risks were especially high among responders to the Great East Japan Earthquake and subsequent Fukushima Nuclear Accident (hereafter referred to as the “Fukushima Nuclear Accident”). Wada et al. (2012) reviewed the occupational health hazards faced by emergency personnel from the Fukushima Nuclear Accident and found that the main exposures were to radiation, heat, stress, machine operation, and manual handling [10]. The prevalence of probable PTSD, depression, and high psychological distress was 6.6%, 14.3%, and 14.5%, respectively, among medical response workers, with similar prevalence rates measured among municipality workers [11]. Symptoms of poor 3

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mental health were high among nurses who responded to the disaster, although those who had more knowledge about radiation displayed fewer symptoms [12]. Finally, Yamada et al. [13] reported that 51% of public health nurses who were dispatched to affected areas at the time of the Great East Japan Earthquake felt “anxiety,” and 46% experienced psychosomatic disorders such as “fatigue,” “difficulty sleeping,” and “depression” during or after their time in the affected areas. Research has also shown that long-term psychological and social effects occur from before the start of activities until after their conclusion [14]. In response, the World Health Organization (WHO) has developed a psychological first aid guide to address these concerns [15], although research on the effectiveness of such interventions is currently unsupported. Multiple systematic reviews have concluded that there is insufficient evidence to support such programs [16,17]. For organizations responding to disaster situations, the Medical Guidelines for Radiation Emergencies (Nuclear Safety Commission; partially revised in October 2008) recommend personnel training that include emergency radiation medical care and that takes into account the specific conditions in local areas. They also emphasize the need for cooperation with related medical fields, the need to conduct research, and the need for training instructors [18]. The National Institute of Radiological Sciences established the Radiation Emergency Medical Assistance Team (REMAT) in 2010, which consists of physicians, nurses, radiation protection experts, and health physicists ready to respond to radiation emergencies [19]. However, the effectiveness of these plans has not been formally evaluated. In response to the Fukushima Nuclear Accident, a REMAT was dispatched to the disaster site [19]. However, problems with the response were not identified or investigated and specific recommendations were not made. Thus, the difficulties (and its sources) faced by organizations that dispatched personnel to the disaster area and the structural and managerial problems faced by organizations that were unable to comply with solicitations to dispatch personnel have yet to be elucidated. We identified 88 organizations that dispatched personnel to disaster areas in response to government solicitations and 157 organizations that did not. Yet, little is known about the structural or managerial problems underlying non-dispatch in this instance. Such knowledge would enable the development of a new medical support system that could be used effectively in nuclear power plant 4

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disasters with consideration of the stressors for dispatched personnel. Our aim, therefore, was to identify the anxiety levels of dispatched personnel and problems faced by organizations dispatching personnel to the Fukushima Nuclear Accident between the time of the accident and March 2012, in order to elicit a list of future reforms for the benefit of medical teams responding to nuclear power plant disasters.

2. Methods In the wake of the March 2011 Fukushima Nuclear Accident, disaster medical assistance teams and specialists in radiation emergencies, radiation measurement, and other radiation-related technologies were dispatched to the area at the request of the Japanese government. However, not only did on-site disaster and radiation emergency medical care not function adequately, but there were shortages in medical personnel from fields other than radiation emergencies as well as an insufficient response from local governments outside of the affected area [20-24]. As a result, advocates, regulators, and government officials have proposed that these problems be reviewed and reevaluated and that countermeasures be put in place to address such issues in the future. 2.1 Questionnaire for personnel dispatched as part of the medical teams Solicitations from the Ministries of Health, Labour, and Welfare and of Education, Culture, Sports, Science, and Technology led to a total of 1,202 personnel being dispatched by 88 organizations based on requests from the medical team at the local headquarters in Fukushima. Considering that some personnel were dispatched multiple times to different teams, a total of 586 unique individuals were sent the questionnaires between February and March 2015. Questionnaires were distributed by mail to the directors of the organizations responsible for dispatching personnel to the nuclear power plant disaster. Written requests, questionnaires, and return envelopes were distributed to the dispatched personnel of all job types, and the individual respondents personally mailed their completed forms directly to the researchers. The questionnaire consisted of demographics (sex, age, occupation), dispatch-related items (number of times dispatched to Fukushima Prefecture, time period, time spent on site, activities at site), knowledge of disaster medicine and radiation emergency medicine prior to dispatch, and anxiety 5

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levels before and after dispatch and reasons for anxiety (Questionnaire in Supplementary Information 1).

2.2 Questionnaire for organizations that did not dispatch medical teams Over the same time period, a second questionnaire was sent to medical teams associated with the Nuclear Emergency Response Headquarters that had not been dispatched in order to ascertain why they did not dispatch personnel to Fukushima Prefecture. These questionnaires were distributed through the mail to the directors of the organizations. The organizations were asked to have their personnel who had been involved with medical team dispatch at the time of the Fukushima Nuclear Accident complete the questionnaires. There were 157 organizations recorded as not having dispatched personnel between the time of the accident and March 2012. Data were collected on institutional personnel dispatched to the medical teams; the current state of radiation emergency medicine initiatives implemented after the Great East Japan Earthquake and their problems; and the institutional personnel’s intention to participate in seminars, lectures, and training in the future (Questionnaire in Supplementary Information 2). Organizations that had dispatched personnel completed the following questionnaire sections: Who requested that their personnel be dispatched, the location of the activity, and how they supported the activity. Organizations that responded that they dispatched personnel only to locations outside Fukushima Prefecture or that they did not dispatch personnel to disaster-stricken areas were asked to provide information regarding the following topics via multiple-choice questions: Whether they received a request to dispatch personnel and the reasons they did not dispatch personnel in response to such a request. All respondents were asked to return the questionnaires by mail. Complete responses were received from 58 organizations (response rate: 36.9%).

2.3 Statistical analysis Statistical analysis of the questionnaire data was performed using IBM SPSS 22.0 (Armonk, NY: IBM Corp.). Spearman’s rank correlation coefficient, the Kruskal-Wallis test, and the chi-square test were used for analysis. The standard of significance was set at 0.05. 6

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2.4 Ethical considerations Administration of the questionnaires was conducted anonymously. Respondents were provided with a survey request form and explanations of the following: The purpose and methods of the study, the fact that they were free to drop out of the study at any time, the fact that they would suffer no negative consequences whether they participated or not, and the fact that the study was being partially conducted as part of a government-commissioned project. The study was conducted in accordance with the ethical regulations of the National Institute of Radiological Sciences; however, approval was not required for this research.

3. Results 3.1 Responses from dispatched medical team members 3.1.1 Demographics of the respondents Of the 586 questionnaires sent out, we received responses from 221, for a response rate of 37.7%. As shown in Table 1, 76.9% of the respondents were male and the majority of the respondents were in their forties. Almost half (45.7%) were affiliated with medical institutions, and physicians (22.2%), nurses (22.2%), or professionals directly related to radiology (23.1%) were most prevalent. While 71.9% of the respondents were dispatched only once, 12.7% were sent five or more times, most often for 3–5 days at a time. Upon arrival, they participated in various activities, of which the majority were involved in screening, dealing with evacuees, working at first aid centers, or providing radiationemergency-medicine-related support.

3.1.2 Knowledge and anxiety levels prior to being dispatched Knowledge and anxiety levels of personnel before being dispatched are shown in Table 2. Of those who responded that they had knowledge prior to being dispatched for the first time (“had a full understanding” or “had a general understanding”), the highest percentage of personnel said their knowledge was regarding their own role (83.7%), the lowest percentage said their knowledge was about meteorological issues such as wind direction and climate (41.7%). In contrast, of those who said 7

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they had no prior knowledge (“had little understanding” or “had no understanding at all”), the majority said that they had no knowledge of radiation emergency medicine as a whole (76.9%), or no knowledge of disaster medicine in Fukushima Prefecture (other than radiation emergency medicine) as a whole (76.5%), and no knowledge of medical facilities in the vicinity (71.9%). Fewer respondents indicated they were “not very anxious” or “not anxious at all” compared to those who reported being “extremely anxious” or “slightly anxious.” Of those who reported anxiety, 41.8% were males who said they were anxious while females totaled 53.0%. In contrast, 57.6% of the males said they were not anxious, while 47.0% of the females said they were not anxious. In order to investigate the relationship between knowledge and the level of anxiety (indicated in the following four categories: “not anxious at all,” “not very anxious,” “slightly anxious,” and “extremely anxious”), we applied Spearman’s rank correlation coefficient (Table 3). The results indicated that there was a statistically significant negative correlation between anxiety and knowledge for all of the question categories, except for knowledge of meteorological issues such as wind direction and climate.

3.1.3 Knowledge of “general disaster medicine,” “radiation emergency medicine,” and level of anxiety prior to being dispatched A total of 54.8% respondents said they had little or no knowledge of general disaster medicine, while 43.4% said they did have knowledge of general disaster medicine. Both those who said they had knowledge of radiation emergency medicine and those who said they did not totaled 49.4%. An investigation by job type indicated that of those who said they had knowledge of general disaster medicine, the highest percentage was physicians at 57.2%, while the lowest percentage was clerical workers/drivers at 22.9%. Of those who said they had knowledge of radiation emergency medicine, the highest percentage was radiological management and health physics specialists at 90%, while the lowest percentage was clerical workers/drivers at 19.7%. There were statistically significant differences between those with knowledge of general disaster medicine (p < 0.001) and radiation emergency medicine (p < 0.001). The comparison of job type and level of anxiety when it was 8

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decided an individual would be dispatched also showed a statistically significant difference (p = 0.043). The highest percentage of those who said they were anxious were nurses at 57.2% (Table 4). In order to investigate the relationship between knowledge of “general disaster medicine” and “radiation emergency medicine” and level of anxiety, the Spearman’s correlation coefficient was applied. The results indicated negative correlations between knowledge of “radiation emergency medicine” and anxiety (r = −0.337, p < 0.001) and between knowledge of “general disaster medicine” and anxiety (r = −0.257, p < 0.001).

3.1.4 Reasons for anxiety prior to participation in activities in Fukushima Prefecture and changes following participation in activities Descriptive reasons provided by the respondents for feeling anxiety at the time it was decided that the individual would be dispatched were organized into the following eight sub-categories: “Possibility of radiation exposure,” “lack of information about radiation levels in affected areas,” “lack of information about damage, my own role, and specific support activities,” “lack of knowledge regarding radiation and radiation emergency medicine,” “anxiety about my own skills,” “possibility of an explosion at the nuclear power plant,” “anxiety regarding aftershocks and tsunamis,” and “anxiety regarding essential services and utilities.” These were then organized into the following four categories: “Lack of information,” “lack of knowledge,” “lack of experience,” and “inability to anticipate events.” A comparison of the sub-categories by job type indicated a statistically significant difference (p = 0.042). A total of 50.0% of the radiological management and health physics specialists, who had the most knowledge of radiation emergency medicine, said they had a “lack of information about damage, their own role, and specific support activities,” while 25.9% of the clerical workers/drivers, who had the least knowledge of radiation emergency medicine, were the largest group to report anxiety regarding the “possibility of radiation exposure” and “lack of knowledge regarding radiation and radiation emergency medicine.” While there were no statistically significant differences between reasons for anxiety and job types, 58.3% of the nurses, who were the most common job type to report anxiety, said they had anxiety regarding the “lack of information,” and 29.2% of the nurses reported 9

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anxiety regarding the sub-category of “lack of information regarding damage, their own role, and specific support activities” (Table 5).

3.1.5 Changes in anxiety pre- and post-dispatch An analysis of changes in anxiety after being dispatched indicated that the most common response was “no change” at 50.7%, followed by “anxiety was alleviated” at 32.6%. However, 12.7% reported that their “anxiety increased.” When changes were examined by job type, 64.1% of “other” reported “no change,” while 38.8% of “nurses” reported that their “anxiety was alleviated.” The job type most likely to report that “anxiety increased” was “other” at 14.3%. Descriptions of the reasons why the anxiety that was felt before dispatch was alleviated were organized into the following seven sub-categories: “Gained knowledge of conditions in the affected area,” “gained knowledge of radiation levels,” “gained knowledge of radiation exposure,” “gained knowledge of my own role,” “the nuclear accident did not worsen during my time there,” “gained experience,” and “use of protective equipment.” These were then organized into the following three categories: “Information gathering and transmission on site,” “learning through experience,” and “safety.” Our comparison of the sub-categories by job type indicated a statistically significant difference (p = 0.009). The clerical workers/drivers, the job type with the least knowledge of radiation emergency medicine, were the largest group to report “gained knowledge of conditions in the affected area,” at 36.4%. In contrast, nurses, who most commonly reported anxiety prior to participating in activities in Fukushima Prefecture, reported “information gathering and transmission on location” (50.0%), “learning by experience” (31.3%), and “safety” (18.8%; Table 6). Descriptions of the reasons why anxiety increased were organized into the following four sub-categories: “Radiation levels/radiation exposure” at 32%, “inability to anticipate nuclear accidents” and “inability to anticipate events in affected areas” at 28%, and “my own skills” at 12%. The comparison of these sub-categories by job type indicated no statistically significant differences.

3.2 Responses from organizations with no record of dispatched medical team members 3.2.1 Response rate and types of organizations. 10

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Of the areas affected by the Great East Japan Earthquake, 30 organizations (51.7%) dispatched personnel to medical teams only outside of Fukushima Prefecture, 19 organizations (32.8%) dispatched personnel to medical teams within Fukushima Prefecture, and 9 organizations (15.5%) dispatched personnel to medical teams that were not active within Fukushima Prefecture or in the areas affected by the event. The 19 organizations that did dispatch personnel to Fukushima Prefecture did so in response to other requests and not due to the government’s request for nuclear disaster response. 3.2.2 Reasons for non-dispatch The investigation of whether the 39 organizations that did not dispatch personnel to Fukushima Prefecture (the 30 organizations that dispatched medical teams only to areas outside Fukushima Prefecture and the 9 organizations that dispatched medical teams to affected areas) received requests to do so revealed the following. Twenty-four organizations (61.5%) reported that “the request was only for areas outside Fukushima Prefecture,” eight organizations (20.5%) reported that “no request was received,” six organizations (15.4%) reported that “the request was for both within Fukushima Prefecture and outside Fukushima Prefecture,” and one organization (2.6%) reported that “the request was only for within Fukushima Prefecture.” Only three organizations responded to the question on why personnel were not dispatched. Two organizations (67%) cited a lack of information regarding the local area and the accident and one organization (33%) cited a lack of personnel knowledgeable in radiation and radiation emergency medicine. Other reasons included, “we responded that we were able to dispatch personnel, but we were not selected to dispatch personnel within Fukushima Prefecture” and “since we have no medical staff that we were able to dispatch, we dispatched personnel other than medical staff” (Table 7).

4. Discussion For this questionnaire-based survey, we received responses on the knowledge and anxiety levels of the personnel dispatched to the Fukushima Nuclear Accident site as well as from

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organizations that did not send personnel to Fukushima Prefecture. Our findings indicated that knowledge of disaster medicine and radiation medicine and effective communication are key improvements to be made for efficient disaster control. We observed a negative correlation between knowledge of disaster medicine in general and radiation emergency medicine, and the anxiety levels the dispatched personal experienced, which was similar to the results found among combat veterans responding to disaster situations [25]. Knowledge within medical teams was unevenly distributed among the various job types, as shown by the significant differences across job types in knowledge of disaster medicine in general and radiation emergency medicine. A study by Ojino [20] reported that “insufficient knowledge” was one of the problems related to the lack of ability of medical professionals from facilities other than radiation medical facilities to deal with on-site conditions. Matsukiyo and Uehira [26] hypothesized that it may be possible to alleviate the anxiety felt by dispatched personnel by providing them with stress management education during the disaster preparation period. Our findings suggest that it would be important to provide training in the specialized knowledge and practical skills required to handle the unique conditions presented by this type of disaster. Practical service training from the time a person is dispatched by their medical facility until the time they return has been reported to be useful in ensuring a smooth performance of activities during actual disasters [27]. This type of training can also be expected to provide experience-based learning that will help professional development [28]. It is also necessary for different job types to be able to engage in teamwork easily in disasteraffected areas. For example, good team functioning, identified job roles, and high job satisfaction were protective against PTSD and anxiety symptoms among personnel responding to the 2010 earthquake in Haiti [29]. The fact that clerical workers and drivers who were engaged in activities had the lowest percentage of knowledge of disaster medicine in general and radiation emergency medicine in particular and that those with the least knowledge of radiation experienced the greatest anxiety highlights the fact that there are professionals involved in disaster response that need additional training on radiation and radiation emergency medicine in preparation for disasters.

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When all respondents to the questionnaires were queried about the relationship between the information they possessed prior to being dispatched, the actual state of the nuclear accident, and their own on-site role, many responded that they had a sufficient or general understanding. However, it was also reported that it was difficult to obtain information about the status of radiation emergency medicine capabilities, disaster medicine, and conditions at medical facilities in the vicinity, as well as medical care in general. The job type for which individuals experienced the most anxiety prior to being dispatched was nursing, and more than half of the nurses indicated that the reason for their anxiety was “lack of information.” Similar to our findings, another study of experiences in nursing activities in Fukushima Prefecture at the time of the Great East Japan Earthquake found that unreliable information caused anxiety and confusion that led to activities being halted, and highlighted nurses’ need to alleviate excessive distress by acquiring accurate information [30]. We believe that the anxiety experienced by those in clerical and driver positions, who reported having the least information regarding radiation emergency medicine, was alleviated through their experiences gathering information and other logistical activities, which was one of their on-site roles. Medical organizations that did not dispatch personnel to Fukushima Prefecture also cited “lack of information” as one of their reasons. Many of these organizations’ responses to the questionnaires indicated the need for centralized locations to improve the appropriate transmission of information on the constantly changing conditions that teams dispatched to unstable disaster sites face, as well as the importance of intra-team briefings. Based on these responses, communication, which is a fundamental organizational principle mentioned in the Medical Response to Major Accidents and Disasters [31], was shown to be an important factor when dispatching medical teams during times of nuclear disasters. Responses to questionnaire items regarding support activities during the period of initial activity after the disaster indicated that some organizations cited the fact that they were unable to prepare a sufficient amount of radiation measurement and protective equipment as the reason for not dispatching personnel to the disaster site. Indeed, the Nuclear Emergency Response Guidelines [32] stipulate that in situations with the potential for radiation to affect the public, preventive measures for residents such as preparations for evacuation must be made, and since their evacuation may require 13

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more time than others and as they are not subject to higher health risks from evacuation, persons with special needs (the elderly, disabled, foreign nationals, infants and babies, pregnant women, the sick and injured, hospitalized patients, etc.) should be prepared for evacuation and evacuated earlier than others due to their greater need for medical support from the early stages of a disaster. Our study had several limitations. The respondents in this study were limited to those from organizations solicited by the national government of Japan, and because we had low response rates, non-response and selection bias must be considered when drawing conclusions. The individuals and organizations who decided to participate in the study are likely different from those who did not participate, and as such, the generalizability of the results is limited. Moreover, few organizations answered the questions related to why teams were not dispatched to impacted areas suggesting this area of inquiry requires additional investigation. Assessment of anxiety levels and applicable knowledge prior to the disaster was assessed after the initial response period, and recall bias is a concern. It was not possible to objectively measure anxiety and stress by a medical profession, and it is possible that the experiences of the response personnel during deployment, news coverage of the event, or other depictions of the disaster influenced their responses. For similar reasons, causation cannot be inferred. Further, the present study did not elucidate whether there was a correlation with physical and psychological stress levels after the personnel left the affected areas. Personnel who were dispatched to Fukushima Prefecture may have experienced subsequent psychological and physical effects from real or potential radiation exposure, and future research is needed on the topic. If education and training during the disaster preparation period are indeed linked, not only to anxiety levels, but also to subsequent mental health, then prior education and training must be considered doubly important. In addition, it would be beneficial to study the differences in and evaluations of the effectiveness of the education and training of medical teams dispatched to areas where nuclear power plants are located as opposed to areas with no nuclear power plants, as well as ways to deal with the anxiety and stress experienced under the particular conditions presented by nuclear power plant disasters.

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Personnel on the medical teams dispatched to assist with the Fukushima Nuclear Accident with greater prior knowledge of radiation emergency medicine reported less anxiety than their counterparts with less knowledge on radiation emergency medicine. Notably, the causes of anxiety differed by job type, suggesting the preparatory education and training may require reevaluation. It would also be desirable to establish organizational systems to create guidelines for on-site activities and improve communication during disaster response.

Conflict of interest: None

Acknowledgements We would like to express our heartfelt thanks to Yuki Shuto, Director of the Research Institute for Social Safety, for her support from the planning stage to the implementation of the surveys conducted as part of my doctoral dissertation. We would also like to express our appreciation to all of the individuals and organizations that participated in this study. We received funding from the Nuclear Regulation Authority as part of a commissioned project. We would like to give a heartfelt thanks to Editage, Cactus Communications, for providing editorial and writing support.

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21. H. Kondo, J. Shimada, K. Morino, C. Tase, T. Tominaga, H Tatsuzaki, M. Akashi, K. Tanigawa, Y. Iwasaki, M. Ichihara, Y. Kohayagawa, Y. Koido, Activities of the disaster medical assistance team (DMAT) in response to the TEPCO Fukushima Nuclear Power Plant accident, J．Natl．Inst． Public Health. 60 (2011) 502–509. 22. M. Kako, J. Ranse, A. Yamamoto, P. Arbon, What was the role of nurses during the 2011 Great East Earthquake of Japan? An integrative review of the Japanese literature, Prehosp. Disaster Med. 29 (2014) 275–279. https://doi.org/10.1017/S1049023X14000405 23. Y. Watanabe, Japanese Red Cross Society relief activities during the Fukushima Dai-ichi Nuclear Power Plant accident and future problems, First Japanese Red Cross Society Radiation Disaster Seminar, 2013. http://ndrc.jrc.or.jp/infolib/cont/01/G0000001nrcarchive/000/070/000070848.pdf. (Accessed 9 Nov 2018). 24. S. Kanbara, How should nurses extend their role in disaster? Second Annual Conference of Japan Association for Human Security Studies, 30 Sep 2012. 25. D. Kranke, E.L. Weiss, K.C. Heslin, A. Dobalian. “We are disaster response experts”: A qualitative study on the mental health impact of volunteering in disaster settings among combat veterans. Soc Work Public Health. 32 (8) (2017) 500–509. 26. Y. Matsukiyo, E. Uehira, The psychological state and background of nurses involved in support activities during the Great East Japan Earthquake, J. Jpn. Soc. Disaster Nurs. 15 (2) (2013) 15–24. 27. K. Tanno, J. Hirayama, R. Rei, K. Hashimoto, Y. Kamada, Experience of DMAT participation in actual disasters in a short time against effective background practice for 4 days, J. Jpn. Assoc. Acute Med. 18 (11) (2007) 769–774. doi:10.3893/jjaam.18.769. 28. Y. Fukushima, T. Tominaga, Y. Koji, O. Makiko, N. Masaki, Y. Mayumi, M. Yamauchi, M. Kasai, J. Mikami, H. Hanada, A study on experiential learning by radiation disaster medical team personnel, J. Jpn. Assoc. for Radiat. Accid./Disaster Med. 1 (2015) 1–8. 29. P.G. van der Velden, P. van Loon, C.C. Benight, T. Eckhardt. Mental health problems among search and rescue workers deployed in the Haïti earthquake 2010: a pre-post comparison. Psychiatry Res. 198 (1) (2012) 100–105.

18

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30. Hiroshima University (Ed.), The Great East Japan Earthquake/Fukushima Nuclear Accident and Hiroshima University, Hiroshima University, Hiroshima, 2013, p. 17. 31. Advanced Life Support Group (original author) [MIMMS Japan Council (translation)]. Medical response to major disasters: A practical approach to on-site activities, third edition, Nagai Shoten, Osaka, 2013. 32. Nuclear Regulation Authority, Guidelines for radiation disaster measures (October 31, 2012; completely revised on October 1, 2018). http://www.nsr.go.jp/data/000024441.pdf (Accessed 9 Nov 2018).

19

20

Tables: Table 1. Characteristics of questionnaire respondents (n = 221) Item

n

%

Number of questionnaires distributed

586

Number of responses

221

37.7

Respondents’ sex Male

170

76.9

49

22.2

2

0.9

20–29

16

7.2

30–39

47

21.3

40–49

79

35.7

50–59

69

30.8

60 and above

10

4.5

No response

1

0.5

101

45.7

Educational organization (e.g., university)

49

22.2

Independent administrative institution

46

20.8

Public-service corps (e.g., NPO, incorporated association/foundation)

15

6.8

Other

8

3.6

No response

2

0.9

Types of jobs held Clerical, driver

62

28.1

by personnel

Physician

49

22.2

dispatched to

Nurse

49

22.2

medical teams

Radiation management, health physics

30

13.6

Radiologist

21

9.5

Other

9

4.1

No response

1

0.5

Female No response Age

Affiliation

Medical institution (e.g., hospital)

20

21

Number of times 1

159

71.9

dispatched to

2

21

9.5

Fukushima

3

13

5.9

Prefecture

4

0

0

5 or more

28

12.7

Total Number of

1–2

36

16.3

days dispatched

3–5

152

68.8

6–10

29

13.1

Other

2

0.9

No response

2

0.9

Activities in

Screening at screening centers

59

26.7

Fukushima

Dealing with evacuees (other than radiation-related tasks)

45

20.4

Prefecture

Working at temporary cold areas (not contaminated with radiation)

36

16.3 8.6

Radiation-emergency-medicine-related support at the nuclear accident 19 response base Working at temporary hot areas (potentially contaminated with radiation)

8

3.6

Environmental monitoring

7

3.2

Radiation emergency medicine-related support at secondary radiation

0.9 2

exposure medical facility Medical support other than radiation emergency medicine at initial radiation

0.9 2

emergency medical facilities Radiation dose notification (explanation) on a temporary basis

2

Medical support other than radiation emergency medicine at secondary

0.9 0.5

1 radiation exposure medicine facilities Other

27

12.2

Multiple answers

13

5.9

21

22

Table 2. Knowledge and anxiety level prior to being dispatched Information obtained

Percentage (%)

Knowledge levels Full or general prior knowledge of their own role

83.7

the nuclear accident

62.0

radiation levels at their destination

45.7

conditions faced by evacuees and victims

43.0

meteorological issues

41.7

Little or no prior knowledge of radiation emergency medicine as a whole

76.9

disaster medicine in Fukushima Prefecture

76.5

medical facilities in the vicinity

71.9

Anxiety levels Not very anxious or not anxious at all

54.8

Extremely or slightly anxious

44.8

22

23

Table 3. Relationship between knowledge and anxiety levels prior to being dispatched Degree of anxiety experienced

Information obtained

Status of the nuclear accident

Degree of knowledge

Spearman’s

Not anxious

Not very

Slightly

Extremely

rank

at all

anxious

anxious

anxious

correlation

(1)

(2)

(3)

(4)

coefficient

n

P value

Had no knowledge at all (1)

12

0%

16.7%

50.0%

33.3%

Had only some knowledge (2)

70

7.1%

38.6%

42.9%

11.4%

Had general knowledge (3)

123

19.5%

41.5%

30.1%

8.9%

Had sufficient knowledge (4)

14

50.0%

28.6%

21.4%

0%

Had no knowledge at all (1)

8

0%

25.0%

25.0%

50.0%

Had only some knowledge (2)

28

7.1%

17.9%

64.3%

10.7%

Had general knowledge (3)

134

13.4%

44.8%

32.1%

9.7%

Had sufficient knowledge (4)

50

32.0%

36.0%

26.0%

6.0%

Had no knowledge at all (1)

23

13.0%

30.4%

26.1%

30.4%

Status of evacuees and

Had only some knowledge (2)

102

11.8%

38.2%

38.2%

11.8%

victims

Had general knowledge (3)

80

17.5%

43.8%

33.8%

5.0%

Had sufficient knowledge (4)

15

46.7%

26.7%

26.7%

0%

Own role at the destination

−0.296

< 0.001

−0.290

< 0.001

−0.221

0.001

23

24

Had no knowledge at all (1)

40

7.5%

37.5%

37.5%

17.5%

Radiation levels at the

Had only some knowledge (2)

79

10.1%

41.8%

34.2%

13.9%

destination

Had general knowledge (3)

78

23.1%

38.5%

33.3%

5.1%

Had sufficient knowledge (4)

23

30.4%

30.4%

34.8%

4.3%

Had no knowledge at all (1)

63

9.5%

36.5%

34.9%

19.0%

Radiation emergency

Had only some knowledge (2)

107

15.0%

41.1%

34.6%

9.3%

medicine as a whole

Had general knowledge (3)

44

22.7%

40.9%

34.1%

2.3%

Had sufficient knowledge (4)

5

60.0%

0%

40.0%

0%

Had no knowledge at all (1)

67

13.4%

32.8%

31.3%

22.4%

Medical facilities in the

Had only some knowledge (2)

92

13.0%

45.7%

32.6%

8.7%

vicinity

Had general knowledge (3)

52

21.2%

34.6%

44.2%

0%

Had sufficient knowledge (4)

8

37.5%

37.5%

25.0%

0%

Disaster medicine in

Had no knowledge at all (1)

67

16.4%

31.3%

31.3%

20.9%

Fukushima Prefecture

Had only some knowledge (2)

102

10.8%

46.1%

35.3%

7.8%

(other than radiation

Had general knowledge (3)

45

20.0%

37.8%

40.0%

2.2%

Had sufficient knowledge (4)

5

80.0%

0%

20.0%

0%

−0.203

0.003

−0.196

0.004

−0.177

0.008

−0.157

0.020

emergency medicine) as a whole

24

25

Had no knowledge at all (1)

43

16.3%

37.2%

32.6%

14.0%

Had only some knowledge (2)

85

16.5%

37.6%

35.3%

10.6%

Had general knowledge (3)

83

14.5%

39.8%

37.3%

8.4%

Had sufficient knowledge (4)

9

33.3%

44.4%

11.1%

11.1%

Meteorological issues such −0.046

as wind direction and

0.502

climate

25

26

Table 4. Relationship between knowledge of “general disaster medicine” and “radiation emergency medicine” and level of anxiety prior to being dispatched Had nearly

Job type

n

Had no

Had almost no

Had a certain extent

knowledge at all

knowledge

of knowledge

(1)

(2)

(3)

enough

P

knowledge

value*

(4) Clerical worker/driver

61

42.6%

34.4%

18.0%

4.9%

Physician

49

4.1%

38.8%

38.8%

18.4%

Nurse

49

4.1%

42.9%

40.8%

12.2%

Radiologist

21

4.8%

66.7%

28.6%

0%

29

13.8%

24.1%

55.2%

6.9%

Others

8

12.5%

37.5%

37.5%

12.5%

Clerical worker/driver

61

47.5%

32.8%

16.4%

3.3%

Physician

49

14.3%

36.7%

36.7%

12.2%

Nurse

49

6.1%

44.9%

40.8%

8.2%

Radiologist

21

0%

19.0%

57.1%

23.8%

Radiological management and

30

0%

10.0%

66.7%

23.3%

Knowledge of disaster < 0.001

medicine as a whole Radiological management and health physics specialists

Knowledge of radiation < 0.001

emergency medicine

26

27

health physics specialists Others

8

25.0%

12.5%

37.5%

Not very anxious

Slightly anxious

(2)

(3)

Not anxious at

25.0% Extremely

all

anxious

(1)

(4)

Clerical worker/driver

61

9.8%

41.0%

29.5%

19.7%

Physician

49

20.4%

40.8%

34.7%

4.1%

Nurse

49

6.1%

36.7%

49.0%

8.2%

Radiologist

21

19.0%

42.9%

23.8%

14.3%

30

33.3%

30.0%

30.0%

6.7%

9

33.3%

33.3%

33.3%

0%

Anxiety regarding 0.043

activities Radiological management and health physics specialists Others *Kruskal-Wallis test

27

28

Table 5. Comparison of reasons for anxiety prior to participating in activities in Fukushima Prefecture by job type Knowledge

Experience

inadequacy

inadequacy

Information inadequacy

Inadequate

Unpredictability

Inadequate

Inadequate Possibility

information

information

knowledge

n

Anxiety

of explosion regarding

Job type

Anxiety

Anxiety

Possibility regarding the

regarding

towards

towards

of

at the radiation dose,

damage status,

radiation or

own

radiation

aftershocks nuclear

etc., at the

own role, or

radiation

P about value* lifeline

and tsunamis

abilities power plant

affected area

support

treatment

Clerical 27

25.9%

14.8%

0%

25.9%

11.1%

0%

22.2%

0%

Physician

15

33.3%

20.0%

13.3%

0%

20.0%

6.7%

6.7%

0%

Nurse

24

20.8%

8.3%

29.2%

4.2%

25.0%

0%

8.3%

4.2%

worker/driver

0.042 Radiologist

7

14.3%

14.3%

14.3%

0%

14.3%

28.6%

14.3%

0%

10

10.0%

10.0%

50.0%

0%

20.0%

0%

10.0%

0%

Radiological management and health

28

29

physics specialists Others

3

33.3%

0%

33.3%

0%

33.3%

0%

0%

0%

*χ2 test

29

30

Table 6. Comparison of reasons anxiety was alleviated after participating in activities in Fukushima Prefecture by job type On-site information gathering and sharing

Learning from experience

Safety

No change in the Knowledge of

Knowledge of

Knowledge of

Based on Knowledge

Job type

n

the affected

the radiation

the radiation

area’s status

dose

status

Prior use of status of the

one’s of own role

P protective

nuclear accident experience

value* equipment

while at work Clerical 27

36.4%

27.3%

9.1%

4.5%

22.7%

0%

0%

Physician

15

33.3%

11.1%

22.2%

11.1%

0%

0%

22.2%

Nurse

24

31.3%

12.5%

0%

6.3%

31.3%

0%

18.8%

Radiologist

7

0%

50.0%

12.5%

0%

12.5%

25.0%

0%

worker/driver

0.009 Radiological management and 10

25.0%

0%

0%

50.0%

0%

25.0%

0%

3

0%

0%

0%

0%

66.7%

0%

33.3%

health physics specialists Others *χ2 test

30

31

Table 7. Questionnaire survey of medical organizations Item

n

Number of questionnaires

%

157

distributed Number of complete responses Medical teams dispatched (n = 58)

Dispatch request

58

36.9

Dispatched within Fukushima Prefecture (Pref.)

19

32.8

Dispatched only to affected areas outside Fukushima Pref.a

30

51.7

Not dispatched to affected areas a

9

15.5

No dispatch request

8

20.5

Request was for dispatch only to areas outside Fukushima Pref.

24

61.5

Request was for both within and outside Fukushima Pref. b

6

15.4

Request was only for within Fukushima Pref. b

1

2.6

2

28.6

1

14.3

0

0

Reason for not responding

Unable to obtain sufficient information about conditions in the local

to the request

area and the status of the accident

(multiple responses)

Lack of personnel with knowledge of radiation/radiation emergency medicine Insufficient command and supervision function

31

32

Lack of radiation-related equipment

0

0

Lack of disaster-related equipment

0

0

No one expressed the desire to participate

0

0

Other

5

71.4

Definitely participate

4

6.9

seminars, courses, and trainings Participate to the extent possible

33

56.9

that provide specialized

Probably participate

4

6.9

knowledge in radiation disaster

Definitely not participate

0

0

medicine (n = 58)

Don’t know

13

22.4

No response

4

6.9

Intention to participate in

a b

Organizations that dispatched personnel only to areas outside Fukushima Pref. or did not dispatch personnel (n = 39) Organizations that did not respond to the request n = 7

32