Introduction 
According to the United Nations Office for Disaster Risk Reduction (UNDRR), disaster is “ a serious disruption of the functioning of a society leading to widespread human, material, economic, and environmental losses that exceed the capacity of a community to cope using its resources” [1]. Disasters challenge the ability of health systems to meet the needs of society. Damage to infrastructure, staff shortages at all levels, and an increasing need for health services will jeopardize the functioning of health systems [2, 3]. Therefore, healthcare providers (HCPs) must be prepared to manage a surge in the number of patients should a disaster occur [4, 5]. Some disasters may be followed by a lack of workforce and loss of equipment and supplies [6, 7, 8, 9]. In a disaster, HCPs are expected to provide care and treatment for the casualties and the nonemergency patients while concerned about their families [4].
Most people believe that HCPs, firefighters, and relief workers in general who participate in relief operations tend to work in any disaster. In contrast, these people are not always willing to work. Indeed, their intention to work in disaster relief operations is highly dependent on the type of disaster [10, 11]. Evidence also shows that the intention to work varies between 25% and 80% among HCPs in public health emergencies. Factors associated with the nurses’ intention to work in disasters included insufficient knowledge and skills, fear of contracting infectious diseases, overworking, sense of responsibility, perceived self-efficacy, financial compensation, age, gender, knowledge and attitude, and academic degree [12-16].
As an effective measure in the preparedness phase of disaster risk management, identifying the factors related to the intention to participate in disaster relief operations will lead to planning better and coping with such situations. This study used a systematic literature review approach to find the factors affecting the intention of HCPs to work in disaster response.

Materials and Methods
The protocol of this study is registered in PROSPERO (CRD42021234620). To obtain relevant studies from the databases, all original articles examining the intention of HCPs to participate in disaster response operations were enrolled in the study. There were no restrictions on the language of the publications. It is noteworthy that articles on the intention of other relief workers, such as firefighters, to participate in disasters, as well as those in the form of letters to the editor, literature review, short study or brief communication, and conference papers, were excluded.
Scopus, PubMed, and Web of Science (WoS) databases were searched to obtain relevant studies published between 1950 and November 1, 2020. To develop the search strategy, several relevant studies on the intention of HCPs to work in disasters were reviewed to extract the keywords. Regarding the frequent use of”human resource,” all entry terms for this keyword were collected using the MeSH feature. Words were combined using the Boolean search method: AND and the OR operators. 
All the retrieved documents using the above syntaxes were imported into EndNote, and duplicates were removed. The articles were screened for titles and abstracts, and the relevant items were selected. Next, the full-text articles were assessed by two authors for eligibility criteria. Any disagreement between the two authors was resolved through group discussion and consensus. In case of disagreement after the group discussion, advice and the opinion of a third party were considered. The references of the included articles were also examined to find possible related articles. Using the Scopus database, key journals in the area of the research title were also reviewed.
After the search was completed, data extraction was provided, and they were imported into Microsoft Excel, version 2010. Each extracted factor affecting the intention of HCPs was entered into Excel, and then the concatenate function was connected to the related article code. All extracted factors were then categorized by thematic analysis, i.e. first, all the affecting factors were listed and then classified into categories and subcategories through a group discussion attended by the research authors and using the data validation feature in Excel. The same factors mentioned in different studies were merged, and a common label was chosen for similar factors. Any uncertainty over labeling and categorizing the factors was discussed with the review team.

Results 
An initial search in Scopus, PubMed, and Web of Science databases yielded 5721 documents, of which 1818 duplicates were removed after being imported into EndNote, version 9 (Figure 1). The 16 enrolled studies in the systematic review were conducted between 2009 and 2020 in Australia (2), South Korea (3), the United States (4), Israel (3), Yemen (1), China (1), Taiwan (1), and Brazil (1). There was one mixed methods study, and the other 15 were performed using quantitative methods. In total, 13 studies specifically examined the intention of nurses to work in disasters, of which one investigated only nursing students and 3 surveyed a combination of nurses, physicians, physicians and or nurses, and emergency medical technicians (Table 1).






Regarding data collection tools, four studies used specific tools to assess the intention of HCPs in disasters, and the remaining 11 employed researcher-made tools based on the review of previous studies or modification of other non-specific questionnaires of staff intention to work. Only one study approached the issue in a qualitative design using interviews and focus group discussions.
As explained in the study methods, using the concatenate function in Excel, every factor affecting the intention of HCPs was imported into Excel and then connected to the study with the related article code. Next, all extracted factors were categorized by thematic analysis. First, all the affecting factors were listed and then classified through a group discussion attended by the research authors and using the data validation feature in Excel into the following categories and subcategories: Organizational factors (supply management, risk management, organizational environment, organizational climate, managerial support, financial incentives), personal factors (demographic, familial, beliefs and values, health status of HCP, individual experiences, knowledge and education, occupational, self-efficacy), and nature of the disaster (type of disaster, prevention, and treatment). The same factors mentioned in different studies were merged, and a common label was chosen for similar factors. The review team discussed any uncertainty over labeling and categorizing the factors (Table 2).




Considering the results of the articles, 75 factors affecting the intention of HCPs were identified and classified into 3 categories and 16 subcategories. 

Discussion
In the present study, 13 studies explicitly examined the intention of nurses to participate in disasters, of which one investigated only nursing students, and three surveyed a combination of nurses, physicians, or nurses, physicians, and emergency medical technicians. This finding revealed that health systems had focused on assessing nurses’ intentions as one of the critical health professions. Nurses, as the largest part of the HCPs, are the frontline responders in an emergency or disaster. During disasters, especially in non-conventional ones, nurses experience considerable anxiety [34]. Although caring for irradiated patients in radiological incidents poses the least risk for the HCPs [35-37], such anxiety could have a significant impact on their performance. As a practical solution, training can be used to increase the intention of HCPs in this regard. In most cases, the reluctance of HCPs was due to insufficient knowledge of the nature of disasters [38], leading to delays or refusal to provide care to the patients in disasters, especially chemical, biological, and radiological incidents [38, 39].
In the present study, safety-related issues, categorized into personal and organizational factors, affected the staff’s intention to work during a disaster. Concerns about the safety of family, colleagues, and HCPs were among the most frequent barriers to staff intention to work during disaster [2, 11, 40-45]. HCPs are vulnerable to many occupational hazards and experience a great deal of emotional stress as a result of working in healthcare settings [2, 46]. HCPs are concerned about their safety against illnesses, injuries, and even death, and this issue will ultimately lead to reluctance to work during a disaster [47-50]. The availability of appropriate treatments, prophylaxis, and infection control may increase their willingness to work in such conditions [41, 49, 51, 52]. Lack of trust in employers to provide safe conditions for employees during a disaster could be associated with a decrease in willingness to work [2, 40, 43, 53]. Providing none or contradictory information to HCPs can also cause some degrees of distrust in employers in the health system [2, 54, 55]
In this study, individual factors were demographic, familial, beliefs and values, the health status of HCPs, individual experiences, knowledge and education, occupational, and self-efficacy. Previous experience working in disasters was one of the factors affecting the willingness of HCPs to work during disasters. Nurses with prior disaster experience can play an important role in a crisis and perform triage and life-saving measures [21]. Other studies emphasized the experience of working in difficult situations [2, 17, 22, 23, 30] and prior experience of responding to a disaster [4, 17, 23, 24, 26, 27, 30]. Gaining experience is always beneficial, and by increasing a person’s experience in the natural disaster response team, HCP can be better present in the following events.
A higher level of knowledge and education due to increasing age obtaining more information and improving knowledge about accidents and disasters can increase the level of preparedness of nurses to respond to natural disasters [21, 23-25, 28, 30, 33].
Gender was another important individual factor [4, 21, 22, 26, 27, 30]. A man’s gender is one factor that relates to people’s physical and psychological condition. Since male nurses have more resilience and emotional control, they can perform better in this field. Special needs of female nurses in dealing with disasters can be a challenge that needs attention to reduce their psychological and emotional problems in these situations [56]. 
Communicating with family members was another influential factor that can improve the willingness of HCPs to be involved in disaster response operations, so one of the barriers was their perceived disability to communicate with their family members while working in such situations [40, 57, 58]. Working long shifts away from family members could cause concern for HCPs, who must be quarantined[40, 57]. Providing various communication methods with family members and friends might increase staff satisfaction and willingness to work in the event of a disaster.
Professional commitment was another important factor that persuaded the staff to work in times of disaster. Evidence suggests a strong sense of professional duty among HCPs worldwide [2, 43, 47, 51, 52, 55]. In some cases, HCPs stated that concerns for their personal or family’s safety might be overlooked in their desire to take on professional responsibilities [2, 40, 43]. Even some studies found the sense of professional duty to be the most influential factor in the intention of the emergency department staff to work during a disaster. However, some evidence predicated that HCPs felt compelled to work during a disaster [42, 47, 52]. 
The type of disaster was another factor affecting the staff’s intention. HCPs were more inclined to work in case of natural disasters such as earthquakes, floods, and storms, while their willingness to work diminished in non-conventional disasters such as biological, chemical, radiological, and nuclear incidents. A study on the desire of firefighting program students also yielded similar results, where more than 90% of the students were interested in participating in fire incidents and earthquake relief operations. In comparison, about 40% preferred not to be involved in nuclear disasters [59]. Smith et al. depicted that prehospital emergency technicians were more concerned about working in radiological and nuclear incidents [60]. Such a mentality could reduce human resources and disrupt response operations in radiological and nuclear incidents [61].
Epidemic of infectious diseases is another disaster the HCPs were less inclined to get involved in. HCPs experience severe psychological distress during the outbreak of infectious diseases [2, 62]. During the outbreak of MERS (the Middle East respiratory syndrome) as a contagious disease epidemic, evidence shows that more than 90% of HCPs in Saudi Arabia, nearly half of whom were nurses, had a negative attitude towards suspected or infected patients [63]. With the onset of reports on morbidity and mortality of such diseases, the level of anxiety and stress rise among HCPs, as they are likely to be called to the front line to fight against the disease due to a lack of manpower. Furthermore, if HCPs involved in managing the disease become infected or die from the disease, HCPs are more likely to avoid suspected or infected patients [64]. 
Evidence from previous studies suggested that factors related to the willingness of HCPs to work after public health disasters could be placed into four categories: Personal, professional, organizational, and safety (threat-related) factors; among the personal factors, the findings revealed that women were less willing to work in such situations than men [61, 62]. Concerns about family members, friends, pets, and personal commitments such as caring for a child or older adults were reported as powerful barriers to intention to work in times of disaster [16, 65, 66]. Among the professional factors, evidence indicates that clinical staff are more willing to work than non-clinical staff [65]. Belief in duty to care, knowledge, and a sense of efficiency were described as facilitators of intention to work in the event of a disaster. Organizational factors have not been widely discussed. Apparently, confidence in the employer’s ability to meet the basic needs of the staff (such as food, water, etc.) and other concerns was a key factor in this regard. Findings on safety-related factors depicted a lower tendency to work for disasters, posing a greater personal risk to the practitioners, such as infectious disease epidemics and biological, chemical, and radiological incidents compared to natural and other man-made disasters [16, 65, 67].
In addition to high morbidity and mortality that jeopardize the health of a community, epidemics of infectious diseases are considered a significant threat to the health system and especially the HCPs for being the frontline responders in such situations [12, 68, 69].
Studies have shown that the intention to work during a disaster might be associated with the nature and type of the event, professional needs, individual needs, work environment, atmosphere, knowledge about the incident, and a perception of efficacy [4, 16, 66]. Contrary to the popular belief that HCPs tend to work in any disaster, their intention to work highly depends on the type of disaster, the risk to their health and that of their families, their commitment to the community, professional and financial issues, responsibility, and so on. 

Ethical Considerations
Compliance with ethical guidelines
The study was approved by the Ethics Committee of Shahid Sadoughi University of Medical Sciences and Health Services. 

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Study design: Mohammad Reza Khajehminian, Mehdi Raadabadi, and Maryam Nikfard; Search strategy: Mohammad Reza Khajehminian and Mehdi Raadabadi; Databases search: Mehdi Raadabadi, Maryam Nikfard, and Mahnaz Eider; Analysis and interpretation of data: Mohammad Reza Khajehminian, Mehdi Raadabadi, and Maryam Nikfard; Drafting of the manuscript: Mehdi Raadabadi and Mahnaz Eider; Critically revision of the article: Mohammad Reza Khajehminian and Maryam Nikfard; Supervision: Mohammad Reza Khajehminian; Final approval: All authors. 

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors are grateful to all scholars who have conducted useful studies in other countries to examine the intention of HCPs to work in times of disaster, and this study is a review of their results. In addition, the authors consider it their duty to appreciate all HCPs who try to promote community health through their professional services.


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