Being a woman or a man has a significant impact on health, as a result of both biological and gender-related differences. The health of women is of particular concern because, in many societies, they are disadvantaged by discrimination rooted in sociocultural factors. One of the sociocultural factors that prevent middle-aged women from having the advantage of quality health services and attaining the best possible level of health are the social norms that result in poor education and health literacy.1 Middle-aged women have a lot of biopsychosocial changes. Menopause add physical and psychological problems. Depression, anxiety, osteoporosis and ischemic heart disease are some of the psychological and somatic problems. Therefore, the middle-aged women need to get education about the developmental crisis like menopause and situational crises such as emergencies and disasters. Since both being female and being old are known as vulnerabilities,2 the improvement of women's health in crises is a key issue and within the scope of World Health Organization's Health Action in Crises1 responsibilities. Inadequate preparation risks the ability of this group to independently obtain food, water, electricity3 or access standard medical care in the post-disaster phase, which can result in previously managed chronic health conditions and cause significant medical problems that require hospitalization or lead into death. In addition the menopause may induce and exaggerate problems in disasters4 and disaster has the potential to affect human health in many ways.5 Disaster prevention training is intended to cultivate the skills and awareness needed to react positively and actively to disaster.6 Therefore, disaster health literacy has a greater impact in the crises7 and risk reduction.

Specifically, disaster literacy is defined as an individual's ability to read, understand, and use information to make informed decisions and follow instructions in the context of mitigating, preparing, responding, and recovering from a disaster.8 Disaster health literacy is the ability to critically question health-related information, the health care system in general and then use this information to actively address the social, economic and environmental determinants of health.9 It can play an effective role in sustainable development.10 Educational and interventional programs about disaster health literacy are essential for middle-aged women.11 That is because educated women showed a lower incidence of psychological and somatic symptoms.412

Disaster health literacy can be improved by asking stockholders to develop specific skills that increase the likelihood of using information sources and increase benefits.13 Health literacy can establish link between individual's literacy skills and health outcomes or information.14 Individuals have to develop disaster health literacy skills, face a variety of changes, and cultivate their abilities.15 Low health literacy in older adults has increased mortality rates and burden of disease. Hence, health literacy is a vital factor in improving health.16 An established goal of the Healthy People 2020 initiative is increasing the health literacy skill.8 It includes knowledge, motivation and competence to access, understand, appraise and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, prevention and health promotion to maintain or improve quality of life. Low health literacy has also been associated with inappropriate use of emergency services, higher rates of hospitalization, and increased health care costs.1718 Individuals with adequate literacy tend to more resilient.19 These result show that negative outcomes in disasters and emergencies are more likely to be experienced by middle-aged women with low disaster literacy.

As inadequate disaster health literacy has been variously found to be a predictor of inappropriate health care. As a result, disaster literacy should be understood as a strategic priority inspiring the future shapes of the health care systems.18 Health care professionals should assess clients' health literacy levels.20 They also should provide information, advice, and support the client to cope with developmental changes (like menopausal symptoms) according to their needs and conditions. The assessment of menopausal health literacy may be also useful for developing crisis interventions to improve the coping behaviors of women with symptoms.21 The Minimum Initial Service Package (MISP) is a series of crucial actions required to respond to reproductive health needs at the onset of every humanitarian crisis. MISP offers a plan for comprehensive sexual and reproductive health care, integrated into primary health care (PHC), as the situation permits. The goal of the MISP is to reduce mortality, morbidity and disability among populations affected by crises, particularly women. Some of the objectives and activities include: (1) To identify organizations and individuals to facilitate the coordination and implementation of the MISP; (2) To prevent sexual violence and provide appropriate assistance to survivors by ensuring systems and ensuring medical services including psychosocial support; (3) To reduce the transmission of human immunodeficiency virus by guaranteeing the availability of condoms; (4) To plan for the provision of comprehensive health services integrated into PHC.22

However, one of the problems in disaster health literacy is a lack of evidence-based practices for effectively disseminating messages to old populations.8 There is a gap between the educational needs and skills to understand disaster risk. Therefore, this review can help to clarify the concept of disaster health literacy of the middle-aged women.

This study was a review article. It was conducted from January 1, 2011 to November 2017 to assess published articles about disaster health literacy of middle-aged women. We searched databases including Google Scholar, Web of Science, ScienceDirect, PubMed, SCOPUS, OVID, ProQuest, and Springer, and Wiley. The data was collected with key words related to the research topic. Using Medical Subject Headings synonyms of the keywords were also extracted. Boolean-operators OR and AND were combined with keywords and entered in the search box of the databases as follows: (“Women's health” OR “Geriatric health”) AND (“Health literacy” OR “Disaster health literacy” OR “Disaster prevention literacy” OR “Risk knowledge” OR “Knowledge management”) AND (“Disasters” OR “Risk OR “Crises”). We reviewed the full text English-language articles published between 2011 and 2017. Additional references were identified from reference lists in the targeted publications, review articles and books.

Recent disasters, and the likelihood of large-scale disasters in the future, make addressing and improving disaster literacy for the population, and in particular women, a pressing public health concern. Older adults at risk considered vulnerable are those who are at increased risk for adverse outcomes pre/during/post disasters due to a variety of factors that can include sensory an cognitive impairment, physical decline, and medical illness. In addition to preexisting medical conditions, other factors which are reported to negatively affect the ability to remain safe pre/during/post disasters include sex, age, social isolation, limited financial resources, low education, and low disaster literacy. Some factors are identified as important reasons for the development of literacy. Literacy can be improved through education and training, along with developing the ability to think about important questions, explain phenomena and use scientific evidence.

This review showed that disaster health literacy is important for middle-aged women because they may suffer from physical and psychological problems caused by menopause as a developmental crisis and disasters as situational crises. Disaster literacy can help the middle-aged women to reduce disaster risk and to improve resiliency. Education has also an essential role in health promotion and disaster preparedness.

Nowadays, there are reports that show populations were inadequately prepared. Elderly women as a population that suffer from physical and psychological problems caused by menopause are vulnerable. They are susceptible to osteoporosis, heart disease, depression, post-traumatic stress disorder, sexually transmitted diseases such as acquired immune deficiency syndrome and hepatitis and so on. That is why disaster health literacy is important for them. Policy makers and managers have to find out resources on supporting and educating middle-aged women, or raising awareness among members of the particular health and safety concerns for older women in emergencies and disasters. Organizations responsible for disaster planning and educational programs have to routinely promote awareness about how to prepare for disasters, obtain safe shelter, cope with adverse events, initiate the recovery process, medical needs, mental health, education, food, nutrition and sanitation. Policy makers and managers have to pay attention to the specific needs of middle-aged women.23 An urgent attempt is required for future policy development of the achievements of the Sustainable Development Goals to incorporate disaster health literacy, promoting a holistic approach to the empowerment of individuals specially women, families and communities.24 Organizational and system factors can influence literacy, which in turn may affect acquirement of awareness and new knowledge.25 Disaster risk reduction and its priority, “risk knowledge” can play an effective role in sustainable development. The inadequacy of disaster literacy research and development is disadvantageous to the safety of the middle-aged population. This article reviews the disaster health literacy of middle-aged women, proposes an attention for disaster literacy and emphasizes education and training for disaster risk reduction.

Policymakers and managers should be aware of the problems of elderly women as a vulnerable group and have to plan programs to increase disaster health literacy and preparedness. Due to the growing elderly population, it is necessary for health organizations, especially in developing countries, to consider seriously the issue of elderly healthcare and their educational needs in disasters.