Consensus on Key Domains for Emergency Medical Teams Deployment Evaluation: A Delphi Method Study

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Bausch, Arlinda Cerga Pashoja, Joanna Schellenberg This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7491115/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Feb, 2026 Read the published version in Conflict and Health → Version 1 posted 10 You are reading this latest preprint version Abstract Background Emergency Medical Teams (EMT) deploy to provide urgent care during and after sudden onset disasters. Although the World Health Organisation has set standards for EMTs on training, personnel, and operations, there is presently no standardised evaluation framework to assess deployments. Methods As a step towards creation of an EMT deployment evaluation framework with an agreed upon common set of criteria, we used a two-round modified Delphi method to elicit perspectives from key stakeholders, including EMT members, researchers, funders, representatives of deploying governments, and host organisations. We asked participants to rate themes and questions relevant to EMT evaluation, derived from a previous study, using a four-point Likert scale, with consensus considered reached when 75% or more respondents rated the themes or questions ‘slightly suitable’ or ‘highly suitable’. Results Two rounds of the Delphi process were completed by 15 and 16 participants, respectively, with all first-round participants plus an additional person participating in the second round. Participants reached consensus on all 23 proposed themes and 162 of 165 (98%) proposed questions, with near unanimous views on many: 17 themes and 55 questions reached 100% consensus. Conclusions Based on these findings and guided by the categorisation of pillar themes and questions outlined in the World Health Organization’s After Action Review guidance document, we proposed a preliminary structure for an EMT devaluation. These findings can serve as a foundation to inform the future design of a standardised evaluation framework. Further research is needed to continue to identify priority areas within the evaluation framework, as well as the methodology for conducting the evaluation. natural disasters humanitarian emergencies disaster aid evaluation Delphi method Figures Figure 1 Figure 2 Figure 3 Figure 4 Background An Emergency Medical Team (EMT) is composed of health professionals providing urgent care during sudden onset disasters, both “natural” and human-caused (1). In 2014, the World Health Organization (WHO) launched the EMT Initiative to set common standards for EMT healthcare services to enhance and ensure response quality. The EMT initiative includes a process of EMT classification, encouraging all EMTs to register within the WHO EMT system, and have their services and skills validated by the initiative (2). Initially focused on surgical care following earthquakes, the WHO EMT Initiative has adapted to new challenges, creating guidelines for infectious diseases and conflict zones. While the WHO EMT initiative sets minimum standards, countries may nevertheless accept teams that have not been classified by WHO, leading to concerns about EMT service quality and accountability. Even before the WHO initiative was established, there were concerns regarding timing, relevance, and integration of EMT activities with local health systems (3-6). Scepticism regarding the motivations behind international aid continues to grow, particularly among beneficiaries, and media critiques often hold EMTs accountable more effectively than funders (7, 8). Transparency in evaluation methods is critical in learning from past deployments (9). Recent literature stresses the need for quality assurance and adherence to WHO standards (10, 11). Despite a 2023 study highlighting the need for standardised reporting and sharing of experiences (12), the EMT sector lacks a standardised evaluation framework to assess EMT deployments. Instead, it often relies on daily reports submitted during deployment that emphasise clinical data, an approach that is not conducive to overall assessment of accountability and effectiveness, and making it hard to draw lessons across deployments (7, 11, 13, 14). EMT evaluation that have been performed tend to focus on funder requirements rather than improvements. There is often reluctance to share data or publish data (15, 16), perhaps to avoid manifesting shortcomings in expectations and performance gaps (6, 17-19), rendering it difficult to make evidence-based decisions (7, 11, 13, 14, 20). The publications that do exist often focus on descriptive narratives and ‘lives saved’, rather than a broader range of measures that can provide a better idea on usage of resources to better support local health infrastructure (13, 18, 19, 21-23). Standardised evaluations of EMT deployments could help improve adherence to the standards set by WHO (3, 24). In its strategic priorities for 2022-2024, the Inter-Agency Standing Committee, an inter-agency forum of the United Nations and non-UN humanitarian partners founded in 1991 to strengthen humanitarian assistance, included improving ‘Accountability to Affected People,’ ensuring that no one is overlooked, and that community feedback is considered (25, 26). However, international disaster rules and standards require improved implementation, and practical methods to support adherence must be developed. While there are no established frameworks for EMT evaluations, various prominent organisations in the humanitarian field have developed frameworks for longer-term humanitarian assistance. An extensive review of existing reports, documents, and guidelines related to humanitarian assistance evaluations reveals that, although most humanitarian organisations have their own evaluation frameworks, the criteria used vary widely, and are generally not directly applicable to EMT evaluations, which require quicker assessments during EMT deployments compared to the longer humanitarian assistance. Given the lack of an evaluation framework for EMT deployments, we sought to gather views of experts in this field on key themes and questions to be incorporated into a future EMT evaluation, with a goal of eventually producing a framework that can demonstrate accountability, foster discussions for improvement and knowledge sharing, and provide an overview of resource allocation. We focussed on the three most common types of disasters that required international aid: floods, tropical cyclones, and earthquakes and related tsunamis. The Organisation for Economic Co-operation and Development classifies evaluations into five types: formative, process, output, outcome or performance, and impact (27). This study focussed on process, output, and outcome evaluations, which assess short-term outputs, which are most relevant to EMT deployments. Methods The reporting in this paper adheres to the Conducting and Reporting DElphi Studies (CREDES) checklist(28). Study design This is a mixed methods study using the Delphi method, including both qualitative and quantitative data. Ethics approval Ethics approval was provided by the London School of Hygiene & Tropical Medicine Ethics Committee (Ref: 29517). Participants gave written informed consent before each round of the Delphi questionnaire. The Delphi method The Delphi method is a widely used approach that facilitates consensus among experts, particularly in the development of standards, frameworks, and guidelines (29). We selected the Delphi method to obtain expert consensus on a relatively novel topic. This approach allows participants to remain anonymous, thereby reducing the influence of dominant individuals and facilitating unbiased consensus-building. We employed a modified Delphi method, drawing on findings from published literature and qualitative interviews to inform the development of the first-round questionnaire. (Unpublished manuscript. [1] ) As a result, the process did not begin with open-ended questions (30). We administered two rounds of questionnaires. In addition to questions about the content of an EMT evaluation, in Round 1 we included questions related to the process – who should conduct the evaluation and how long post-EMT deployment. Figure 1 shows the stages of the Delphi method process in this research, from the preparation to analysis. We generated common evaluation themes and questions in a previous study in which EMT stakeholders were interviewed about their perspectives and current practices in evaluating EMT deployments.(Unpublished manuscript. 1 ) We grouped the themes and questions according to the six After Action Review pillars established by the WHO to assess response to significant public health events (31). We asked participants to rate the evaluation themes and respective questions on their perceived suitability for an EMT deployment evaluation framework, using a four-point Likert scale: ‘highly suitable’, ‘slightly suitable’, ‘slightly unsuitable’ and ‘highly unsuitable’. We then gave participants the opportunity to explain their choices, as well as to provide new suggestions to be added to the list. Round 2 included evaluation themes and questions that had not reached consensus in the first round, along with items that received suggestions for modification and new proposals emerging from participants’ comments in Round 1. For questions that reached consensus but were accompanied by suggested revisions, we asked participants to indicate whether they preferred the original version or supported the proposed changes. We considered all participant comments provided in both rounds of the Delphi, adjusting and incorporating suggestions for new evaluation themes and questions from Round 1 into Round 2 as appropriate. We took note of any patterns to identify respondents who consistently provided low ratings. Sampling and recruitment A panel of 10 - 15 experts is considered ideal for the Delphi method (32). We sent invitations to 27 potential participants to include various stakeholder groups and to account for non-response (Table 1). The inclusion criteria required participants to hold a leadership role and have experience working with or within EMTs during floods, tropical cyclones, or earthquakes and related tsunamis, both before and after the COVID-19 pandemic. Table 1 Characteristics of Participants in the Delphi Study Parameter Participants, n (%) Round 1 Round 2 Type of stakeholder Researchers in Emergency Medical Teams and humanitarian assistance 3 (20%) 3 (19%) World Health Organization classified and unclassified Emergency Medical Teams 8 (53%) 9 (56%) Deploying governments or funders 1 (7%) 1 (6%) Host governments 2 (13%) 2 (13%) Host partners (e.g., local health services) 1 (7%) 1 (6%) Gender Male 11 (73%) 11 (69%) Female 4 (27%) 5 (31%) World Bank income groups of participants’ nationality (102) Low income 0 (0%) 0 (0%) Lower-middle income 1 (7%) 1 (6%) Upper-middle income 5 (33%) 5 (31%) High income 9 (60%) 10 (63%) World Health Organisation Region of participants’ nationality Africa 0 (0%) 0 (0%) Americas 1 (7%) 2 (13%) Eastern Mediterranean 2 (13%) 2 (13%) Europe 7 (47%) 7 (44%) South-East Asia 1 (7%) 1 (6%) Western Pacific 3 (20%) 3 (19%) There were no declared conflicts of interest. Piloting the questionnaire We piloted the first Delphi questionnaire with seven individuals, five with substantial experience working in EMTs and two with expertise in questionnaire administration who provided feedback on structure and flow. None of the seven were included as participants in the subsequent study. Based on feedback from the pilot, we revised the questionnaire layout, introductory text, and wording to enhance clarity. We used an online surveying tool, Jisc Online Surveys (Jisc, United Kingdom). The questionnaire was available in English only. Data analysis For each round, we defined consensus as 75 percent or more participants rating the evaluation themes and questions as ‘slightly suitable’ or ‘highly suitable’. Questions that reached consensus but did not yield agreement on suggested modifications were retained within the ‘reached consensus’ category, with annotations indicating the lack of consensus on the proposed changes. Similarly, for suggested changes, we considered the change agreed if 75 percent or more participants rated ‘I agree with the change’. Results Participants Of the 27 invited participants, 15 (56%) participated in Round 1, and 16 (59%) participated in Round 2 (Table 1 ). All Round 1 participants also took part in Round 2, with one additional participant joining in the second round. Delphi method findings After two rounds of the Delphi process, all 23 proposed evaluation themes and 162 out of 165 questions achieved consensus (Fig. 2 ). Consensus was unanimous (100%) for 17 themes and 55 questions (Table 2 ). Notably, the majority of items receiving 100% consensus fell under the After Action Review pillar of “Health operations and technical expertise”, suggesting that this theme consistently aligns with the views and interests of participants. Many themes and questions also aligned closely with the existing literature on EMTs, indicating their prominence in current EMT publications. A full list of the evaluation themes and questions and their respective level of agreement is contained in Appendix 3. Table 2 Evaluation Themes that Reached Consensus across Two Rounds of Delphi Method After Action Review Pillar Evaluation themes Agreement Intensity (Absolutely Suitable + Slightly Suitable) 1. Leadership Leadership 100% Teamwork 100% 2. Partner coordination Deploying organisation 100% Local Communities 93% Host Organisations 100% World Health Organization, Emergency Medical Teams Coordination Cell and other Emergency Medical Teams 100% 3. Information management and planning Preparation of evaluation 93% 3. Information management and planning Information Management 100% Documentation 100% 4. Health operations and technical expertise Team Members’ Experience 100% Filling in gaps of needs 86% Patient Numbers 100% Clinical Care 100% Referral of Patients 100% Local engagement 100% Post-deployment follow-up 100% 5. Operations support and logistics Arrival 100% Quality assurance 100% Equipment, supplies and logistics 93% Safety 94% Exit 100% 6. Finance and administration Finance & Administration 100% Publications and reports 100% For the three themes and questions on which consensus was reached but without agreement on proposed changes, the disagreements were largely related to syntax (i.e. “host organisation” versus “local government” or “ministry of health”) and how a particular theme should be categorised (i.e. under “Information management and planning” or “Operations support and logistics”). Consensus was not reached for three questions: 1) How long did it take for patients to arrive at the hospital? (Agreement ≤ 69%. No comments provided.) 2) Did the EMT do any follow-up to patients after the it exited the country? (Agreement ≤ 63%. Five participants commented on the difficulty and infeasibility of doing this in the field.) 3) Were there repeat visits of EMT members to the disaster area after the deployment? (Agreement ≤ 69%. No comments provided.) Conducting the evaluation Participants’ views on who should conduct evaluations varied, but most thought it required a team approach, often including the EMT leader, and sometimes external consultants (Fig. 3 ). A majority (53%) of participants thought that the evaluation should take place within two months after end of the deployment, and 93% thought within three months (Fig. 4 ). Discussion Despite widespread agreement of the need, there is currently no standardised framework for evaluating EMT deployments. Our study represents a first step toward a solution, highlighting relevant themes and questions for such a framework for which there is significant consensus, indeed nearly unanimity, among key stakeholders. Many of these themes and questions are supported by existing literature. The Delphi method proved to be a useful tool, ensuring anonymity and preventing “groupthink”, which can lead to unchallenged, poor-quality decision-making ( 33 ). While our study does not result in, and nor do we propose here, a finished EMT evaluation tool, it lays a foundation for further discussion and research toward that goal. Participants’ rejection of evaluation themes or questions that would require longer-term follow-up of patients are understandable, given the challenges of doing so once the EMT has left the field. Nevertheless, such follow-up is essential for continuity of care, and it would behove EMTs to work with local providers to ensure that such follow-up takes place. (Unpublished manuscript. 1 ) Issues of post-deployment follow-up have been increasingly signalled in other research ( 10 , 34 ). Participants’ conviction that EMT deployments should be evaluated within a few months after completion are consistent with WHO’s guidance on After action Review, which calls for review within 3 months after official declaration of the end of the event. For questions that reached consensus but did not reach agreement, standard terms used in WHO’s Classification and Minimum Standards for EMTs, or the After Action Review guideline, could be used to guide the choice of words in future studies and a final EMT evaluation framework. We note the following limitations to our study: Less than 60 percent of those invited to participate agreed – a common challenge when trying to get time from undoubtedly busy professionals participating out of their own interest, with no compensation. Key voices may be missing from stakeholders who did not participate. Furthermore, the purposive sampling approach may have introduced selection bias, since those more actively engaged with EMTs or affiliated with certain organisations may have been more inclined to participate. Although the participants included diverse stakeholders, the findings may not be fully generalisable across all global EMT contexts, particularly those underrepresented in the study, such as from regions outside the WHO classification or local nongovernmental organisations. We chose to make it optional for participants to provide reasons for their choices to make it easier to complete the questionnaire and thus encourage participation, and indeed completeness in both rounds was high. However, since many participants did not explain their rationale, there could have been a loss of valuable insights they might have. The study focused primarily on identifying areas of agreement and did not explore in depth the reasons for disagreement, which could have yielded additional insights into contentious areas of EMT evaluation. The questionnaire was administered solely in English, limiting potentially valuable contributions from non-English-speaking stakeholders and introducing potential interpretation biases. While consensus was reached on framework content, the evaluation tool itself has not yet been piloted or validated in operational EMT settings, which is a necessary step for future implementation. We did not include deployments related to human-caused disasters such as armed conflicts, since they present different challenges for EMTs ( 35 , 36 ). EMT members are expected to undergo competency-based training prior to deploying, so the most appropriate skills are brought to the field, and team leaders are expected to undergo specific leadership training ( 37 ). A clear command and communication structure within the EMT can facilitate decision-making ( 24 ). Team members should be well-informed about the deployment context before deployment ( 38 ). For EMTs to be effective, collaboration among key players—such as local governments, host organisations, the WHO, and NGOs—is essential. Each stakeholder influences EMT operations, requiring active engagement from all ( 39 ). Timely information sharing is critical to minimise delays in responding to disaster victims, potentially reducing morbidity and mortality ( 12 ). During sudden onset disasters, EMTs should report to local health ministries to enhance coordination, and a robust reporting system led by the WHO is essential ( 39 , 40 ). Additionally, EMTs must respect host country regulations, as accepting international aid can have political implications ( 41 ). Effective EMT deployment requires the host country to request and approve assistance ( 42 ). Life-saving interventions can only be performed within 48 hours of an sudden onset disaster, but they often arrive too late ( 43 ). EMTs should have ready-to-deploy equipment and restock supplies locally for better self-sufficiency ( 14 , 44 ). Real-time patient data such as epidemiological data and health needs can help identify underserved populations ( 45 ), maintain care quality, and for early outbreak detection ( 46 , 47 ). EMTs provide crucial primary care when local services are compromised ( 21 , 22 ). In areas with weakened local health infrastructure, EMTs may receive patients from clinics or act as referral centres for local hospitals to prevent overwhelming local facilities ( 48 , 49 ). Building relationships with local health providers boosts community confidence and facilitates the resumption of local services ( 47 ). As humanitarian assistance evolves, considering the perspectives of patients and communities is essential to align aid with their needs ( 50 , 51 ). Sustainability of care post-deployment is increasingly important, particularly for ongoing health needs ( 20 , 52 ). Developing follow-up protocols, and longer deployments can enhance sustainability ( 23 ). Current guidelines focus on clinical care but often overlook aspects like patient safety and mental health ( 53 ). Shared challenges include language barriers and cultural differences, which can affect community acceptance ( 54 , 55 ). Equipment must be suitable for local conditions ( 12 , 56 ), and teams must be prepared for unstable logistics ( 57 , 58 ). Effective coordination of resources is essential for targeting aid, aligning capabilities with local needs, based on rapid needs assessments after sudden onset disasters ( 12 , 39 , 47 , 59 ). EMTs should also publish all collected data and establish a global information network to share lessons learned with other teams ( 54 ). Conclusions This study aimed to develop a consensus-based evaluation framework for EMT deployments using a modified Delphi method. The resulting evaluation themes and questions reflect strong stakeholder consensus and may inform future framework development. The consensus achieved suggests a shared understanding of core domains for assessing EMT deployments, particularly in the area of health operations and technical expertise. Despite a number of limitations, detailed above, the Delphi approach enabled anonymity and broad engagement, yielding perspectives that provide a valuable foundation for advancing EMT evaluation. Further research is needed to prioritise the identified indicators, refine language for clarity, and explore feasible and context-appropriate methods of data collection. Operational testing and feedback will be essential for ensuring that the framework is both practical and adaptable across different disaster contexts and deployment environments, with an ultimate goal of enhancing the quality, accountability, and sustainability of emergency health responses worldwide. Abbreviations EMT: Emergency Medical Team CREDES: Conducting and Reporting DElphi Studies WHO: World Health Organization Declarations Ethics approval and consent to participate: Ethical approval was provided by the LSHTM ethics committee. Participant consent was sought for both rounds of the Delphi method. Consent for publication: Not applicable. Availability of data and materials: The datasets used for analysis in this study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: The authors received no specific funding for this work. 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The patient safety practices of emergency medical teams in disaster zones: a systematic analysis. BMJ Glob Health. 2019;4(6):e001889. Pearce A, Mark P, Gray N, Curry C. Responding to the Boxing Day tsunami disaster in Aceh, Indonesia: Western and South Australian contributions. Emerg Med Australas. 2006;18(1):86-92. Bompangue D, Oyugi B, Bokulu M, Tshijuke SM, Das T, Conteh IN, et al. COVID-19 as an Accelerator of the Implementation of Emergency Medical Teams Initiative in the AFRO Region. Disaster Medicine and Public Health Preparedness. 2023;17:e489. Chauhan A, Chopra BK. Deployment of Medical Relief Teams of the Indian Army in the Aftermath of the Nepal Earthquake: Lessons Learned. Disaster Medicine and Public Health Preparedness. 2017;11(3):394-8. Redmond AD, Watson S, Nightingale P. The south Manchester Accident Rescue Team and the earthquake in Iran, June 1990. BMJ. 1991;302(6791):1521-3. Roshchin GG, Mazurenko OV. Ukranian's Disaster Medicine Team Mission to India following the earthquake of 2001. Prehospital and Disaster Medicine 2002;17(3):163-6. Djalali A, Ingrassia PL, Corte FD, Foletti M, Gallardo AR, Ragazzoni L, et al. Identifying deficiencies in national and foreign medical team responses through expert opinion surveys: implications for education and training. Prehospital and Disaster Medicine 2014;29(4):364-8. Footnotes Yeung T, Bausch DG, Cerga-Pashoja A, Schellenberg J. Stakeholder Perspective on Evaluating Emergency Medical Teams Deployments. 2025 Additional Declarations No competing interests reported. Supplementary Files Appendix1.docx Cite Share Download PDF Status: Published Journal Publication published 05 Feb, 2026 Read the published version in Conflict and Health → Version 1 posted Editorial decision: Revision requested 26 Nov, 2025 Reviewers agreed at journal 22 Nov, 2025 Reviewers agreed at journal 12 Nov, 2025 Reviews received at journal 30 Oct, 2025 Reviewers agreed at journal 23 Oct, 2025 Reviewers agreed at journal 30 Sep, 2025 Reviewers invited by journal 08 Sep, 2025 Editor assigned by journal 08 Sep, 2025 Submission checks completed at journal 08 Sep, 2025 First submitted to journal 29 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7491115","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":512740249,"identity":"a045a7ec-f415-4f07-b5b7-de58b2780144","order_by":0,"name":"Tiffany Yeung","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIiWNgGAWjYDACZsYHHxC8CgsGAxhbAocOHmZmwxkI7hkJBgM2QloYkLUwthGhxZ6dmbHh547DDAbHe8wefp0nYW8u353A8KOGIXFmA06HMTb2ngFqOXPG3Fh2m0TizjbeDYw9xxgSZ+P0C//xB7xtQC03csykJbdJJBgc493AwNvAkDgPpxagLX9BWu6/AWqZI2EP0sL4l4CWZogtPGaSHxskGDcAtTCDbMHpsMNALbJt6TySZ9LKpBmOSSRuOJa74bDMMQljXN5n7z/M2Pi2zVqO7/jhbZI/amzsDQ6f3fjwTY2N7IwDOKyBgGYeBaACZh4o9wDuWIGDOgZ5oDMYfxBSNwpGwSgYBSMSAAB6UVdgDGwjdgAAAABJRU5ErkJggg==","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":true,"prefix":"","firstName":"Tiffany","middleName":"","lastName":"Yeung","suffix":""},{"id":512740250,"identity":"7b0fc316-374c-41e0-911a-fea69ded4001","order_by":1,"name":"Daniel G. Bausch","email":"","orcid":"","institution":"National University of Singapore","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"G.","lastName":"Bausch","suffix":""},{"id":512740251,"identity":"b3c2e95e-1a3d-482a-a446-116de7d39ee6","order_by":2,"name":"Arlinda Cerga Pashoja","email":"","orcid":"","institution":"St Mary’s University","correspondingAuthor":false,"prefix":"","firstName":"Arlinda","middleName":"Cerga","lastName":"Pashoja","suffix":""},{"id":512740252,"identity":"dbb45851-f088-4b81-a50c-6b8f3336ee17","order_by":3,"name":"Joanna Schellenberg","email":"","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Joanna","middleName":"","lastName":"Schellenberg","suffix":""}],"badges":[],"createdAt":"2025-08-29 19:08:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7491115/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7491115/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13031-026-00751-y","type":"published","date":"2026-02-05T15:57:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91307806,"identity":"ac16baaa-d6d6-4f33-9866-1eb34e62fe0f","added_by":"auto","created_at":"2025-09-15 06:41:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":87991,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStages of the Delphi Method\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7491115/v1/c156d5a82f8a3e09d880f02a.png"},{"id":91307807,"identity":"1d0c828a-3337-41b1-aab8-c54464471ff2","added_by":"auto","created_at":"2025-09-15 06:41:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":116514,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe Flow of Evaluation Themes and Questions Over Two Delphi Rounds\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7491115/v1/0af3daab4c63c1621632df39.png"},{"id":91306682,"identity":"806c86dd-be45-4698-9749-384521e378f9","added_by":"auto","created_at":"2025-09-15 06:33:12","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":42779,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eParticipants' Response on Who Should be Involved in the Evaluation of an EMT Deployment\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7491115/v1/81860c001acbc9875e421f73.png"},{"id":91306685,"identity":"f961f767-87e4-41e9-8d99-89be2a687e76","added_by":"auto","created_at":"2025-09-15 06:33:12","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":32786,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eParticipants’ Response on When Should the Evaluation be Completed\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7491115/v1/164552f12f3219c655195d12.png"},{"id":102233964,"identity":"e228ee1c-38bc-466e-bba6-11728062ca6c","added_by":"auto","created_at":"2026-02-09 16:00:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1008248,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7491115/v1/6612f615-7cd1-4ec5-ad43-015779eb5439.pdf"},{"id":91306686,"identity":"cdc33da3-0e25-4ecf-8b0d-273b5e41b46f","added_by":"auto","created_at":"2025-09-15 06:33:12","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":96334,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7491115/v1/9b86396eb352467fed41830a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Consensus on Key Domains for Emergency Medical Teams Deployment Evaluation: A Delphi Method Study","fulltext":[{"header":"Background","content":"\u003cp\u003eAn Emergency Medical Team (EMT) is composed of health professionals providing urgent care during sudden onset disasters, both “natural” and human-caused (1). In 2014, the World Health Organization (WHO) launched the EMT Initiative to set common standards for EMT healthcare services to enhance and ensure response quality. The EMT initiative includes a process of EMT classification, encouraging all EMTs to register within the WHO EMT system, and have their services and skills validated by the initiative (2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInitially focused on surgical care following earthquakes, the WHO EMT Initiative has adapted to new challenges, creating guidelines for infectious diseases and conflict zones. While the WHO EMT initiative sets minimum standards, countries may nevertheless accept teams that have not been classified by WHO, leading to concerns about EMT service quality and accountability. Even before the WHO initiative was established, there were concerns regarding timing, relevance, and integration of EMT activities with local health systems (3-6). Scepticism regarding the motivations behind international aid continues to grow, particularly among beneficiaries, and media critiques often hold EMTs accountable more effectively than funders (7, 8). Transparency in evaluation methods is critical in learning from past deployments (9). Recent literature stresses the need for quality assurance and adherence to WHO standards (10, 11).\u003c/p\u003e\n\u003cp\u003eDespite a 2023 study highlighting the need for standardised reporting and sharing of experiences (12), the EMT sector lacks a standardised evaluation framework to assess EMT deployments. Instead, it often relies on daily reports submitted during deployment that emphasise clinical data, an approach that is not conducive to overall assessment of accountability and effectiveness, and making it hard to draw lessons across deployments (7, 11, 13, 14). EMT evaluation that have been performed tend to focus on funder requirements rather than improvements. There is often reluctance to share data or publish data (15, 16), perhaps to avoid manifesting shortcomings in expectations and performance gaps (6, 17-19), rendering it difficult to make evidence-based decisions (7, 11, 13, 14, 20). The publications that do exist often focus on descriptive narratives and ‘lives saved’, rather than a broader range of measures that can provide a better idea on usage of resources to better support local health infrastructure (13, 18, 19, 21-23). Standardised evaluations of EMT deployments could help improve adherence to the standards set by WHO (3, 24). In its strategic priorities for 2022-2024, the Inter-Agency Standing Committee, an inter-agency forum of the United Nations and non-UN humanitarian partners founded in 1991 to strengthen humanitarian assistance, included improving ‘Accountability to Affected People,’ ensuring that no one is overlooked, and that community feedback is considered (25, 26). However, international disaster rules and standards require improved implementation, and practical methods to support adherence must be developed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile there are no established frameworks for EMT evaluations, various prominent organisations in the humanitarian field have developed frameworks for longer-term humanitarian assistance. An extensive review of existing reports, documents, and guidelines related to humanitarian assistance evaluations reveals that, although\u003c/p\u003e\n\u003cp\u003emost humanitarian organisations have their own evaluation frameworks, the criteria used vary widely, and are generally not directly applicable to EMT evaluations, which require quicker assessments during EMT deployments compared to the longer humanitarian assistance.\u003c/p\u003e\n\u003cp\u003eGiven the lack of an evaluation framework for EMT deployments, we sought to gather views of experts in this field on key themes and questions to be incorporated into a future EMT evaluation, with a goal of eventually producing a framework that can demonstrate accountability, foster discussions for improvement and knowledge sharing, and provide an overview of resource allocation. We focussed on the three most common types of disasters that required international aid: floods, tropical cyclones, and earthquakes and related tsunamis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Organisation for Economic Co-operation and Development classifies evaluations into five types: formative, process, output, outcome or performance, and impact (27). This study focussed on process, output, and outcome evaluations, which assess short-term outputs, which are most relevant to EMT deployments. \u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe reporting in this paper adheres to the Conducting and Reporting DElphi Studies (CREDES) checklist(28). \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eStudy design\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis is a mixed methods study using the Delphi method, including both qualitative and quantitative data. \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eEthics approval\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eEthics approval was provided by the London School of Hygiene \u0026amp; Tropical Medicine Ethics Committee (Ref: 29517). Participants gave written informed consent before each round of the Delphi questionnaire. \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eThe Delphi method\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe Delphi method is a widely used approach that facilitates consensus among experts, particularly in the development of standards, frameworks, and guidelines (29). We selected the Delphi method to obtain expert consensus on a relatively novel topic. This approach allows participants to remain anonymous, thereby reducing the influence of dominant individuals and facilitating unbiased consensus-building. We employed a modified Delphi method, drawing on findings from published literature and qualitative interviews to inform the development of the first-round questionnaire. (Unpublished manuscript.\u003csup\u003e[1]\u003c/sup\u003e) As a result, the process did not begin with open-ended questions (30). We administered two rounds of questionnaires. In addition to questions about the content of an EMT evaluation, in Round 1 we included questions related to the process \u0026ndash; who should conduct the evaluation and how long post-EMT deployment. Figure 1 shows the stages of the Delphi method process in this research, from the preparation to analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe generated common evaluation themes and questions in a previous study in which EMT stakeholders were interviewed about their perspectives and current practices in evaluating EMT deployments.(Unpublished manuscript.\u003csup\u003e1\u003c/sup\u003e) We grouped the themes and questions according to the six After Action Review pillars established by the WHO to assess response to significant public health events (31). We asked participants to rate the evaluation themes and respective questions on their perceived suitability for an EMT deployment evaluation framework, using a four-point Likert scale: \u0026lsquo;highly suitable\u0026rsquo;, \u0026lsquo;slightly suitable\u0026rsquo;, \u0026lsquo;slightly unsuitable\u0026rsquo; and \u0026lsquo;highly unsuitable\u0026rsquo;. We then gave participants the opportunity to explain their choices, as well as to provide new suggestions to be added to the list.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRound 2 included evaluation themes and questions that had not reached consensus in the first round, along with items that received suggestions for modification and new proposals emerging from participants\u0026rsquo; comments in Round 1. For questions that reached consensus but were accompanied by suggested revisions, we asked participants to indicate whether they preferred the original version or supported the proposed changes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe considered all participant comments provided in both rounds of the Delphi, adjusting and incorporating suggestions for new evaluation themes and questions from Round 1 into Round 2 as appropriate. We took note of any patterns to identify respondents who consistently provided low ratings.\u003c/p\u003e\n\u003ch2\u003eSampling and recruitment\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eA panel of 10 - 15 experts is considered ideal for the Delphi method (32). We sent invitations to 27 potential participants to include various stakeholder groups and to account for non-response (Table 1). The inclusion criteria required participants to hold a leadership role and have experience working with or within EMTs during floods, tropical cyclones, or earthquakes and related tsunamis, both before and after the COVID-19 pandemic.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1 Characteristics of Participants in the Delphi Study\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Participants, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRound 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRound 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 604px;\"\u003e\n \u003cp\u003eType of stakeholder \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eResearchers in Emergency Medical Teams and humanitarian assistance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3\u0026nbsp;(20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3\u0026nbsp;(19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eWorld Health Organization classified and unclassified Emergency Medical Teams\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e8\u0026nbsp;(53%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e9\u0026nbsp;(56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eDeploying governments or funders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eHost governments\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eHost partners (e.g., local health services)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 604px;\"\u003e\n \u003cp\u003eGender\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e11\u0026nbsp;(73%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e11\u0026nbsp;(69%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e4\u0026nbsp;(27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u0026nbsp;(31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 604px;\"\u003e\n \u003cp\u003eWorld Bank income groups of participants\u0026rsquo; nationality (102)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eLow income\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eLower-middle income\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eUpper-middle income\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e5\u0026nbsp;(33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u0026nbsp;(31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eHigh income\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e9\u0026nbsp;(60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e10\u0026nbsp;(63%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 604px;\"\u003e\n \u003cp\u003eWorld Health Organisation Region\u0026nbsp;of participants\u0026rsquo; nationality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eAfrica\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eAmericas\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2\u0026nbsp;(13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eEastern Mediterranean \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2\u0026nbsp;(13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2\u0026nbsp;(13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eEurope\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e7\u0026nbsp;(47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7\u0026nbsp;(44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eSouth-East Asia \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eWestern Pacific \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3\u0026nbsp;(20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3 (19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThere were no declared conflicts of interest. \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003ePiloting the questionnaire\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eWe piloted the first Delphi questionnaire with seven individuals, five with substantial experience working in EMTs and two with expertise in questionnaire administration who provided feedback on structure and flow. None of the seven were included as participants in the subsequent study. Based on feedback from the pilot, we revised the questionnaire layout, introductory text, and wording to enhance clarity. We used an online surveying tool, Jisc Online Surveys (Jisc, United Kingdom). The questionnaire was available in English only. \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData analysis\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eFor each round, we defined consensus as 75 percent or more participants rating the evaluation themes and questions as \u0026lsquo;slightly suitable\u0026rsquo; or \u0026lsquo;highly suitable\u0026rsquo;. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQuestions that reached consensus but did not yield agreement on suggested modifications were retained within the \u0026lsquo;reached consensus\u0026rsquo; category, with annotations indicating the lack of consensus on the proposed changes. Similarly, for suggested changes, we considered the change agreed if 75 percent or more participants rated \u0026lsquo;I agree with the change\u0026rsquo;.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eParticipants\u003c/p\u003e\n\u003cp\u003eOf the 27 invited participants, 15 (56%) participated in Round 1, and 16 (59%) participated in Round 2 (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). All Round 1 participants also took part in Round 2, with one additional participant joining in the second round.\u003c/p\u003e\n\u003cp\u003eDelphi method findings\u003c/p\u003e\n\u003cp\u003eAfter two rounds of the Delphi process, all 23 proposed evaluation themes and 162 out of 165 questions achieved consensus (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Consensus was unanimous (100%) for 17 themes and 55 questions (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Notably, the majority of items receiving 100% consensus fell under the After Action Review pillar of \u0026ldquo;Health operations and technical expertise\u0026rdquo;, suggesting that this theme consistently aligns with the views and interests of participants. Many themes and questions also aligned closely with the existing literature on EMTs, indicating their prominence in current EMT publications. A full list of the evaluation themes and questions and their respective level of agreement is contained in Appendix 3.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eEvaluation Themes that Reached Consensus across Two Rounds of Delphi Method\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAfter Action Review Pillar\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEvaluation themes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAgreement Intensity\u003c/p\u003e\n \u003cp\u003e(Absolutely Suitable\u0026thinsp;+\u0026thinsp;Slightly Suitable)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e1. Leadership\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeadership\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTeamwork\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e2. Partner coordination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDeploying organisation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLocal Communities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHost Organisations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWorld Health Organization, Emergency Medical Teams Coordination Cell and other Emergency Medical Teams\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3. Information management and planning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreparation of evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e3. Information management and planning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInformation Management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDocumentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"7\"\u003e\n \u003cp\u003e4. Health operations and technical expertise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTeam Members\u0026rsquo; Experience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFilling in gaps of needs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatient Numbers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClinical Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReferral of Patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLocal engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePost-deployment follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003e5. Operations support and logistics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArrival\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuality assurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEquipment, supplies and logistics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSafety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e6. Finance and administration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFinance \u0026amp; Administration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePublications and reports\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eFor the three themes and questions on which consensus was reached but without agreement on proposed changes, the disagreements were largely related to syntax (i.e. \u0026ldquo;host organisation\u0026rdquo; versus \u0026ldquo;local government\u0026rdquo; or \u0026ldquo;ministry of health\u0026rdquo;) and how a particular theme should be categorised (i.e. under \u0026ldquo;Information management and planning\u0026rdquo; or \u0026ldquo;Operations support and logistics\u0026rdquo;).\u003c/p\u003e\n\u003cp\u003eConsensus was not reached for three questions:\u003c/p\u003e\n\u003cp\u003e1) How long did it take for patients to arrive at the hospital? (Agreement\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;69%. No comments provided.)\u003c/p\u003e\n\u003cp\u003e2) Did the EMT do any follow-up to patients after the it exited the country? (Agreement\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;63%. Five participants commented on the difficulty and infeasibility of doing this in the field.)\u003c/p\u003e\n\u003cp\u003e3) Were there repeat visits of EMT members to the disaster area after the deployment? (Agreement\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;69%. No comments provided.)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConducting the evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants\u0026rsquo; views on who should conduct evaluations varied, but most thought it required a team approach, often including the EMT leader, and sometimes external consultants (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eA majority (53%) of participants thought that the evaluation should take place within two months after end of the deployment, and 93% thought within three months (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDespite widespread agreement of the need, there is currently no standardised framework for evaluating EMT deployments. Our study represents a first step toward a solution, highlighting relevant themes and questions for such a framework for which there is significant consensus, indeed nearly unanimity, among key stakeholders. Many of these themes and questions are supported by existing literature. The Delphi method proved to be a useful tool, ensuring anonymity and preventing \u0026ldquo;groupthink\u0026rdquo;, which can lead to unchallenged, poor-quality decision-making (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhile our study does not result in, and nor do we propose here, a finished EMT evaluation tool, it lays a foundation for further discussion and research toward that goal.\u003c/p\u003e\u003cp\u003eParticipants\u0026rsquo; rejection of evaluation themes or questions that would require longer-term follow-up of patients are understandable, given the challenges of doing so once the EMT has left the field. Nevertheless, such follow-up is essential for continuity of care, and it would behove EMTs to work with local providers to ensure that such follow-up takes place. (Unpublished manuscript.\u003csup\u003e1\u003c/sup\u003e) Issues of post-deployment follow-up have been increasingly signalled in other research (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Participants\u0026rsquo; conviction that EMT deployments should be evaluated within a few months after completion are consistent with WHO\u0026rsquo;s guidance on After action Review, which calls for review within 3 months after official declaration of the end of the event.\u003c/p\u003e\u003cp\u003e For questions that reached consensus but did not reach agreement, standard terms used in WHO\u0026rsquo;s Classification and Minimum Standards for EMTs, or the After Action Review guideline, could be used to guide the choice of words in future studies and a final EMT evaluation framework.\u003c/p\u003e\u003cp\u003eWe note the following limitations to our study:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eLess than 60 percent of those invited to participate agreed \u0026ndash; a common challenge when trying to get time from undoubtedly busy professionals participating out of their own interest, with no compensation. Key voices may be missing from stakeholders who did not participate. Furthermore, the purposive sampling approach may have introduced selection bias, since those more actively engaged with EMTs or affiliated with certain organisations may have been more inclined to participate.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAlthough the participants included diverse stakeholders, the findings may not be fully generalisable across all global EMT contexts, particularly those underrepresented in the study, such as from regions outside the WHO classification or local nongovernmental organisations.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWe chose to make it optional for participants to provide reasons for their choices to make it easier to complete the questionnaire and thus encourage participation, and indeed completeness in both rounds was high. However, since many participants did not explain their rationale, there could have been a loss of valuable insights they might have.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe study focused primarily on identifying areas of agreement and did not explore in depth the reasons for disagreement, which could have yielded additional insights into contentious areas of EMT evaluation.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe questionnaire was administered solely in English, limiting potentially valuable contributions from non-English-speaking stakeholders and introducing potential interpretation biases.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhile consensus was reached on framework content, the evaluation tool itself has not yet been piloted or validated in operational EMT settings, which is a necessary step for future implementation.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWe did not include deployments related to human-caused disasters such as armed conflicts, since they present different challenges for EMTs (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eEMT members are expected to undergo competency-based training prior to deploying, so the most appropriate skills are brought to the field, and team leaders are expected to undergo specific leadership training (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). A clear command and communication structure within the EMT can facilitate decision-making (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Team members should be well-informed about the deployment context before deployment (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFor EMTs to be effective, collaboration among key players\u0026mdash;such as local governments, host organisations, the WHO, and NGOs\u0026mdash;is essential. Each stakeholder influences EMT operations, requiring active engagement from all (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Timely information sharing is critical to minimise delays in responding to disaster victims, potentially reducing morbidity and mortality (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). During sudden onset disasters, EMTs should report to local health ministries to enhance coordination, and a robust reporting system led by the WHO is essential (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Additionally, EMTs must respect host country regulations, as accepting international aid can have political implications (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Effective EMT deployment requires the host country to request and approve assistance (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Life-saving interventions can only be performed within 48 hours of an sudden onset disaster, but they often arrive too late (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). EMTs should have ready-to-deploy equipment and restock supplies locally for better self-sufficiency (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eReal-time patient data such as epidemiological data and health needs can help identify underserved populations (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), maintain care quality, and for early outbreak detection (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEMTs provide crucial primary care when local services are compromised (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In areas with weakened local health infrastructure, EMTs may receive patients from clinics or act as referral centres for local hospitals to prevent overwhelming local facilities (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Building relationships with local health providers boosts community confidence and facilitates the resumption of local services (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). As humanitarian assistance evolves, considering the perspectives of patients and communities is essential to align aid with their needs (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). Sustainability of care post-deployment is increasingly important, particularly for ongoing health needs (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Developing follow-up protocols, and longer deployments can enhance sustainability (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCurrent guidelines focus on clinical care but often overlook aspects like patient safety and mental health (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). Shared challenges include language barriers and cultural differences, which can affect community acceptance (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). Equipment must be suitable for local conditions (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e), and teams must be prepared for unstable logistics (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEffective coordination of resources is essential for targeting aid, aligning capabilities with local needs, based on rapid needs assessments after sudden onset disasters (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEMTs should also publish all collected data and establish a global information network to share lessons learned with other teams (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study aimed to develop a consensus-based evaluation framework for EMT deployments using a modified Delphi method. The resulting evaluation themes and questions reflect strong stakeholder consensus and may inform future framework development. The consensus achieved suggests a shared understanding of core domains for assessing EMT deployments, particularly in the area of health operations and technical expertise.\u003c/p\u003e\u003cp\u003eDespite a number of limitations, detailed above, the Delphi approach enabled anonymity and broad engagement, yielding perspectives that provide a valuable foundation for advancing EMT evaluation. Further research is needed to prioritise the identified indicators, refine language for clarity, and explore feasible and context-appropriate methods of data collection. Operational testing and feedback will be essential for ensuring that the framework is both practical and adaptable across different disaster contexts and deployment environments, with an ultimate goal of enhancing the quality, accountability, and sustainability of emergency health responses worldwide.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEMT: Emergency Medical Team\u003c/p\u003e\n\u003cp\u003eCREDES: Conducting and Reporting DElphi Studies\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Ethical approval was provided by the LSHTM ethics committee. Participant consent was sought for both rounds of the Delphi method. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used for analysis in this study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe authors received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u0026nbsp;\u003c/strong\u003eTY conceived the research idea, performed the data collection and analysis, and wrote the manuscript. DGB, ACP and JS provided critical ideas in the conception and analysis stages and read and edited the full manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUnited Nations Office for Disaster Risk Reduction. Terminology: Disaster. PreventionWeb. https://www.preventionweb.net/terminology/disaster#:~:text=A%20sudden%2Donset%20disaster%20is,critical%20infrastructure%20failure%2C%20transport%20accident. Accessed 20 Aug 2025. \u003c/li\u003e\n\u003cli\u003eWHO EMT Initiative. WHO EMT Extranet. https://extranet.who.int/emt/. Accessed 20 Aug 2025.\u003c/li\u003e\n\u003cli\u003eTan YSA, von Schreeb J. Humanitarian assistance and accountability: what are we really talking about? Prehosp Disaster Med. 2015;30(3):264-70.\u003c/li\u003e\n\u003cli\u003eAbdelmagid N, Checchi F, Garry S, Warsame A. 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Missions in 2022. 2023 2023.\u003c/li\u003e\n\u003cli\u003eSeverin PN, Jacobson PA. Types of disasters. In: Goodhue CJ, Blake N, editors. Nursing Management of Pediatric Disaster. Cham: Springer International Publishing; 2020. p. 85-197.\u003c/li\u003e\n\u003cli\u003eAmat Camacho N, Hughes A, Burkle FJ, Ingrassia P, Ragazzoni L, Redmond A, et al. Education and Training of Emergency Medical Teams: Recommendations for a Global Operational Learning Framework. PLOS Currents. 2016;21(doi:10.1371/currents.dis.292033689209611ad5e4a7a3e61520d0).\u003c/li\u003e\n\u003cli\u003eJackson A, Little M. On the ground in Nias in response to an earthquake--an emergency team\u0026apos;s experience. Emerg Med Australas. 2006;18(2):199-202.\u003c/li\u003e\n\u003cli\u003eHamilton ARL, S\u0026ouml;derg\u0026aring;rd B, Liverani M. The role of emergency medical teams in disaster response: a summary of the literature. Natural Hazards. 2022;110(3):1417-26.\u003c/li\u003e\n\u003cli\u003eKubo T, Salio F, Koido Y. Breakthrough on health data collection in disasters\u0026mdash;knowledge arises in Asia spread to the world. In: Chan EYY, Shaw R, editors. Public Health and Disasters: Health Emergency and Disaster Risk Management in Asia. Singapore: Springer Singapore; 2020. p. 299-312.\u003c/li\u003e\n\u003cli\u003eTakada Y, Otomo Y, Karki KB. Evaluation of Emergency Medical Team Coordination Following the 2015 Nepal Earthquake. Disaster Medicine and Public Health Preparedness. 2021;15(3):308-15.\u003c/li\u003e\n\u003cli\u003eBroby N, Lassetter JH, Williams M, Winters BA. Effective International Medical Disaster Relief: A Qualitative Descriptive Study. Prehospital and Disaster Medicine 2018;33(2):119-26.\u003c/li\u003e\n\u003cli\u003eArbon P. Applying lessons learned to the Haiti Earthquake response. 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Can J Surg. 2015;58(3 Suppl 3):S146-52.\u003c/li\u003e\n\u003cli\u003eRedmond AD, Li J. The UK medical response to the Sichuan earthquake. Emerg Med J. 2011;28(6):516-20.\u003c/li\u003e\n\u003cli\u003eSacchetto D, Raviolo M, Lovesio S, Salio F, Hubloue I, Ragazzoni L. Italian Field Hospital Experience in Mozambique: Report of Ordinary Activities in an Extraordinary Context. Prehospital and Disaster Medicine 2022;37(4):553-7.\u003c/li\u003e\n\u003cli\u003eLaperri\u0026egrave;re H. Evaluations, International Agencies and Censorship: A Field Doer\u0026rsquo;s Viewpoint. Evaluation. 2014;20(3):296-310.\u003c/li\u003e\n\u003cli\u003eWHO Evaluation Office. Guidance note on integrating health equity, gender equality, disability inclusion and human rights in WHO evaluations. Geneva; 2023.\u003c/li\u003e\n\u003cli\u003eAloudat T, Khan T. Decolonising humanitarianism or humanitarian aid? PLOS Glob Public Health. 2022;2(4):e0000179.\u003c/li\u003e\n\u003cli\u003eEl-Khani U, Ashrafian H, Rasheed S, Veen H, Darwish A, Nott D, et al. The patient safety practices of emergency medical teams in disaster zones: a systematic analysis. BMJ Glob Health. 2019;4(6):e001889.\u003c/li\u003e\n\u003cli\u003ePearce A, Mark P, Gray N, Curry C. Responding to the Boxing Day tsunami disaster in Aceh, Indonesia: Western and South Australian contributions. Emerg Med Australas. 2006;18(1):86-92.\u003c/li\u003e\n\u003cli\u003eBompangue D, Oyugi B, Bokulu M, Tshijuke SM, Das T, Conteh IN, et al. COVID-19 as an Accelerator of the Implementation of Emergency Medical Teams Initiative in the AFRO Region. Disaster Medicine and Public Health Preparedness. 2023;17:e489.\u003c/li\u003e\n\u003cli\u003eChauhan A, Chopra BK. Deployment of Medical Relief Teams of the Indian Army in the Aftermath of the Nepal Earthquake: Lessons Learned. Disaster Medicine and Public Health Preparedness. 2017;11(3):394-8.\u003c/li\u003e\n\u003cli\u003eRedmond AD, Watson S, Nightingale P. The south Manchester Accident Rescue Team and the earthquake in Iran, June 1990. BMJ. 1991;302(6791):1521-3.\u003c/li\u003e\n\u003cli\u003eRoshchin GG, Mazurenko OV. Ukranian\u0026apos;s Disaster Medicine Team Mission to India following the earthquake of 2001. Prehospital and Disaster Medicine 2002;17(3):163-6.\u003c/li\u003e\n\u003cli\u003eDjalali A, Ingrassia PL, Corte FD, Foletti M, Gallardo AR, Ragazzoni L, et al. Identifying deficiencies in national and foreign medical team responses through expert opinion surveys: implications for education and training. Prehospital and Disaster Medicine 2014;29(4):364-8.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Yeung T, Bausch DG, Cerga-Pashoja A, Schellenberg J. Stakeholder Perspective on Evaluating Emergency Medical Teams Deployments. 2025\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"conflict-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"conf","sideBox":"Learn more about [Conflict and Health](http://conflictandhealth.biomedcentral.com/)","snPcode":"13031","submissionUrl":"https://submission.nature.com/new-submission/13031/3","title":"Conflict and Health","twitterHandle":"@Conflict_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"natural disasters, humanitarian, emergencies, disaster aid, evaluation, Delphi method","lastPublishedDoi":"10.21203/rs.3.rs-7491115/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7491115/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eEmergency Medical Teams (EMT) deploy to provide urgent care during and after sudden onset disasters. Although the World Health Organisation has set standards for EMTs on training, personnel, and operations, there is presently no standardised evaluation framework to assess deployments.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eAs a step towards creation of an EMT deployment evaluation framework with an agreed upon common set of criteria, we used a two-round modified Delphi method to elicit perspectives from key stakeholders, including EMT members, researchers, funders, representatives of deploying governments, and host organisations. We asked participants to rate themes and questions relevant to EMT evaluation, derived from a previous study, using a four-point Likert scale, with consensus considered reached when 75% or more respondents rated the themes or questions \u0026lsquo;slightly suitable\u0026rsquo; or \u0026lsquo;highly suitable\u0026rsquo;.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eTwo rounds of the Delphi process were completed by 15 and 16 participants, respectively, with all first-round participants plus an additional person participating in the second round. Participants reached consensus on all 23 proposed themes and 162 of 165 (98%) proposed questions, with near unanimous views on many: 17 themes and 55 questions reached 100% consensus.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003e Based on these findings and guided by the categorisation of pillar themes and questions outlined in the World Health Organization\u0026rsquo;s After Action Review guidance document, we proposed a preliminary structure for an EMT devaluation. These findings can serve as a foundation to inform the future design of a standardised evaluation framework. Further research is needed to continue to identify priority areas within the evaluation framework, as well as the methodology for conducting the evaluation.\u003c/p\u003e","manuscriptTitle":"Consensus on Key Domains for Emergency Medical Teams Deployment Evaluation: A Delphi Method Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-15 06:33:07","doi":"10.21203/rs.3.rs-7491115/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-26T15:25:12+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"289898590062370316419729882788306501464","date":"2025-11-23T01:43:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"128605428348711329095956584624348250079","date":"2025-11-12T17:43:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-30T17:43:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"264764623490510266604919995060120667942","date":"2025-10-23T11:58:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304189253378131812007421635737240787361","date":"2025-09-30T13:14:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-08T06:39:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-08T05:47:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-08T05:46:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"Conflict and Health","date":"2025-08-29T18:55:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"conflict-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"conf","sideBox":"Learn more about [Conflict and Health](http://conflictandhealth.biomedcentral.com/)","snPcode":"13031","submissionUrl":"https://submission.nature.com/new-submission/13031/3","title":"Conflict and Health","twitterHandle":"@Conflict_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fc6c9dc3-cb7c-47c2-a190-99b2b657f898","owner":[],"postedDate":"September 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:00:22+00:00","versionOfRecord":{"articleIdentity":"rs-7491115","link":"https://doi.org/10.1186/s13031-026-00751-y","journal":{"identity":"conflict-and-health","isVorOnly":false,"title":"Conflict and Health"},"publishedOn":"2026-02-05 15:57:16","publishedOnDateReadable":"February 5th, 2026"},"versionCreatedAt":"2025-09-15 06:33:07","video":"","vorDoi":"10.1186/s13031-026-00751-y","vorDoiUrl":"https://doi.org/10.1186/s13031-026-00751-y","workflowStages":[]},"version":"v1","identity":"rs-7491115","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7491115","identity":"rs-7491115","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}