More frequent hazards are progressively challenging health and health care systems [1,2]. Hazards can be natural (earthquakes, tsunamis, cyclones, extreme temperatures, and floods), biological (disease outbreaks), technological (explosions and infrastructure failures), or societal (conflict, wars, and humanitarian emergencies) [3]. Their impact reflects the interplay between the exposure and the vulnerability of the affected population [4-7]. A hazard becomes a disaster when these 2 factors interact in complex ways with system capacity to trigger a major disruption in the functioning of a community or society [8]. In contrast, emergencies involve hazardous events that do not precipitate large-scale societal disruption [8]. Several populations are more vulnerable to the impacts of these disasters and emergencies, and patients with kidney diseases in particular experience a disproportionately higher risk with hazard exposure [9].

The survival of those with end-stage kidney disease who receive dialysis depends on the safe provision of this therapy multiple times a week [10-12]. Receiving dialysis is dependent on intact and functioning infrastructure, the availability of medical personnel, and the supply of medical equipment and medications, all of which can be disrupted during a disaster or emergency setting [11,13-25]. Surveys of health care providers such as physicians, nurses, and technicians have reported challenges they experienced in getting to a dialysis center and providing services during or following disasters [20,22-24]. Several studies have reported disruptions in dialysis care delivered to patients in such settings [10,20,22,24,26-28]. For example, in a survey of patients impacted by Hurricane Sandy in 2012, a total of 26.3% of participants reported missing dialysis sessions during the storm, and 8% reported missing 3 or more sessions [26,29]. Similarly, postdisaster analyses have reported an increased risk of emergency department visits, hospitalizations, and short-term mortality among patients receiving hemodialysis exposed to a disaster [27,30,31]. All-cause mortality with hurricane exposure among 187,388 patients undergoing dialysis in the United States from 1997 to 2017 increased by 13% compared to those who were not exposed [31]. Furthermore, vulnerability is compounded by both medical and socioeconomic factors, particularly given that kidney disease disproportionately affects racial and ethnic minority groups and those experiencing structural disadvantages across several other social determinants of health [32-39].

The Canadian Disaster Database reported 424 climate-, conflict-, and technology-related disasters from 2000 to 2020 that have resulted in 1741 deaths and 12,792 injuries, displaced 603,549 individuals, and cost more than CAD $19 billion (US $14 billion) [40]. Anecdotal experiences and reports in the lay press suggest that the kidney care community in Canada has faced numerous disasters and emergencies over the past 2 decades [41-45]. For example, in 2023, many remotely located Indigenous people who received dialysis in the satellite facilities had to be evacuated due to the wildfires. In 2021, torrential rain and winds impacted the care of 72 patients, who needed to be evacuated and repatriated to other dialysis units [45]. While, in the United States, dialysis facilities are mandated by federal regulations to have a disaster plan [16], in Canada, there is no such national initiative in disaster preparedness, response, and recovery in kidney care, although some regional isolated efforts exist. We have highlighted the need to champion disaster and emergency risk reduction and management (DERRM) in kidney care in Canada and underscored the importance of a unified national approach to strengthening system resilience [9]. However, advancing such an approach first requires a clearer understanding of existing systems.

In the Canadian setting, a better understanding of the experiences, resiliency, and vulnerabilities of existing systems is needed to strengthen preparedness efforts and other risk reduction strategies and build “resilient health systems capable of anticipating, responding to, coping with, recovering from, and adapting to climate-related shocks and stress” [7]. Moreover, a better understanding of system weaknesses, practice gaps, and response capacities can help develop adaptation priority actions that can mitigate risks to patients with kidney diseases. The goal of this research is to conduct a vulnerability and adaptation assessment (VAA) of Canadian provincial health systems and individual kidney care networks (KCNs) with respect to natural and human-caused disasters and emergencies. Our research aims are to map existing KCNs across Canada, contextualize the current and future vulnerability of health systems and patients to disasters and emergencies, and identify and prioritize adaptation measures in partnership with key interest holders. Our overarching goal is to strengthen system preparedness and resilience.

A VAA is a key tool in identifying critical health risks, vulnerable populations, capacities, and weaknesses in the involved systems and the interventions needed to mitigate, manage, and respond to arising risks [7,48,49]. The World Health Organization suggests that VAAs are a foundational step in preparing health systems for hazards. Such an exercise is essential to assess the potential impacts of climate- and human-caused hazards on health systems, profiling the impacted populations, whether patients or health care personnel, and the capacity of health institutions and systems to address arising situations [50]. A VAA explores the components of a health system to assess potential areas of vulnerability to disasters, where capacities stand and/or fail if future risks arise, and what adaptive measures can be taken to achieve a more resilient health system [48]. A bottom-up approach to VAA focuses on the context instead of the outcome of a hazard. It starts with the stakeholders impacted and examines the elements of the involved health systems [51]. Rather than a top-down approach focusing on a particular hazard and estimating its future impact, we used the bottom-up approach to explore the underlying contexts and elements of a system that potentially develop vulnerabilities and limit DERRM [51,52]. Moreover, instead of using model-generated climate data, this approach relies on participatory input from different stakeholder sources to understand disaster management directly from the perspective of those who have experienced or may experience it [52].

Often used in nursing and health research, a qualitative descriptive approach is important for gaining insights into underexplored research areas [53]. It is the method of choice when straight descriptions of phenomena are desired and for understanding user experiences of processes within health care systems [54]. Moreover, a qualitative descriptive approach recognizes the subjective nature of research questions in health research and explores the answers through the different perspectives of participants’ experiences [53]. In practice, this translates into understanding important clinical issues within their unique contexts. This approach also benefits from a flexible inductive process to pursue deeper descriptive knowledge, contributing to change and quality improvement in the practice setting without the need to transform data into a theoretical or conceptual reflection [55,56]. Overall, we are adopting a qualitative descriptive design with the intention of obtaining straightforward descriptions of experiences and perceptions in an area with little prior investigation [53,57].

Ethics approval for this study was obtained from the Research Ethics Board at McGill University Health Centre, Montreal, Quebec (2025-11213). This study is being conducted in accordance with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans 2 (2022) [79].

Written or electronic informed consent will be obtained from interview participants via email prior to commencing the interviews. It will briefly explain the study and its purpose, the voluntary nature of participation, the duration of the interview, and that any personally identifiable information will not be collected or will be omitted from the transcripts. Participants will be compensated with a CAD $50 (US $38) gift card following their participation in the interviews.

This study aims to operationalize a DERRM framework to conduct a VAA of KCNs in Canada. This pan-Canadian initiative will identify and address the vulnerability of the kidney health community (ie, health care providers, patients with kidney disease, kidney care units, and provincial renal health authorities), identify approaches to adaptation, facilitate DERRM, and strengthen health system resilience to disasters. We want to identify the existing operational and human vulnerabilities and the associated risks, as well as explore lessons learned from previous experiences, to develop needed adaptations. Emerging data suggest that this varies widely between programs and provinces. As mentioned above, only 38.2% (21/55) of the responding programs have written documents specifying policies on disaster management. Input gathered has covered managerial and operational aspects, ensuring relevance to applicable policy and lived practices and experiences [7]. The snowball recruitment approach enabled us to reach individuals who are often difficult to engage, including those supporting rural communities and working in direct, frontline roles with patients [46]. These participants contributed valuable experiences in managing disasters through working with different dialysis modalities, holding tenure in their institutions, working with remote communities, and being exposed to a multitude of hazards. All participants interviewed thus far have offered differing perspectives on disaster management in different Canadian contexts. Document review will serve as complementary data collection and as a means of triangulation with interview data [59]. By examining both existing directives and lived experiences and the expertise of health care professionals (clinicians, administrators, technicians, nurses, and other allied health professionals), this approach provides a comprehensive assessment of DERRM at the individual, provincial, and health system levels while directly advancing our research aims.

This will be the first VAA of kidney care facilities across Canada. In addition to investigating vulnerabilities and adaptations at the KCN level, analysis will highlight provincial and regional variations based on prior exposure to disasters and perceived current and future risks. Future research will explore patient and caregiver perspectives and adaptation recommendations to generate actionable goals to guide relevant interest holders in prioritizing and planning responses to current and future health threats. Furthermore, as per the World Health Organization, VAA can serve as a baseline for monitoring changes in risk and evaluating the effectiveness of adaptation measures over time.

The following limitations may be present in our analysis, and we are undertaking steps to address some of them. First, despite extensive consultations with collaborators and ongoing verification during interviews, we may not have fully captured all existing KCNs in Canada. Although we attempted to engage every KCN to achieve pan-Canadian representation, several regions could not be reached to validate their inclusion, and we are continuing efforts to engage with them. During our ongoing data collection, significant differences are emerging regarding the vulnerabilities of patients on various kidney replacement therapies. We are attempting to recruit participants who will represent the full scale of therapies across adult and pediatric populations.

Regarding our methods, our recruitment approach may be susceptible to nonresponse bias as only those with a personal interest in the research topic may have agreed to participate. Additionally, those who perceived their KCN as insufficiently prepared may have opted not to participate, potentially limiting the range of perspectives captured. This may potentially skew insights into system vulnerabilities and the applicability of potential adaptations. However, we are undertaking several measures to increase our outreach efforts to ensure that all perspectives are represented. Finally, although the document review serves as a contextual reference for existing policies on disaster management at KCNs complementary to interview data, we acknowledge that it may not be exhaustive as documents are shared through participants and dependent on their knowledge of their own unit’s directives or lack thereof.

The target population focused on the main dialysis center within each KCN, and we only recruited participants from satellite units through snowballing when recommended. We acknowledge that other units within a network can also offer valuable, nuanced input; however, considering that administrative functions and managerial functions are localized to main units, we believe that this level of representation is sufficient. In parallel, the study examines organizational-level vulnerabilities and adaptations without addressing individual-level risk factors, including patient experience with different kidney replacement therapy modalities. Patient perspectives will be pursued in the following stages of the study.

Patients with kidney diseases are uniquely vulnerable to the impacts of a hazard. Delay in the provision of dialysis or medications can be a life-threatening or organ-threatening event for these patients. This VAA, guided by a framework we previously developed within the DERRM model and informed by an extensive literature review and experiential knowledge, represents the first initiative of its kind in kidney care. The findings will provide a critical foundation for understanding vulnerability, supporting strategic planning, and guiding adaptation measures that can strengthen health system resilience. Ultimately, this work will help protect patients with kidney diseases and the broader kidney community from the escalating risks of evolving hazards within Canada and may serve as a model for similar efforts elsewhere.