Assessed Adaptive Capacity of Healthcare Facilities for Air-Pollution Episodes in Dust- Storm-Prone Khuzestan, Iran: A Cross-Sectional Study

<title>Abstract</title> <p> <bold>Background:</bold> Sand and dust storms can increase healthcare demand and disrupt service delivery, yet evidence of facility-level preparedness in dust-prone health systems is limited. We assessed the adaptive capacity for air-pollution episodes among hospitals and county health centres in Khuzestan Province, Iran. <bold>Methods:</bold> A cross-sectional census was conducted in 2024 across 52 units, comprising 24 county-level health-network units and 28 hospitals. A 40-item checklist assessed seven adaptive-capacity domains on a 0–100 scale. “Yes” responses were coded as 1, while “no” and “do not know” were coded as 0, as the analytical dataset did not distinguish between them. Differences between hospitals and health centres were estimated using Welch tests, 95% confidence intervals (CIs), Hedges’ g, permutation tests, and false-discovery-rate (FDR) correction. Sensitivity analyses were performed, and managers’ preparedness and county social vulnerability were examined exploratorily. Dust was treated as a regional hazard context because matched facility-level environmental measurements were unavailable. <bold>Results:</bold> Hospitals scored higher than health centres for infrastructure and resources (72.0 [SD 24.5] vs 52.1 [23.7]; mean difference 19.9 points, 95% CI 6.5–33.4; Hedges’ g=0.81; FDR-adjusted p=0.031), the only domain-level difference retained after FDR correction. The lowest mean scores overall were for air-quality monitoring and evaluation (61.2), infrastructure and resources (62.8), and response and recovery capacity (67.9). Only 30.8% used air-quality information to prioritise services, 36.5% reported adequate equipment to receive affected patients, and 38.5% regularly received reliable air-quality data. Hospital managers reported higher perceived preparedness than health-centre managers (56.9 vs 47.2 on the 0–80 scale; mean difference 9.7, 95% CI 5.8–13.6; Hedges’ g=1.38; p&lt;0.001). Social-vulnerability associations were inconsistent, while the infrastructure difference remained directionally consistent across sensitivity analyses. <bold>Conclusions:</bold> Hospitals had stronger assessed infrastructure and higher manager-reported preparedness, but system-wide gaps remained in air-quality intelligence, resources, and operational response and evaluation. Findings support linking validated alerts to predefined facility actions, resource mobilisation, continuity planning, and auditable performance indicators. Prospective studies should determine whether assessed adaptive capacity translates into demonstrated resilience. </p>