568709 research-article2015
APHXXX10.1177/1010539514568709Asia-Pacific Journal of Public HealthSrikuta et al
Original Manuscript
Health Vulnerability of Households in Flooded Communities and Their Adaptation Measures: Case Study in Northeastern Thailand
Asia-Pacific Journal of Public Health 1–13 © 2015 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539514568709 aph.sagepub.com
Phatcharee Srikuta, MPH1, Uraiwan Inmuong, MSc, PhD2, Yanyong Inmuong, PhD2, and Peter Bradshaw, BSc(Hons), DAP(Clin)3
Abstract Floods adversely affect community well-being and health. This study aims to assess the present health vulnerability of households to floods in a rural flood-prone area of northeastern Thailand, as well as their adaptation measures. The participants were the representatives of 312 randomly selected households, and data were collected using an interview questionnaire. Health vulnerability was assessed in terms of flood exposure, flood sensitivity, and flood adaptive capacity. The data were analyzed with descriptive statistics. The results showed that 47.1% of the households had a low level of health vulnerability to flooding, while in 21.2% the level was high. Households had been adapting themselves to cope with the health impacts from flood. Their coping practices included special arrangements for the protection of property, food management, the provision of water supply and waste disposal, the elimination of sources of vector-borne diseases, family health care, the protection of family livelihood, and communication and transportation. Keywords health vulnerability, flood, households, adaptation, rural, environmental health, Thailand
“Disaster” is a serious disruption of the functioning of a community or a society, involving widespread human, material, economic, or environmental losses and impacts, which exceed the ability of the affected community or society to cope using its own resources.1 Between 1970 and 2011, the Asia-Pacific region accounted for more than 74% of global human fatalities from disasters.2 Flooding is a major disaster in Southeast Asia countries. Floods in these countries during from 2000 to 2013 caused more than 10,000 fatalities and affected the lives of >76 million people, with estimated losses of about US$50 billion.3 The Lower Mekong Basin, a region that includes part of northeastern Thailand, has faced a major impact on agriculture and fisheries from 1Faculty
of Public Health, Khon Kaen University, Khon Kaen, Thailand of Environmental Health Science, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand 3Department of Epidemiology, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand 2Department
Corresponding Author: Uraiwan Inmuong, Department of Environmental Health Science, Faculty of Public Health, Khon Kaen University, 123 Moo 16 Mittapap Rd, Nai-Muang, Muang District, Khon Kaen 40002, Thailand. Email: [email protected]
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flooding.4 Most at risk are those communities that have settled in flood-prone areas, where they are threatened by extensive inundation of rice paddies and farm land as well as by disruption of transportation and communications. In 2011, Thailand experienced the worst flood disaster in half a century when flooding occurred in 66 of the nation’s 77 provinces.2 The floods heavily affected housing, which was the second-largest sector after manufacturing to be affected, with both sectors suffering comparable losses in terms of proportions of the total damage. While about 1.9 million houses were affected and 19,000 homes destroyed, the greatest damage was to household goods.5 Floods have adverse impacts on community health and household well-being. These impacts are not simply the immediate consequences of the direct effects on physical and mental health; there are also longer-term impacts on community livelihood and the environment that occur through a variety of pathways.6 The concept of vulnerability refers to a relative inability to withstand the effects of a hostile environment, and the level of vulnerability depends on the degree of exposure to a hazard, the extent to which its impacts are experienced, and the capacity for dealing with and adapting to these experiences.7,8 Health vulnerabilities to floods in Thailand are changing as a result of many factors.9 During a flood, environmental hazards expose families to changed conditions, which also change many social determinants, including those that affect health. Family health vulnerability to flooding is revealed as the result of these changes.10 A study of overall health burden associated with extreme weather in Thailand from 2006 to 2010 indicated that a total of 12,872 disability-adjusted life years were lost from floods alone.11 Understanding health vulnerability to flooding at the household level can help to strengthen household and community public health responses to a flood and lead to the development of preventive action to minimize suffering by increasing the adaptive capacity of households and the wider community. There has been no recent study of health vulnerability at the household level in the flood plains of Thailand. The current study aims to assess the present health vulnerability of households to floods in a rural flood-prone area of northeastern Thailand. The findings are expected to help communities and local support agencies to identify weaknesses, especially in adaptive capacities, and to indicate ways of reducing future health vulnerability.
Methods Study Area and Survey Sample This cross-sectional analytical study was conducted from August to December 2013 in 6 rural village communities that have been among the hardest hit by the impacts of flooding. The communities are located in the Muang Phia subdistrict of Ban Phai, which is a district of Khon Kaen province in northeastern Thailand, all of which are situated in lowland areas between the Chi River and the Kaeng Lawa wetland. The villagers had been experiencing increasingly severe flood conditions since 2007 and annual flooding from the end of September to late November. Each year, they endured inundation of their dwellings and/or heavy flood flow into farming areas. The household survey was conducted mainly after flooding receded in December 2013. The survey participants were the heads of households or the most senior available household representatives >18 years of age in 312 households that were selected by simple random sampling from the total of 967 households in the study area. The number of households sampled in each village was proportional to its contribution to the total number of households in all 6 villages. No households refused to participate, but there was a small number for which no household representative was available. When this occurred, the interviewers approached the nearest household with a representative. All participants provided written informed consent before they were interviewed.
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Srikuta et al Vulnerability
=
Risk Adaptive Capacity
where Risk = Sensitivity x Exposure Figure 1. Relationships among vulnerability, risk, and adaptive capacity.
Table 1. Categorization of Total Scores for Each Flood Component. Level Lowa Medium Highb aNone
Exposure
Sensitivity
Adaptive Capacity
1-6 7-12 13-18
1-12 13-24 25-36
1-13 14-26 27-39
of respondents had scores of 0. scores are 18, 36, and 39, respectively
bMaximum
Table 2. Decision Matrix for Determining a Household’s Flood Risk Level. Flood Sensitivity Level Flood Exposure High Medium Low
High
Medium
Low
High High Medium
High Medium Low
Medium Low Low
Survey Questionnaire and Health Vulnerability Assessment Data were collected with a structured interview questionnaire that was administered by trained public health students. The questionnaire was written in Thai, and the items were designed to elicit household demographic information, to acquire details of each household’s flood experience and adaptations to flooding, and to assess the household’s health vulnerability to floods. The health vulnerability assessment was based on the studies by Ebi et al12 and Nelson et al.13 Health vulnerability was defined as the degree to which households are unable to cope with the adverse health outcomes and health impacts due to flood, and it was deemed to have 3 components8,14: flood exposure (6 items), the extent to which households had experienced the impacts of flooding; flood sensitivity (12 items), the degree to which a household had been affected by flood exposure (the effects may be direct or indirect), with particular regard to factors having negative health impacts; and flood adaptive capacity (13 items), the potential ability of a household to cope with the consequences of a flood. For metric purposes, the relationship between vulnerability and the 3 components can be represented as shown in Figure 1, which is adapted from Adger.15 There were 4 defined response options for each item, and responses were scored 0 to 3 (none, low, medium, and high) in terms of increasing levels of response to an item (see appendix). The total component scores for exposure, sensitivity, and adaptive capacity were categorized as low, medium, and high (Table 1). Following the model in Figure 1, decision matrices were used to define individual household levels of risk (Table 2) and then individual household levels of health vulnerability (Table 3).
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Table 3. Decision Matrix for Determining a Household’s Health Vulnerability Level. Flood Risk level Flood Adaptive Capacity Low Medium High
High
Medium
Low
High High Medium
High Medium Low
Medium Low Low
Table 4. Demographic Characteristics of the Study Respondents (N = 312). Demographic Characteristics Sex Female Male Age, yrs. 19-30 31-40 41-50 51-60 61-65 Education Illiterate Primary Basic secondary Secondary–high school College University bachelor degree or higher Occupation Farming/agriculture work Laborer Retailer Government/private sector employee Others
No. (%) 208 (66.7) 104 (33.3) 21 (6.7) 49 (15.7) 110 (35.3) 106 (34.0) 26 (8.3) 4 (1.3) 247 (79.2) 23 (7.4) 21 (6.7) 6 (1.9) 11 (3.5) 244 (78.2) 24 (7.7) 22 (7.1) 14 (4.5) 8 (2.5)
Data Analysis and Ethical Approval The data were analyzed using descriptive statistics and Stata 10.0 software. Ethical approval to conduct the study was obtained from the Khon Kaen University Ethics Committee for Human Research in accordance with the Declaration of Helsinki and the ICH good clinical practice guidelines (HE562118).
Results The demographic characteristics of the household respondents are shown in Table 4. The overall impacts of flooding in terms of exposure, sensitivity, adaptive capacity, and health vulnerability are shown in Table 5.
Flood Exposure Most households (71.8%) reported a medium level of exposure to flooding. When the households were divided into 4 groups according to the type of area exposed to flooding, 64.1% were farm Downloaded from aph.sagepub.com at UNIV NEBRASKA LIBRARIES on October 13, 2015
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Srikuta et al Table 5. Level of Household’s Health Vulnerability to Flood, No. (%).
Total Score Level From the Household Assessment (N = 312) Components Related to Flood Exposure Sensitivity Adaptive capacity Health vulnerability
High
Medium
Low
87 (27.9) 42 (13.5) 35 (11.2) 66 (21.2)
224 (71.8) 87 (27.9) 235 (75.3) 99 (31.7)
1 (0.3) 183 (58.6) 42 (13.5) 147 (47.1)
households, 4.8% were residential households, 30.8% were both farm and residential households, and 0.3% were households in areas not exposed to flooding. Almost all the households (97.8%) had experienced an annual flood disaster. Survey respondents recalled that flooding had occurred since 1953, and many (42.3%) recognized that the most severe flood was in 1978. In the past, floods did not cause serious impacts; water overflowed into rice paddies and houses for nearly a week, and then the flood waters gradually receded. Since 1997, the intensity of the floods has continually increased due to the building of a dyke that retains flood water in the areas where the communities are located and to an increase in precipitation during the monsoon season (May to November): flooding normally occurs every year between October and November. The majority of household representatives (77.6%) considered that the most severe flooding in more recent times happened in 2011. During the latest flood event, most families (56.9%) experienced a gradual inundation of rice paddies and farm areas, but many (38.5%) also faced a flash flood. For flooded farm areas, the longest period of flooding was 79 days and the shortest, 33 days. In flooded resident areas, the longest and shortest periods were 55 and 24 days. The average flood level in the farm areas was 2.4 m, while that in the residential areas was 0.8 m. The recovery time for both areas of flooding was about 1 month.
Flood Sensitivity While more than half the respondents (58.6%) reported a low level of flood sensitivity, a small but nevertheless sizable group of households (13.5%) had struggled with high impacts. The average distance from farms to the Chi River, which was the main source of runoff from the upper catchment area, was 1.3 km. There were 18 households with farms close to the river, and production on these farms was always damaged. The average distance of houses to the river was 0.8 km. The nearest distance between a house and the river was only 50 m. During the most recent flood, 94.5% of households with rice paddies had their crops damaged by flood water, with an estimated loss of 25% of their average annual family income. More than one-third of households (35.6%) had faced serious consequences from the flooding of their homes, with an average estimated loss of household assets and house damage of 6% of their average annual family income. For many families (77.2%), these effects resulted in a major loss of income. Many household respondents (44.9%) considered the health status of their families to be quite good, with little sickness and with an ability to work normally. However, about half the households (52.6%) had at least 1 member who was ill, mainly due to hypertension (24.7%), diabetes (21.2%), muscle and bone symptoms (4.5%), and heart disease (4.5%). About half the households (52.9%) reported that during the flooding period, families experienced acute health problems due to skin infections (48.1%), common colds (20.2%), conjunctivitis (12.8%), muscle pains (6.4%), and diarrhea (4.8%). While the physical health problems associated with flooding were mainly skin diseases, fevers, and muscle pains, mental health problems due to losses incurred as a result of flooding were also mentioned. A large minority (45.5%) felt that the worst impact on their families was the loss of farm production; this reduced household income, increased mental stress, and was seen as a loss of food security.
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The majority of households (75.3%) reported experiencing hardships in their daily living due to flood conditions. For many (69.5%), the environmental health risks were magnified by the increased number of poisonous animals and vector-borne diseases. More than a third of families (36.5%) were faced with needing to cope with an unclean water supply when the floodwaters contaminated their usual sources of water. Due to the inundation of roads and areas around the houses, 33.0% reported that the disposal of household waste could not be properly achieved by the local authorities. Some people (29.5%) therefore threw their waste into the floodwaters, with the result that water became contaminated, and there was an increased risk of skin infections and gastrointestinal problems. A further daily living hardship was the lack of properly functioning toilets (27.6%), and some households lacked food (23.7%) and drinking water (15.3%). Many respondents (72.1%) also considered that their families had become stressed by the flooding and were very worried about losses.
Flood Adaptive Capacity Most respondent households (75.3%) reported a medium level of the adaptive capacity for coping with flooding. While families made their own preparations for adapting to flood conditions, they were supported by others in the community and by the government and private sectors. The majority (69.2%) perceived floods as natural events, but some (23.7%) thought that floods happened because of faults in the water management system that should not have occurred. While more than half the households (57.2%) considered that the severity of floods had increased considerably over the years, a majority (76.3%) believed that their adaptation practices were good enough to handle the impacts. Nevertheless, some families (16.7%) still found it hard to deal with the impacts. During the interviews, respondents had been given a list of possible adaptation measures and were asked to indicate which measures their households had adopted. The results of this are shown in Table 6. Most of the farming families (97.8%) received compensation from the district agricultural office in accordance with the government’s disaster support policy. In addition, households who had insured their rice product with the Bank for Agriculture and Agricultural Cooperatives were able to obtain compensation from this source for damaged crops. The purposes of this compensation were for the investment costs of the next crop (78.9%), debt payment (30.5%), and family living expenses (29.2%). Households were also strongly supported by the subdistrict health promotion hospitals and related health agencies, and community health volunteers assisted by providing relevant hygiene and health care knowledge as part of their health promotion–related activities.
Health Vulnerability to Flood Almost all households (99.7%) were affected by floods. While many (47.1%) had only a low level of health vulnerability to flooding, 21.2% were highly vulnerable. The household’s health vulnerability is reduced when sensitivity and exposure are low and adaptation is high. The factors that appeared to make families more vulnerable to the negative impacts of flooding were location in both a residential and farming area; poverty and the reduced availability of clean water during floods; lack of healthcare knowledge; and having household members who were patients with chronic diseases, young children, elderly, disabled, or already suffering from a skin disorder.
Discussion The findings of this study indicated that the most vulnerable group of households in the flooded communities was composed of those who had children, chronic disease patients, and/or disabled persons. This group needed special health care support and medication during floods. The
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Srikuta et al Table 6. Household Flood Adaptation Measures (N = 312). Adaptation Measures
No. (%)
Arrangements for housing shelter and property Piling soil on the ground floor Elevating the houses Relocation of belongings to high places Clearing and extending water drainage system Money saving Possession of evacuation kits Possession of devices/equipment for response to flood (eg, temporary bridge, sand bags, dyke) Seeking alternative living area in case of severe event House and assets insurance Food and water supply management Storage of water for drinking Storage of cooking gas/wood Storage of clean water for general use Storage of food in advance Provisions for waste disposal Storage of plastic bags for waste Clearing lavatory tank before flood Elimination of sources of vector-borne diseases Cleaning of living area to infestation by dangerous animals/insects Possession of nets for insect protection Storage of insect repellents Family health care Always washing after exposure to flood water Arranging and keeping essential medicines Provision of boots Seeking alternative accommodation for children and the elderly in case of evacuation Protection of family livelihood Rice production insurance Adjustment or postponement of rice cultivation season Farm investment reduction or decrease in production Finding additional jobs in other locations Asking for support from government agencies Changing livestock/plant species Doing work other than farming and livestock feeding Communication and transportation Frequent attention to communications about flood conditions from community leader and related agencies Boat provision
246 (78.8) 182 (58.5) 176 (56.4) 173 (55.5) 125 (40.1) 116 (37.2) 111 (35.6) 51 (16.4) 10 (3.2) 236 (75.6) 208 (66.7) 194 (62.2) 169 (54.2) 162 (51.9) 66 (21.2) 262 (83.9) 239 (76.6) 190 (60.9) 284 (91.0) 267 (85.6) 258 (82.7) 89 (28.5) 186 (59.6) 117 (37.5) 102 (32.7) 116 (37.2) 85 (27.2) 60 (19.2) 46 (14.7) 293 (93.9) 120 (38.5)
interview findings revealed that the households were supported by local agencies, such as the local administrative organization, the community health promotion hospital, the public health district office, Thailand’s Red Cross Society, the district agricultural office, and various private sector groups. These added to the effectiveness of the household adaptation strategies in reducing health vulnerability and health impacts by increasing the ability of households to cope with changed conditions.
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The households had chosen to use different adaptation strategies. Such choices are determined by many factors such as household income, educational background, flood characteristics, occupation, and distance from a riverbank.16 Households had learned from past experience and their mistakes in ways of responding to previous floods. This had enhanced their capacity to adopt the best measures for maintaining health and minimizing risks. They were aware of the dangers associated with floods and had a basic understanding of how to react at a household level before, during, and after a flood event. Household’s health vulnerability to flood varies in different contexts, and there is a wide range in the level of preparedness adaptation. Lowe et al indicated that many factors can increase health vulnerability, such as age, sex, previous flood experiences, greater flood depth or flood trauma, existing illnesses, medication interruption, and low education or socioeconomic status. The potential risk factors may differ according to the timing of exposure; whether before, during, or after flood events, these can also cause households to take action to prevent flood impacts.17 An increasing frequency of extreme weather and its results, such as flooding, is a potential consequence of global warming and climate change. The Intergovernmental Panel on Climate Change18 reports that increased incidences of water-borne diseases (eg, diarrhea) and vectorborne diseases (eg, dengue fever) are likely health impacts of climate change in Southeast Asia. In the study site and other parts of Thailand, the increased risks of water-related diseases due to climate change are likely to be similar to those identified for Cambodia, especially for the poorer sections of society living in flood-prone areas because of their more limited access to an uncontaminated water supply and good sanitation.19 It is important for households, communities, and official bodies to plan on how to manage such events and increase resilience to the associated risks and health impacts. Long-term public health adaptation to climate change impacts will be a new challenge for the health sector nexus, especially the task of identifying those groups who are particularly vulnerable to the impacts of disasters.20 Health care systems need to be proactive and increase their adaptive capacity and resilience to environmental change.21,22 To prepare for the impacts of climate change, the health system should be flexible, strategically allocated, and robust. Close coordination is necessary among different sectors, including nonhealth sectors and community members. All must work collectively for long-term disaster prevention and emergency preparedness to be effective.23 In the case of the villages in the current study, their adaptation measures had already embraced health impacts as an issue of concern. An elaborate early warning system based on community networks was operating in the upper river basin; community human capital capacity building has occurred; the primary health system has been strengthened by, for example, improved disease surveillance; and flooded communities have been engaged in disaster prevention planning and involved in the implementation of appropriate relief measures, as well as the evaluation of community effectiveness.24 The present study has several limitations. Firstly, the respondent household representatives may not always have accurately reflected the views of the household. They were, in a sense, only a “convenience sample” drawn from within the selected households. For example, the majority were female, and this occurred because male members of the households were often away at work. Given the sex role differences in village life, it is possible (even likely) that this distorted the results. Secondly, the findings are unlikely to generalize to communities affected by other types of flood events—especially the more unpredictable flash floods, rather than a highly predictable gradual annual flooding of the kind experienced in the study area. These types of flood events are likely to lead to a much greater adaptive capacity and lesser vulnerability. Thirdly, generalization of the findings is limited due to differences in cultural and social factors. One example of this is that in a rural village, perhaps especially in northeastern Thailand, people are
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unlikely to consider moving away to a different region as an adaptive strategy because of their especially strong local family and community bonds.
Conclusion/Recommendation The results indicated that while many of the households in the study communities had a low level of health vulnerability to flooding (47.1%), for most (52.9%) the level was high (21.2%) or medium (31.7%). Households had been adapting themselves to cope with the health impacts from flood. Their coping practices included special arrangements for the protection of property, food management, the provision of water supply and waste disposal, the elimination of sources of vector-borne diseases, family health care, the protection of family livelihood, and communication and transportation. As this case study demonstrated, it is most important for people and local agencies to communicate with one another about the risks related to flooding in their communities and to appreciate the cost-effectiveness of various measures to mitigate the impacts of flood events. These understandings motivate households in flood-prone areas to take preventive action to reduce the worst consequences of flooding.17 They also help flood-relevant agencies to take a proactive role in assisting households to reduce the potential health impacts through a decrease in health vulnerability. A potential weakness of the present study is that, in answering the health vulnerability assessment items, householders were not necessarily replying in terms of the most recent flooding and were free to respond by integrating their past experiences over more than 1 year in the past. In future studies, the various components of health vulnerability should be assessed by attempting to collect data from respondents before, during, and immediately after a particular flood event. In this way, the associations between health vulnerability and exposure, sensitivity, and adaptive capacity can be more directly investigated. Larger-scale research into health vulnerability to flooding is required at district and provincial levels. This can benefit the local policy makers and public health sector in their planning and establishment of local-level strategies to deal with a problem that is likely to increase with climate change and an aging (and hence more dependent) population.
Appendix Household’s Health Vulnerability Assessment to Flood. Household’s Vulnerability Assessment Components 1. Flood Exposure 1.1 Duration of flood. 1.2 Flood level. 1.3 Flooding of farm area. 1.4 Flooding of home area. 1.5 Assets damaged. 1.6 Recovery time.
Response Options and Scoring 0 = None No flood. No flood. No flood in a farm area. No flood in home area. No assets damaged. No flood / No need for recovery.
1 = Low < 2 weeks. < 30 cm. < 10% of total farm areas. < 10% of total home areas. < 10% of total assets. < 1 weeks.
2 = Medium 2-4 weeks. 31-100 cm. 11-50% of total farm areas. 11-50% of total home areas. 11-50% of total assets. 1-4 weeks.
3 = High > 4 weeks. > 100 cm. > 50% of total farm areas. > 50% of total home areas. > 50% of total assets. > 4 weeks.
(continued)
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Appendix (continued) Household’s Vulnerability Assessment Components 2. Flood Sensitivity 2.1 Flood risk of residential location.
Response Options and Scoring 0 = None No risk.
1 = Low
2 = Medium
3 = High
Low risk of flood (far away from flood areas, high land). Low risk of flood (far away from flood areas, high land). Some family members were sick but no need to see the doctor / recovered within a week. Felt stressed and felt better within a week.
Quite a risk of flooding.
High risk of flooding.
Quite a risk of flooding.
High risk to flood.
Some family members were sick and recovered within 1-4 weeks.
There were some impacts and needed special measures to produce drinking water (boiling, purifica-tion). There were some impacts and needed special measures to find water for general use. There were some impacts and special measures to find food were needed. There were some impacts and needed special measures to dispose of waste and sewage. There were some impacts and needed to put more effort into accessing health care service (wading long distance). There were some impacts and had additional work during flooding (fishing, planting water plant, weaving etc).
Some family members were sick and recovered after more than 4 weeks / died. Felt stressed and felt better after more than 4 weeks / needed to see a psychologist. Hard to find clean drinking water / lack of drinking water.
2.2 Flood risk of farm location.
No flood.
2.3 Physical health impacts.
No family members were sick.
2.4 Mental health impacts.
No stress or no mental health impacts.
2.5 Drinking water impacts.
No impact.
Little impacts but easy to recover.
2.6 Water use impacts.
No impact.
Little impacts but easy to recover.
2.7 Food supply impacts.
No impact.
Little impacts but easy to recover.
2.8 Waste and sewage management impacts.
No impact.
Little impacts but easy to recover.
2.9 Health care accessibility impacts.
No impact.
Little impacts but easy to recover.
2.10 Livelihood impacts.
No impact.
Little impacts but easy to recover or able to work as normal.
Felt stressed and felt better after 1-4 weeks.
Hard to find clean water / lack of water for general use. Hard to find food / lack of food.
Hard to dispose of waste and sewage / no proper disposal. Hard to access to health care service / could not access health care service.
Hard to work / could not do any work.
(continued)
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Appendix (continued) Household’s Vulnerability Assessment Components
Response Options and Scoring 0 = None
1 = Low
2 = Medium There were some impacts and loss of income 10-50% of total income under normal conditions / needed to earn income from other sources. There were some impacts and needed to change some daily living activities.
Loss of income more than 50% of total income under normal conditions.
Set up an emergency plan and prepared for most activities due to flood impacts. All family members able to cope with mental health impacts and resilience to the impacts. Tools and/or vehicle prepared before flood and worked well.
2.11 Income impacts.
No impact.
Little impacts but easy to recover / loss of income less than 10% of total income under normal conditions.
2.12 Daily living impacts.
No impact.
Little impacts but easy to live normally.
No need to prepare.
Prepared for some activities due to flood impacts.
Prepared for most activities due to flood impacts.
3.2 Mental health preparedness for flood impacts.
No need to prepare.
Some of family members able to cope with mental health impacts.
Most of family members able to cope with mental health impacts.
3.3 Tools and/ or vehicles for response to flood (water pumps, boat, high wheel truck etc). 3.4 Provide equipment for response to flood (dike, sand bags, boots etc).
No need to prepare.
Tools and/or vehicle prepared before flood but did not work.
T ools and/or vehicle prepared before flood but sometimes did not work.
No need to prepare.
3.5 Family evacuation plan.
No evacuation plan.
Provided equipment for response to flood but not enough / did not work. Family thought about evacuation plan but not seriously. Only one of family member has knowledge or skills on how to respond to flood. Household sometimes communicates with community leader.
Provided enough equipment for response to flood but sometimes did not work. Family has evacuation plan but never practised it.
Little communication within household.
Always one way communication within household.
3. Adaptive Capacity 3.1 Overall preparedness for flood impacts.
3.6 Knowledge or skills No knowledge or skills of family members on how to on how to respond respond to to flood. flood. No 3.7 Communication communication between household between and community household and leader. community leader. No 3.8 Communication communication within household within about flood. household.
Most family members have knowledge or skills on how to respond to flood. Household always communicates with community leader by one way communication.
3 = High
Hard to live as normal and needed to change almost all daily living patterns activities.
Provided enough equipment for response to flood and it worked well. Family has evacuation plan and has practised it. All family members have knowledge or skills on how to respond to flood. Household always communicates with community leader by two way communications. Always two way communication within household. (continued)
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Appendix (continued) Household’s Vulnerability Assessment Components 3.9 Relationships in the household. 3.10 External household support.
3.11 Livelihood preparedness for flood (new jobs, additional work etc) 3.12 Shelter preparedness for flood.
3.13 Health behavior adjustment to flooding.
Response Options and Scoring 0 = None
1 = Low
2 = Medium
Little relationship in the household.
Good relationships in the household.
3 = High
Very good relationships in the household. Received support Sometimes received Always received support from from com-munity. support from comcom-munity, munity, government government agencies and private agencies and sector. private sector. Permanent Temporary Livelihood No livelihood livelihood livelihood preparedness for preparedness preparedness for preparedness flood sometimes for flood. flood (eg new job, during flooding (eg farm production additional jobs, insurance etc). fishing etc). Permanent shelter Temporary shelter Shelter No shelter preparedness preparedness preparedness to preparedness to flood (eg, for flood (eg, flood sometimes for flood. piling soil on the belongings / depends on the ground floor, relocated to high situation. construct house place) with waterproof material). All family members All family Only unwell Never adjust members have have adjusted health family members health behavior always maintained behavior during have adjusted during flooding. health and shown flood but only in health behavior good health the beginning of a during flooding. behavior. flood event. Relationships in the household not good. No external household supports.
Acknowledgement We are grateful to the Graduate School, Khon Kaen University, Khon Kaen, Thailand, for financial support to conduct this study and wish to thank the public health students for their assistance in collecting the data and the household respondents for their willing participation.
Declaration of Conflicting Interests The authors declare that there is no potential conflict of interest with respect to the authorship and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: financial support from the Graduate School, Khon Kaen University, Khon Kaen, Thailand, to conduct this study.
References 1. United Nations International Strategy for Disaster Reduction. Terminology on disaster risk reduction. http://www.unisdr.org/we/inform/terminology. Accessed June 25, 2014. 2. Velasquez J, Bonapace T, Srivastava SK, Mohanty S. Reducing Vulnerability and Exposure to Disasters: The Asia-Pacific Disaster Report 2012. Bangkok, Thailand: Economic and Social Commission for Asia and the Pacific & United Nations International Strategy for Disaster Reduction; 2013.
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3. Centre for Research on the Epidemiology of Disasters. Emergency Events Database (EM-DAT), disaster list. http://www.emdat.be/database. Accessed January 7, 2014. 4. Mekong River Commission. Adaptation to Climate Change in the Countries of the Lower Mekong Basin: Regional Synthesis Report. Vientiane, Laos: Mekong River Commission; 2009. MRC Technical Paper No. 24. 5. World Bank. Thai Flood 2011: Rapid Assessment for Resilient Recovery and Reconstruction Planning. Bangkok, Thailand: World Bank; 2012. 6. Alderman K, Turner LR, Tong S. Floods and human health: a systematic review. Environ Int. 2012;47:37-47. 7. Few R. Flooding, vulnerability and coping strategies: local responses to a global threat. Prog Dev Stud. 2003;3:43-58. 8. World Health Organization. Methods of Assessing Human Health Vulnerability and Public Health Adaptation to Climate Change. Copenhagen, Denmark: Regional Office for Europe; 2003. Health and Global Environmental Change Series No. 1. 9. Lebel L, Manuta JB, Garden P. Institutional traps and vulnerability to changes in climate and flood regimes in Thailand. Reg Environ Change. 2013;11:45-58. 10. Hashizume M, Wagatsuma Y, Faruque ASG, et al. Factors determining vulnerability to diarrhea during and after severe floods in Bangladesh. J Water Health. 2008;6:323-332. 11. Plongmak J, Pumijumnong N, Bundhamcharoen K. Health burden of extreme weather in Thailand. Environment Asia. 2013;6:6-12. 12. Ebi KL, Kovats RS, Menne B. An approach for assessing human health vulnerability and public health interventions to adapt to climate change. Environ Health Perspect. 2006;114:1930-1934. 13. Nelson R, Kokic P, Crimp S, et al. The vulnerability of Australian rural communities to climate variability and change: part II. Integrating impacts with adaptive capacity. Environ Sci Policy. 2010;13: 18-27. 14. World Health Organization. Protecting Health From Climate Change: Vulnerability and Adaptation Assessment. Geneva, Switzerland: World Health Organization; 2013. 15. Adger WN. Vulnerability. Glob Environ Chang. 2006;16:268-281. 16. Shitangsu KP. Flood proneness and coping strategies: the experiences of two villages in Bangladesh. Disasters. 2010;34:489-508. 17. Lowe D, Ebi KL, Forsberg B. Factors increasing vulnerability to health effects before, during and after floods. Int J Environ Res Public Health. 2013;10:7015-7067. 18. Hijioka Y, Lin E, Pereira JJ, et al. 2014: Asia. In: Barros VR, Field CB, Dokken DJ, et al, eds. Climate Change 2014: Impacts, Adaptation, and Vulnerability. Part B: Regional Aspects. Contribution of Working Group II to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge, UK: Cambridge University Press; 2014:1327-1370. 19. McIver L, Chan V, Bowen K, Iddings S, Hero K, Raingsey P. Review of climate change and waterrelated diseases in Cambodia and findings from stakeholder knowledge assessments [published online November 10, 2014]. Asia Pac J Public Health. 20. McMichael AJ, Woodruff RE, Hales S. Climate change and human health: present and future risks. Lancet. 2006;367:859-869. 21. Hess JJ, McDowell JZ, Luber G. Integrating climate change adaptation into public health practice: using adaptive management to increase adaptive capacity and build resilience. Environ Health Perspect. 2012;120:171-179. 22. Wirawan M. Public health responses to climate change health impacts in Indonesia. Asia Pac J Public Health. 2010;22:25-30. 23. Blashki G, Armstrong G, Berry HL, et al. Preparing health services for climate change in Australia. Asia Pac J Public Health. 2011;23:133S-143S. 24. Regional Office for South East Asia World Health Organization. Health aspects of disaster preparedness and response: Report from a regional meeting of countries of South East Asia; Bangkok, Thailand, 21-23 November 2005. Prehosp Disaster Med. 2006;21(5):s62-s78. 25. Grothmann T, Reusswig F. People at risk of flooding: why some residents take precautionary action while others do not. Nat Hazards. 2006;38:101-120.
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APHXXX10.1177/1010539514568709Asia-Pacific Journal of Public HealthSrikuta et al
Original Manuscript
Health Vulnerability of Households in Flooded Communities and Their Adaptation Measures: Case Study in Northeastern Thailand
Asia-Pacific Journal of Public Health 1–13 © 2015 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539514568709 aph.sagepub.com
Phatcharee Srikuta, MPH1, Uraiwan Inmuong, MSc, PhD2, Yanyong Inmuong, PhD2, and Peter Bradshaw, BSc(Hons), DAP(Clin)3
Abstract Floods adversely affect community well-being and health. This study aims to assess the present health vulnerability of households to floods in a rural flood-prone area of northeastern Thailand, as well as their adaptation measures. The participants were the representatives of 312 randomly selected households, and data were collected using an interview questionnaire. Health vulnerability was assessed in terms of flood exposure, flood sensitivity, and flood adaptive capacity. The data were analyzed with descriptive statistics. The results showed that 47.1% of the households had a low level of health vulnerability to flooding, while in 21.2% the level was high. Households had been adapting themselves to cope with the health impacts from flood. Their coping practices included special arrangements for the protection of property, food management, the provision of water supply and waste disposal, the elimination of sources of vector-borne diseases, family health care, the protection of family livelihood, and communication and transportation. Keywords health vulnerability, flood, households, adaptation, rural, environmental health, Thailand
“Disaster” is a serious disruption of the functioning of a community or a society, involving widespread human, material, economic, or environmental losses and impacts, which exceed the ability of the affected community or society to cope using its own resources.1 Between 1970 and 2011, the Asia-Pacific region accounted for more than 74% of global human fatalities from disasters.2 Flooding is a major disaster in Southeast Asia countries. Floods in these countries during from 2000 to 2013 caused more than 10,000 fatalities and affected the lives of >76 million people, with estimated losses of about US$50 billion.3 The Lower Mekong Basin, a region that includes part of northeastern Thailand, has faced a major impact on agriculture and fisheries from 1Faculty
of Public Health, Khon Kaen University, Khon Kaen, Thailand of Environmental Health Science, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand 3Department of Epidemiology, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand 2Department
Corresponding Author: Uraiwan Inmuong, Department of Environmental Health Science, Faculty of Public Health, Khon Kaen University, 123 Moo 16 Mittapap Rd, Nai-Muang, Muang District, Khon Kaen 40002, Thailand. Email: [email protected]
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flooding.4 Most at risk are those communities that have settled in flood-prone areas, where they are threatened by extensive inundation of rice paddies and farm land as well as by disruption of transportation and communications. In 2011, Thailand experienced the worst flood disaster in half a century when flooding occurred in 66 of the nation’s 77 provinces.2 The floods heavily affected housing, which was the second-largest sector after manufacturing to be affected, with both sectors suffering comparable losses in terms of proportions of the total damage. While about 1.9 million houses were affected and 19,000 homes destroyed, the greatest damage was to household goods.5 Floods have adverse impacts on community health and household well-being. These impacts are not simply the immediate consequences of the direct effects on physical and mental health; there are also longer-term impacts on community livelihood and the environment that occur through a variety of pathways.6 The concept of vulnerability refers to a relative inability to withstand the effects of a hostile environment, and the level of vulnerability depends on the degree of exposure to a hazard, the extent to which its impacts are experienced, and the capacity for dealing with and adapting to these experiences.7,8 Health vulnerabilities to floods in Thailand are changing as a result of many factors.9 During a flood, environmental hazards expose families to changed conditions, which also change many social determinants, including those that affect health. Family health vulnerability to flooding is revealed as the result of these changes.10 A study of overall health burden associated with extreme weather in Thailand from 2006 to 2010 indicated that a total of 12,872 disability-adjusted life years were lost from floods alone.11 Understanding health vulnerability to flooding at the household level can help to strengthen household and community public health responses to a flood and lead to the development of preventive action to minimize suffering by increasing the adaptive capacity of households and the wider community. There has been no recent study of health vulnerability at the household level in the flood plains of Thailand. The current study aims to assess the present health vulnerability of households to floods in a rural flood-prone area of northeastern Thailand. The findings are expected to help communities and local support agencies to identify weaknesses, especially in adaptive capacities, and to indicate ways of reducing future health vulnerability.
Methods Study Area and Survey Sample This cross-sectional analytical study was conducted from August to December 2013 in 6 rural village communities that have been among the hardest hit by the impacts of flooding. The communities are located in the Muang Phia subdistrict of Ban Phai, which is a district of Khon Kaen province in northeastern Thailand, all of which are situated in lowland areas between the Chi River and the Kaeng Lawa wetland. The villagers had been experiencing increasingly severe flood conditions since 2007 and annual flooding from the end of September to late November. Each year, they endured inundation of their dwellings and/or heavy flood flow into farming areas. The household survey was conducted mainly after flooding receded in December 2013. The survey participants were the heads of households or the most senior available household representatives >18 years of age in 312 households that were selected by simple random sampling from the total of 967 households in the study area. The number of households sampled in each village was proportional to its contribution to the total number of households in all 6 villages. No households refused to participate, but there was a small number for which no household representative was available. When this occurred, the interviewers approached the nearest household with a representative. All participants provided written informed consent before they were interviewed.
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=
Risk Adaptive Capacity
where Risk = Sensitivity x Exposure Figure 1. Relationships among vulnerability, risk, and adaptive capacity.
Table 1. Categorization of Total Scores for Each Flood Component. Level Lowa Medium Highb aNone
Exposure
Sensitivity
Adaptive Capacity
1-6 7-12 13-18
1-12 13-24 25-36
1-13 14-26 27-39
of respondents had scores of 0. scores are 18, 36, and 39, respectively
bMaximum
Table 2. Decision Matrix for Determining a Household’s Flood Risk Level. Flood Sensitivity Level Flood Exposure High Medium Low
High
Medium
Low
High High Medium
High Medium Low
Medium Low Low
Survey Questionnaire and Health Vulnerability Assessment Data were collected with a structured interview questionnaire that was administered by trained public health students. The questionnaire was written in Thai, and the items were designed to elicit household demographic information, to acquire details of each household’s flood experience and adaptations to flooding, and to assess the household’s health vulnerability to floods. The health vulnerability assessment was based on the studies by Ebi et al12 and Nelson et al.13 Health vulnerability was defined as the degree to which households are unable to cope with the adverse health outcomes and health impacts due to flood, and it was deemed to have 3 components8,14: flood exposure (6 items), the extent to which households had experienced the impacts of flooding; flood sensitivity (12 items), the degree to which a household had been affected by flood exposure (the effects may be direct or indirect), with particular regard to factors having negative health impacts; and flood adaptive capacity (13 items), the potential ability of a household to cope with the consequences of a flood. For metric purposes, the relationship between vulnerability and the 3 components can be represented as shown in Figure 1, which is adapted from Adger.15 There were 4 defined response options for each item, and responses were scored 0 to 3 (none, low, medium, and high) in terms of increasing levels of response to an item (see appendix). The total component scores for exposure, sensitivity, and adaptive capacity were categorized as low, medium, and high (Table 1). Following the model in Figure 1, decision matrices were used to define individual household levels of risk (Table 2) and then individual household levels of health vulnerability (Table 3).
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Table 3. Decision Matrix for Determining a Household’s Health Vulnerability Level. Flood Risk level Flood Adaptive Capacity Low Medium High
High
Medium
Low
High High Medium
High Medium Low
Medium Low Low
Table 4. Demographic Characteristics of the Study Respondents (N = 312). Demographic Characteristics Sex Female Male Age, yrs. 19-30 31-40 41-50 51-60 61-65 Education Illiterate Primary Basic secondary Secondary–high school College University bachelor degree or higher Occupation Farming/agriculture work Laborer Retailer Government/private sector employee Others
No. (%) 208 (66.7) 104 (33.3) 21 (6.7) 49 (15.7) 110 (35.3) 106 (34.0) 26 (8.3) 4 (1.3) 247 (79.2) 23 (7.4) 21 (6.7) 6 (1.9) 11 (3.5) 244 (78.2) 24 (7.7) 22 (7.1) 14 (4.5) 8 (2.5)
Data Analysis and Ethical Approval The data were analyzed using descriptive statistics and Stata 10.0 software. Ethical approval to conduct the study was obtained from the Khon Kaen University Ethics Committee for Human Research in accordance with the Declaration of Helsinki and the ICH good clinical practice guidelines (HE562118).
Results The demographic characteristics of the household respondents are shown in Table 4. The overall impacts of flooding in terms of exposure, sensitivity, adaptive capacity, and health vulnerability are shown in Table 5.
Flood Exposure Most households (71.8%) reported a medium level of exposure to flooding. When the households were divided into 4 groups according to the type of area exposed to flooding, 64.1% were farm Downloaded from aph.sagepub.com at UNIV NEBRASKA LIBRARIES on October 13, 2015
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Srikuta et al Table 5. Level of Household’s Health Vulnerability to Flood, No. (%).
Total Score Level From the Household Assessment (N = 312) Components Related to Flood Exposure Sensitivity Adaptive capacity Health vulnerability
High
Medium
Low
87 (27.9) 42 (13.5) 35 (11.2) 66 (21.2)
224 (71.8) 87 (27.9) 235 (75.3) 99 (31.7)
1 (0.3) 183 (58.6) 42 (13.5) 147 (47.1)
households, 4.8% were residential households, 30.8% were both farm and residential households, and 0.3% were households in areas not exposed to flooding. Almost all the households (97.8%) had experienced an annual flood disaster. Survey respondents recalled that flooding had occurred since 1953, and many (42.3%) recognized that the most severe flood was in 1978. In the past, floods did not cause serious impacts; water overflowed into rice paddies and houses for nearly a week, and then the flood waters gradually receded. Since 1997, the intensity of the floods has continually increased due to the building of a dyke that retains flood water in the areas where the communities are located and to an increase in precipitation during the monsoon season (May to November): flooding normally occurs every year between October and November. The majority of household representatives (77.6%) considered that the most severe flooding in more recent times happened in 2011. During the latest flood event, most families (56.9%) experienced a gradual inundation of rice paddies and farm areas, but many (38.5%) also faced a flash flood. For flooded farm areas, the longest period of flooding was 79 days and the shortest, 33 days. In flooded resident areas, the longest and shortest periods were 55 and 24 days. The average flood level in the farm areas was 2.4 m, while that in the residential areas was 0.8 m. The recovery time for both areas of flooding was about 1 month.
Flood Sensitivity While more than half the respondents (58.6%) reported a low level of flood sensitivity, a small but nevertheless sizable group of households (13.5%) had struggled with high impacts. The average distance from farms to the Chi River, which was the main source of runoff from the upper catchment area, was 1.3 km. There were 18 households with farms close to the river, and production on these farms was always damaged. The average distance of houses to the river was 0.8 km. The nearest distance between a house and the river was only 50 m. During the most recent flood, 94.5% of households with rice paddies had their crops damaged by flood water, with an estimated loss of 25% of their average annual family income. More than one-third of households (35.6%) had faced serious consequences from the flooding of their homes, with an average estimated loss of household assets and house damage of 6% of their average annual family income. For many families (77.2%), these effects resulted in a major loss of income. Many household respondents (44.9%) considered the health status of their families to be quite good, with little sickness and with an ability to work normally. However, about half the households (52.6%) had at least 1 member who was ill, mainly due to hypertension (24.7%), diabetes (21.2%), muscle and bone symptoms (4.5%), and heart disease (4.5%). About half the households (52.9%) reported that during the flooding period, families experienced acute health problems due to skin infections (48.1%), common colds (20.2%), conjunctivitis (12.8%), muscle pains (6.4%), and diarrhea (4.8%). While the physical health problems associated with flooding were mainly skin diseases, fevers, and muscle pains, mental health problems due to losses incurred as a result of flooding were also mentioned. A large minority (45.5%) felt that the worst impact on their families was the loss of farm production; this reduced household income, increased mental stress, and was seen as a loss of food security.
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The majority of households (75.3%) reported experiencing hardships in their daily living due to flood conditions. For many (69.5%), the environmental health risks were magnified by the increased number of poisonous animals and vector-borne diseases. More than a third of families (36.5%) were faced with needing to cope with an unclean water supply when the floodwaters contaminated their usual sources of water. Due to the inundation of roads and areas around the houses, 33.0% reported that the disposal of household waste could not be properly achieved by the local authorities. Some people (29.5%) therefore threw their waste into the floodwaters, with the result that water became contaminated, and there was an increased risk of skin infections and gastrointestinal problems. A further daily living hardship was the lack of properly functioning toilets (27.6%), and some households lacked food (23.7%) and drinking water (15.3%). Many respondents (72.1%) also considered that their families had become stressed by the flooding and were very worried about losses.
Flood Adaptive Capacity Most respondent households (75.3%) reported a medium level of the adaptive capacity for coping with flooding. While families made their own preparations for adapting to flood conditions, they were supported by others in the community and by the government and private sectors. The majority (69.2%) perceived floods as natural events, but some (23.7%) thought that floods happened because of faults in the water management system that should not have occurred. While more than half the households (57.2%) considered that the severity of floods had increased considerably over the years, a majority (76.3%) believed that their adaptation practices were good enough to handle the impacts. Nevertheless, some families (16.7%) still found it hard to deal with the impacts. During the interviews, respondents had been given a list of possible adaptation measures and were asked to indicate which measures their households had adopted. The results of this are shown in Table 6. Most of the farming families (97.8%) received compensation from the district agricultural office in accordance with the government’s disaster support policy. In addition, households who had insured their rice product with the Bank for Agriculture and Agricultural Cooperatives were able to obtain compensation from this source for damaged crops. The purposes of this compensation were for the investment costs of the next crop (78.9%), debt payment (30.5%), and family living expenses (29.2%). Households were also strongly supported by the subdistrict health promotion hospitals and related health agencies, and community health volunteers assisted by providing relevant hygiene and health care knowledge as part of their health promotion–related activities.
Health Vulnerability to Flood Almost all households (99.7%) were affected by floods. While many (47.1%) had only a low level of health vulnerability to flooding, 21.2% were highly vulnerable. The household’s health vulnerability is reduced when sensitivity and exposure are low and adaptation is high. The factors that appeared to make families more vulnerable to the negative impacts of flooding were location in both a residential and farming area; poverty and the reduced availability of clean water during floods; lack of healthcare knowledge; and having household members who were patients with chronic diseases, young children, elderly, disabled, or already suffering from a skin disorder.
Discussion The findings of this study indicated that the most vulnerable group of households in the flooded communities was composed of those who had children, chronic disease patients, and/or disabled persons. This group needed special health care support and medication during floods. The
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Srikuta et al Table 6. Household Flood Adaptation Measures (N = 312). Adaptation Measures
No. (%)
Arrangements for housing shelter and property Piling soil on the ground floor Elevating the houses Relocation of belongings to high places Clearing and extending water drainage system Money saving Possession of evacuation kits Possession of devices/equipment for response to flood (eg, temporary bridge, sand bags, dyke) Seeking alternative living area in case of severe event House and assets insurance Food and water supply management Storage of water for drinking Storage of cooking gas/wood Storage of clean water for general use Storage of food in advance Provisions for waste disposal Storage of plastic bags for waste Clearing lavatory tank before flood Elimination of sources of vector-borne diseases Cleaning of living area to infestation by dangerous animals/insects Possession of nets for insect protection Storage of insect repellents Family health care Always washing after exposure to flood water Arranging and keeping essential medicines Provision of boots Seeking alternative accommodation for children and the elderly in case of evacuation Protection of family livelihood Rice production insurance Adjustment or postponement of rice cultivation season Farm investment reduction or decrease in production Finding additional jobs in other locations Asking for support from government agencies Changing livestock/plant species Doing work other than farming and livestock feeding Communication and transportation Frequent attention to communications about flood conditions from community leader and related agencies Boat provision
246 (78.8) 182 (58.5) 176 (56.4) 173 (55.5) 125 (40.1) 116 (37.2) 111 (35.6) 51 (16.4) 10 (3.2) 236 (75.6) 208 (66.7) 194 (62.2) 169 (54.2) 162 (51.9) 66 (21.2) 262 (83.9) 239 (76.6) 190 (60.9) 284 (91.0) 267 (85.6) 258 (82.7) 89 (28.5) 186 (59.6) 117 (37.5) 102 (32.7) 116 (37.2) 85 (27.2) 60 (19.2) 46 (14.7) 293 (93.9) 120 (38.5)
interview findings revealed that the households were supported by local agencies, such as the local administrative organization, the community health promotion hospital, the public health district office, Thailand’s Red Cross Society, the district agricultural office, and various private sector groups. These added to the effectiveness of the household adaptation strategies in reducing health vulnerability and health impacts by increasing the ability of households to cope with changed conditions.
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The households had chosen to use different adaptation strategies. Such choices are determined by many factors such as household income, educational background, flood characteristics, occupation, and distance from a riverbank.16 Households had learned from past experience and their mistakes in ways of responding to previous floods. This had enhanced their capacity to adopt the best measures for maintaining health and minimizing risks. They were aware of the dangers associated with floods and had a basic understanding of how to react at a household level before, during, and after a flood event. Household’s health vulnerability to flood varies in different contexts, and there is a wide range in the level of preparedness adaptation. Lowe et al indicated that many factors can increase health vulnerability, such as age, sex, previous flood experiences, greater flood depth or flood trauma, existing illnesses, medication interruption, and low education or socioeconomic status. The potential risk factors may differ according to the timing of exposure; whether before, during, or after flood events, these can also cause households to take action to prevent flood impacts.17 An increasing frequency of extreme weather and its results, such as flooding, is a potential consequence of global warming and climate change. The Intergovernmental Panel on Climate Change18 reports that increased incidences of water-borne diseases (eg, diarrhea) and vectorborne diseases (eg, dengue fever) are likely health impacts of climate change in Southeast Asia. In the study site and other parts of Thailand, the increased risks of water-related diseases due to climate change are likely to be similar to those identified for Cambodia, especially for the poorer sections of society living in flood-prone areas because of their more limited access to an uncontaminated water supply and good sanitation.19 It is important for households, communities, and official bodies to plan on how to manage such events and increase resilience to the associated risks and health impacts. Long-term public health adaptation to climate change impacts will be a new challenge for the health sector nexus, especially the task of identifying those groups who are particularly vulnerable to the impacts of disasters.20 Health care systems need to be proactive and increase their adaptive capacity and resilience to environmental change.21,22 To prepare for the impacts of climate change, the health system should be flexible, strategically allocated, and robust. Close coordination is necessary among different sectors, including nonhealth sectors and community members. All must work collectively for long-term disaster prevention and emergency preparedness to be effective.23 In the case of the villages in the current study, their adaptation measures had already embraced health impacts as an issue of concern. An elaborate early warning system based on community networks was operating in the upper river basin; community human capital capacity building has occurred; the primary health system has been strengthened by, for example, improved disease surveillance; and flooded communities have been engaged in disaster prevention planning and involved in the implementation of appropriate relief measures, as well as the evaluation of community effectiveness.24 The present study has several limitations. Firstly, the respondent household representatives may not always have accurately reflected the views of the household. They were, in a sense, only a “convenience sample” drawn from within the selected households. For example, the majority were female, and this occurred because male members of the households were often away at work. Given the sex role differences in village life, it is possible (even likely) that this distorted the results. Secondly, the findings are unlikely to generalize to communities affected by other types of flood events—especially the more unpredictable flash floods, rather than a highly predictable gradual annual flooding of the kind experienced in the study area. These types of flood events are likely to lead to a much greater adaptive capacity and lesser vulnerability. Thirdly, generalization of the findings is limited due to differences in cultural and social factors. One example of this is that in a rural village, perhaps especially in northeastern Thailand, people are
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unlikely to consider moving away to a different region as an adaptive strategy because of their especially strong local family and community bonds.
Conclusion/Recommendation The results indicated that while many of the households in the study communities had a low level of health vulnerability to flooding (47.1%), for most (52.9%) the level was high (21.2%) or medium (31.7%). Households had been adapting themselves to cope with the health impacts from flood. Their coping practices included special arrangements for the protection of property, food management, the provision of water supply and waste disposal, the elimination of sources of vector-borne diseases, family health care, the protection of family livelihood, and communication and transportation. As this case study demonstrated, it is most important for people and local agencies to communicate with one another about the risks related to flooding in their communities and to appreciate the cost-effectiveness of various measures to mitigate the impacts of flood events. These understandings motivate households in flood-prone areas to take preventive action to reduce the worst consequences of flooding.17 They also help flood-relevant agencies to take a proactive role in assisting households to reduce the potential health impacts through a decrease in health vulnerability. A potential weakness of the present study is that, in answering the health vulnerability assessment items, householders were not necessarily replying in terms of the most recent flooding and were free to respond by integrating their past experiences over more than 1 year in the past. In future studies, the various components of health vulnerability should be assessed by attempting to collect data from respondents before, during, and immediately after a particular flood event. In this way, the associations between health vulnerability and exposure, sensitivity, and adaptive capacity can be more directly investigated. Larger-scale research into health vulnerability to flooding is required at district and provincial levels. This can benefit the local policy makers and public health sector in their planning and establishment of local-level strategies to deal with a problem that is likely to increase with climate change and an aging (and hence more dependent) population.
Appendix Household’s Health Vulnerability Assessment to Flood. Household’s Vulnerability Assessment Components 1. Flood Exposure 1.1 Duration of flood. 1.2 Flood level. 1.3 Flooding of farm area. 1.4 Flooding of home area. 1.5 Assets damaged. 1.6 Recovery time.
Response Options and Scoring 0 = None No flood. No flood. No flood in a farm area. No flood in home area. No assets damaged. No flood / No need for recovery.
1 = Low < 2 weeks. < 30 cm. < 10% of total farm areas. < 10% of total home areas. < 10% of total assets. < 1 weeks.
2 = Medium 2-4 weeks. 31-100 cm. 11-50% of total farm areas. 11-50% of total home areas. 11-50% of total assets. 1-4 weeks.
3 = High > 4 weeks. > 100 cm. > 50% of total farm areas. > 50% of total home areas. > 50% of total assets. > 4 weeks.
(continued)
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Appendix (continued) Household’s Vulnerability Assessment Components 2. Flood Sensitivity 2.1 Flood risk of residential location.
Response Options and Scoring 0 = None No risk.
1 = Low
2 = Medium
3 = High
Low risk of flood (far away from flood areas, high land). Low risk of flood (far away from flood areas, high land). Some family members were sick but no need to see the doctor / recovered within a week. Felt stressed and felt better within a week.
Quite a risk of flooding.
High risk of flooding.
Quite a risk of flooding.
High risk to flood.
Some family members were sick and recovered within 1-4 weeks.
There were some impacts and needed special measures to produce drinking water (boiling, purifica-tion). There were some impacts and needed special measures to find water for general use. There were some impacts and special measures to find food were needed. There were some impacts and needed special measures to dispose of waste and sewage. There were some impacts and needed to put more effort into accessing health care service (wading long distance). There were some impacts and had additional work during flooding (fishing, planting water plant, weaving etc).
Some family members were sick and recovered after more than 4 weeks / died. Felt stressed and felt better after more than 4 weeks / needed to see a psychologist. Hard to find clean drinking water / lack of drinking water.
2.2 Flood risk of farm location.
No flood.
2.3 Physical health impacts.
No family members were sick.
2.4 Mental health impacts.
No stress or no mental health impacts.
2.5 Drinking water impacts.
No impact.
Little impacts but easy to recover.
2.6 Water use impacts.
No impact.
Little impacts but easy to recover.
2.7 Food supply impacts.
No impact.
Little impacts but easy to recover.
2.8 Waste and sewage management impacts.
No impact.
Little impacts but easy to recover.
2.9 Health care accessibility impacts.
No impact.
Little impacts but easy to recover.
2.10 Livelihood impacts.
No impact.
Little impacts but easy to recover or able to work as normal.
Felt stressed and felt better after 1-4 weeks.
Hard to find clean water / lack of water for general use. Hard to find food / lack of food.
Hard to dispose of waste and sewage / no proper disposal. Hard to access to health care service / could not access health care service.
Hard to work / could not do any work.
(continued)
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Appendix (continued) Household’s Vulnerability Assessment Components
Response Options and Scoring 0 = None
1 = Low
2 = Medium There were some impacts and loss of income 10-50% of total income under normal conditions / needed to earn income from other sources. There were some impacts and needed to change some daily living activities.
Loss of income more than 50% of total income under normal conditions.
Set up an emergency plan and prepared for most activities due to flood impacts. All family members able to cope with mental health impacts and resilience to the impacts. Tools and/or vehicle prepared before flood and worked well.
2.11 Income impacts.
No impact.
Little impacts but easy to recover / loss of income less than 10% of total income under normal conditions.
2.12 Daily living impacts.
No impact.
Little impacts but easy to live normally.
No need to prepare.
Prepared for some activities due to flood impacts.
Prepared for most activities due to flood impacts.
3.2 Mental health preparedness for flood impacts.
No need to prepare.
Some of family members able to cope with mental health impacts.
Most of family members able to cope with mental health impacts.
3.3 Tools and/ or vehicles for response to flood (water pumps, boat, high wheel truck etc). 3.4 Provide equipment for response to flood (dike, sand bags, boots etc).
No need to prepare.
Tools and/or vehicle prepared before flood but did not work.
T ools and/or vehicle prepared before flood but sometimes did not work.
No need to prepare.
3.5 Family evacuation plan.
No evacuation plan.
Provided equipment for response to flood but not enough / did not work. Family thought about evacuation plan but not seriously. Only one of family member has knowledge or skills on how to respond to flood. Household sometimes communicates with community leader.
Provided enough equipment for response to flood but sometimes did not work. Family has evacuation plan but never practised it.
Little communication within household.
Always one way communication within household.
3. Adaptive Capacity 3.1 Overall preparedness for flood impacts.
3.6 Knowledge or skills No knowledge or skills of family members on how to on how to respond respond to to flood. flood. No 3.7 Communication communication between household between and community household and leader. community leader. No 3.8 Communication communication within household within about flood. household.
Most family members have knowledge or skills on how to respond to flood. Household always communicates with community leader by one way communication.
3 = High
Hard to live as normal and needed to change almost all daily living patterns activities.
Provided enough equipment for response to flood and it worked well. Family has evacuation plan and has practised it. All family members have knowledge or skills on how to respond to flood. Household always communicates with community leader by two way communications. Always two way communication within household. (continued)
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Appendix (continued) Household’s Vulnerability Assessment Components 3.9 Relationships in the household. 3.10 External household support.
3.11 Livelihood preparedness for flood (new jobs, additional work etc) 3.12 Shelter preparedness for flood.
3.13 Health behavior adjustment to flooding.
Response Options and Scoring 0 = None
1 = Low
2 = Medium
Little relationship in the household.
Good relationships in the household.
3 = High
Very good relationships in the household. Received support Sometimes received Always received support from from com-munity. support from comcom-munity, munity, government government agencies and private agencies and sector. private sector. Permanent Temporary Livelihood No livelihood livelihood livelihood preparedness for preparedness preparedness for preparedness flood sometimes for flood. flood (eg new job, during flooding (eg farm production additional jobs, insurance etc). fishing etc). Permanent shelter Temporary shelter Shelter No shelter preparedness preparedness preparedness to preparedness to flood (eg, for flood (eg, flood sometimes for flood. piling soil on the belongings / depends on the ground floor, relocated to high situation. construct house place) with waterproof material). All family members All family Only unwell Never adjust members have have adjusted health family members health behavior always maintained behavior during have adjusted during flooding. health and shown flood but only in health behavior good health the beginning of a during flooding. behavior. flood event. Relationships in the household not good. No external household supports.
Acknowledgement We are grateful to the Graduate School, Khon Kaen University, Khon Kaen, Thailand, for financial support to conduct this study and wish to thank the public health students for their assistance in collecting the data and the household respondents for their willing participation.
Declaration of Conflicting Interests The authors declare that there is no potential conflict of interest with respect to the authorship and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: financial support from the Graduate School, Khon Kaen University, Khon Kaen, Thailand, to conduct this study.
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