Health Emergency and Disaster Risk Management (Health-EDRM) in Remote Ethnic Minority Areas of Rural China: The Case of a Flood-Prone Village in Sichuan
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- Chan, E.Y.Y., Guo, C., Lee, P. et al. Int J Disaster Risk Sci (2017). doi:10.1007/s13753-017-0121-1
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Remote, rural ethnic-minority communities face greater disaster-related public health risks due to their lack of resources and limited access to health care. The Ethnic Minority Health Project (EMHP) was initiated in 2009 to work with remote, disaster-prone ethnic-minority villages that live in extreme poverty. One of the project’s aims is to develop and evaluate bottom-up health risk reduction efforts in emergency and disaster risk management (Health-EDRM). This article shares project updates and describes field intervention results from the Yi ethnic community of Hongyan village in China’s Sichuan Province, an area that experiences recurrent floods. It was found that 64% of the village respondents had never considered any form of disaster preparation, even with the recurrent flood risks. Health intervention participants showed sustained knowledge retention and were nine times more likely to know the correct composition of oral rehydration solution (ORS) after the intervention. Participants also retained the improved knowledge on ORS and disaster preparedness kit ownership 12 months after the intervention.
KeywordsDisaster preparedness kit Disaster risk reduction Ethnic minority Health emergency and disaster risk management (Health-EDRM) Oral rehydration solution Recurrent floods Rural China
2 Study Context: Hongyan Village in Sichuan Province
Hongyan village is an ethnic minority-based community that is 91% Yi ethnicity (1% Han Chinese, 8% other ethnic groups). The village is an agricultural, non-migrant based village composed of 217 households and 826 residents. It is one of the 169 villages in Xide County, in the Liangshan Yi Autonomous Prefecture that is situated in the southern area of Sichuan Province. In 2014, the majority of families lived under the United Nations international extreme poverty line (USD 1.25 per day during the study period), with an annual household income around USD 100–120 in 2014.
3 Project Description and Evaluation
Through the support of the China Ministry of Civil Affairs and recommendation by the Wu Zhi Qiao Charitable Foundation, a 3-year project, from 2012 to 2015, was established in Hongyan village after the August 2012 flood. This article summarizes some of the key findings on the effectiveness of a bottom-up training intervention conducted in 2014.
Baseline and post-intervention data were collected through cross-sectional interviewer-administered questionnaire surveys in 2012, 2014, and 2015. Qualitative data were collected through key informant interviews and focus groups in 2012 and 2015. Verbal consent was obtained for all study participants. While all village residents were invited to join the interventions, 54 households (25% of the village community) were selected randomly from the official household register list to participate in periodic cross-sectional household-based surveys to evaluate the project’s impact.
Based on the 2012 needs assessment findings, health and disaster risk reduction promotion interventions, each lasting about 30–45 min, were planned and implemented 28 March–1 April 2014. Although diarrhea and water- and vector-borne diseases are preventable post-disaster health problems, these risks are often neglected by remote communities in western China (Gustafsson and Ding 2009; WHO 2014; Chan 2017). Community training sessions on general health risk awareness (the importance of washing hands, for example), household disaster kit preparation, and the preparation of a homemade oral rehydration solution (ORS) were conducted. Field interventions included education in general water safety and sanitation, indoor environment maintenance, waste management, and other health behaviors. Low-cost and locally accessible items according to the five essential health needs (water/sanitation, food/nutrition, non-food items including shelter/clothing, health care, and information/communication) were included in disaster preparedness kit preparation (Bolton 2006; Chan 2017). Due to the low literacy rate, educational interventions mainly relied on graphical information and dramatized presentations. Validated questionnaires (30 questions) were administered to evaluate intervention effectiveness by comparing the results before and immediately after the interventions. This was followed with an evaluation of the overall project impact 12 months later, in March 2015.
All data were double entered and cleaned by trained staff. Descriptive statistics were generated and group differences were analyzed using Chi square tests (α = 0.05). All statistical analyses were conducted with SPSS version 21.0. Ethics approval was obtained from the sponsoring university.
4 Key Program Findings
Despite the recurrent flood threats, up to 72.5% of the village respondents did not have any form of disaster preparedness before the August 2012 flood. Health intervention participants showed sustained knowledge retention. They were nine times more likely to know the correct composition of oral rehydration solution, and retained the improved knowledge on ORS and disaster preparedness kit ownership 12 months after the intervention.
4.1 The Sample Population
Comparison of sociodemographic characteristics of Hongyan, Sichuan, and China
Hongyan village 2014a
Sichuan Province 2014b
Male to female ratio
Agricultural sector occupation
Mean household size
4.2 Disaster Preparedness and Health Impacts of the August 2012 Flood
Of the village respondents, 80% reported that they had experienced a disaster in the previous 3 years.1 However, 72.5% of the village respondents did not have any disaster preparation before the August 2012 flood, and 64% had never thought about disaster preparedness at all. Barriers to not preparing were the lack of knowledge/awareness of how to prepare a household disaster kit, the formulation of ORS, the purpose of ORS, the disaster implications associated with the villagers’ living environment, and everyday health behaviors (with respect to, for example, water procurement, food safety management (for example, storage and preparation), sanitation and hygiene practices, and control of vector-borne diseases).
No flood-related casualty was reported among these sample households, but 45% had one family member who experienced at least one episode of diarrhea within the first month after the flood. Moreover, children were the vulnerable group who reported more water, food, and vector-borne (mosquitoes) health issues than the other age groups. Outside communication, information, and support were interrupted for an average 7–14 days. Village respondents reported spending an average of 62 days in temporary shelters, and 86% of sample households reported the loss of all cash crops during the August 2012 floods.
4.3 Evaluation of Intervention Effectiveness
Of the 217 households, 47% (n = 102) participated in the intervention training sessions and completed the pre- and post-intervention questionnaires in 2014. The final valid sample size in 2014 was 100.
4.3.1 Disaster Preparedness Kit
List of items covered in the 2014 pre- and post-intervention household questionnaire on the content of a disaster preparedness kit (n = 100) in Hongyan village (necessary items in bold)
Information and communication
Non-food items including shelter and clothing
Food and nutrition
Water and sanitation
4.3.2 Oral Rehydration Solution (ORS) Preparation
Results of the 2014 pre- and post-intervention household questionnaire on ORS-related knowledge (n = 100) in Hongyan village
Immediately post-intervention (%)
Preparation of ORS
How to prepare ORS
Composition of ORS
Regard ORS preparation as difficult
Knowledge of ORS health benefits
Agree diarrhea causes dehydration
Agree dehydration leads to death
Knowledge and attitude change 12 months post-intervention (2015), comparing the 2014 health intervention participants and non-participants (n = 59)
Know the correct composition of ORS
Know the correct proportion of ORS components
Feel confident when making ORS
Feel confident when preparing disaster kit
Have a disaster kit at home (Ownership)
Feel that it is necessary to take a disaster kit in the event of a disaster
4.3.3 Health Risk Management
Comparison of various self-reported health-related beliefs and practices in Hongyan village
Health risk-mitigating practices
2012 (n = 54)
2015 (n = 59) (%)
Water and sanitation
Obtained from pipe water
Drink water without any treatment
After using toilet
Soap or detergent use observed when handwashing
Recycling of plastic bottles
Dump on land
Think preparing a disaster kit is important in case of a disaster
Think family has the ability to protect health and safety when disaster comes in future
Know how to make ORS
5 Discussion and Lessons Identified
Since 2000, China has had the highest number of floods (UNISDR 2015) in the world. Though many Hongyan villagers had experienced devastating economic losses from previous floods, disaster risk perceptions, health risk awareness, and disaster preparedness were remarkably low. These findings are largely consistent with other studies conducted in similar socioeconomic contexts in China (Chan et al. 2014).
Extreme poverty remains a strong barrier that prevents resource deficit communities from acquiring the materials needed for the preparation of disaster preparedness kits. But the bottom-up health risk reduction intervention demonstrated its effectiveness to enhance community disaster preparedness. For all targeted disaster health risk reduction interventions, sustained knowledge enhancement (12 months post-intervention) was demonstrated. Although ORS preparation might be an important low-cost, readily available solution to support disaster health risk reduction, especially for children (Molla et al. 1989; Sillah et al. 2013), the knowledge and use of ORS remain low among rural communities in the world. There was generally limited awareness of ORS as a potential supportive self-help treatment in rural communities.
Despite the effectiveness of the intervention, certain limitations are recognized. First, although an overall effect was observed, it was difficult to differentiate the effective components and messages within the intervention. Complex community intervention trials should be attempted in future studies (Hohmann and Shear 2002; Grant 2013). The decrease of self-reported diarrhea cases in 2015 (12-month post-intervention) from 2012 (4-month post-flood) in the community should be interpreted with caution as there might be a general surge of diarrhea cases immediately after flooding. Nevertheless, a focus group discussion found that participants regarded handwashing habit education as the main reason the overall diarrhea prevalence decreased during the 12 months after the intervention. Second, most field-based interventions promoted by nongovernment or government groups might not be grounded on theoretical models, which makes evaluation challenging. For this project, the precaution adoption process model (Jassempour et al. 2014) proved valuable to support the planning of the health intervention to train up disaster preparedness. Language barriers and low education levels may contribute to any reporting and recall bias.
The long-term impact sustainability beyond 12 months and the results of other risk reduction interventions (for example, water boiling, food safety, and vector control) will be evaluated in future reports. This article aims to communicate that low-cost interventions still hold their value in poor and disaster-prone rural communities.
The findings indicate that in remote and resource-poor areas, health risk awareness and disaster preparedness are limited even though these communities are frequently exposed to recurrent disasters, such as floods. Areas with recurrent disasters will need to strengthen their bottom-up resilience in Health-EDRM to improve preparedness, response capacity, and overall health outcomes. This project progress report highlights that a low-cost health educational approach remains an important bottom-up model to empower remote rural communities to build resilience and reduce health risks associated with disasters and health emergencies. Future studies will be necessary to understand the health emergency and disaster risks and to ascertain the optimal strategies for improving health and reducing disaster risks in remote communities. For more information related to this project or CCOUC, please visit: http://www.ccouc.org.
This project was funded by the CCOUC field research fund, the Chow Tai Fook Charitable Foundation, the I-CARE Programme (The Chinese University of Hong Kong), and the Wu Zhi Qiao Charitable Foundation. The authors express special appreciation to Prof. Edward Ng, Dr. Tony Yung, Mr. Darren Nash, Ms. Crystal Ying-Jia Zhu, Prof. Kevin Hung, Mr. Zhe Huang, Mr. C.S. Wong, Ms. Carol Wong, Ms. Gloria Chan, Dr. Holly Lam, Prof. Jennifer Leaning, Dr. Elizabeth Newnham, and Prof. Jean Kim for their assistance in the data collection and their intellectual and collaborative support throughout the project development process.
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