Managing the Increasing Heat Stress in Rural Areas
Increasing temperatures are likely to impact human health. An increase in severe heat wave days and heat mortalities has been observed in India over the past few decades. At present, there is little evidence on the heat exposure, impact, and the adaptation measures in the rural context. The present study examines vulnerability of rural communities to heat stress in the semiarid villages in Maharashtra state of India.
The study was conducted in five villages of Jalna and Yavatmal districts of Maharashtra. Household survey covering 20% of the households was conducted in Jalna during 2016 summer months. Twenty data loggers were installed to measure the indoor temperatures in Yavatmal.
Exposure to heat in various circumstances, both outdoors and indoors, was reported. Age, gender, wealth, and pre-existing health conditions were significantly associated with occurrence of heat-related symptoms (HRS). Exposure factors such as working outdoors during midday, roofing material, and indoor ventilation were significantly associated with occurrence of HRS. The indoor temperature in houses with tin roofs was found to be higher as compared to cement-roofed houses.
Existing coping strategies appear to be inadequate to protect people from outdoor and indoor heat stress. People from poorer households reported socioeconomic and livelihood challenges in adopting coping strategies as well. A long-term and locally appropriate strategy in terms of knowledge about HRS and infrastructure and access to timely medical facilities is needed. Development of effective surveillance mechanism and a comprehensive state-level heat action plan are needed to prevent and monitor heat mortalities in the future.
KeywordsHeat stress Heat-related symptoms Differential vulnerability Rural health Semiarid regions
The risk of heat-related illnesses and deaths is likely to increase due to rising temperatures (Intergovernmental Panel on Climate Change 2014). In India, there has been an increasing trend of heat wave-related deaths in the last few decades. A report by National Disaster Management Authority highlights that between the periods 1992 and 2015, about 22,562 heat-related deaths were reported (Government of India 2016). In fact, heat stroke was the second major cause of deaths from natural disasters in India (accounting for 15% of those deaths) during the decade 2001–2012 (Paul and Bhatia 2016). Most studies on the health impacts of heat have been conducted within the context of officially declared heat waves. It has been found that significant mortality and morbidity can be attributable to heat exposure. The effect could be up to 43% increase in deaths due to heat wave in urban India (Azhar et al. 2014).
Future climate projections for India indicate that heat waves will likely be more intense, have longer durations, and occur more often and earlier in the year. Intensification of heat waves will also lead to increased mortality rates (Dholakia et al. 2015; Murari et al. 2015). It was also found that death attributable to extreme heat was about the same as moderately high temperatures (Gasparrini et al. 2015).
Increasing heat exposure is linked to occupational health risks and negatively impacts work productivity (Dash and Kjellstrom 2011; Kjellstrom et al. 2009). Studies on occupational heat stress impacts in India found that decreased productivity was reported most commonly among outdoor/semi-outdoor occupations with high workload (e.g., brick manufacturing, metal fabrication, construction, etc.), whereas productivity losses were reported less frequently among indoor workers (Venugopal et al. 2015).
An association between high temperature and noninfectious disease mortality was found in a study conducted in rural western India. Men in working age involved in outdoor activities like agricultural and industrial workers were more vulnerable to heat (Ingole et al. 2015).
In Gujarat and Rajasthan, workers in the rural and semi-urban industries of ceramics, pottery, iron works, and stone quarry were found to be vulnerable (Nag et al. 2009). In the rural context, it was found that among the rice farm workers in West Bengal, high workplace heat exposure caused heat strain and reduced work productivity (Sahu et al. 2013).
Apart from decreased work productivity, increased temperatures also have other social impacts. A 21-year rural longitudinal survey conducted in Pakistan showed that men move out of the village due to extreme heat stress and that the landless and asset-less poor are more likely to do so (Mueller et al. 2014). A large-scale study conducted in Thailand found that working under heat stress conditions is associated with worse overall health and psychological distress (Tawatsupa et al. 2010).
Apart from outdoor heat stress, exposure to hot indoor conditions is also a concern. In a study assessing the impact of heat wave events on dwellings (Quinn et al. 2014), it was found that a substantial fraction of houses exceeded dangerous heat thresholds during extreme events. Older adults staying indoors during hot indoor temperature conditions are at a risk of significant detriment of physical functions (Lindemann et al. 2017). There is a need to improve awareness regarding management of indoor heat stress. The use of passive building design strategies such as shading, thermal mass, and internal air movement has been suggested to mitigate the overheating of dwellings and to postpone the use of active systems (Din and Brotas 2017). It has also been demonstrated in an experimental study that simple and effective hybrid passive cooling system can significantly help in reducing thermal loads of roofs (Ponni and Baskar 2015).
A recent study from urban India identified exposure (geographic location, housing characteristics, and occupational and behavioral factors), susceptibility (age, pre-existing health status, and socioeconomic factors), and adaptive capacity (access to health services and information, coping mechanisms, and societal factors (infrastructure, information, and social capital) determine vulnerability to heat (Tran et al. 2013). Pre-existing conditions, such as cardiovascular diseases, may be exacerbated by heat stress (Khan et al. 2014). However, there is little evidence of the heat experience, impact of heat exposure, and adaptation measures to heat and heat waves in the rural context.
To quantify heat-related symptoms and illnesses in the rural communities during summer time
To identify the categories of the rural population that are most affected by heat stress
To understand exposure to outdoor and indoor heat stress
To identify factors contributing to vulnerability to heat stress
To examine various existing strategies being used to cope with heat stress
The study was conducted in Jalna and Yavatmal districts of Maharashtra. Jalna is located in the central part of Maharashtra state in northern Marathwada region. The district has a sub-tropical climate with average annual rainfall ranging between 650 and 750 mm. The district experiences years of drought with annual rainfall recording as low as 400 mm. The hot dry summer season is from March to June. During summer, the maximum day temperature ranges between 42 °C and 43 °C (Government of India 2018). The summer months are dry, with relative humidity generally between 20% and 25% in the afternoon.
The blocks of Jafrabad and Bhokardan in Jalna district were selected as there was anecdotal evidence of few deaths due to heat stress in 2014. Exploratory visits were undertaken during the months of April and May 2015 to select the villages. The factors considered for selecting the villages were sparse vegetative cover, lack of access to water, and remoteness. Three villages were purposively selected for the study, namely, Adha and Sindi in the Jafrabad block and Goshegaon in the Bhokardan block. In Goshegaon village, the local government authorities had supplied drinking water in tankers during summer of 2015. Village Adha had a primary health subcenter in the village, whereas the nearest government healthcare system for Sindi and Goshegaon villages is located at a distance of 15 km and 7 km, respectively.
Households in each village were categorized according to socioeconomic criteria based on a participatory wealth ranking exercise. Wealth ranking exercise is a participatory tool for classifying the households based on the indicators related to land ownership, asset ownership, food security, migration, and sources of income. The households are classified as very poor, poor, middle class, and better off.
Socioeconomic status of sampled households
Wealth category of household
Total households in the study area
Households included in the study
Information collected from the respondents included the following: living conditions (housing structure, access to water for drinking and domestic use, access to electricity), work profile (type of livelihood activities, exposure to outdoor heat), health problems (pre-existing health conditions, self-reported heat-related symptoms, access to medical facilities, and sources of information on preventive measures), and coping strategies used to manage heat exposure and impacts. This list was informed by the literature and also based on our exploratory qualitative study conducted prior to this survey (Mhaskar et al. 2016).
Monitoring of Indoor and Outdoor Temperatures
The selection of household for installation of data loggers was made based on types of roofing. Twenty indoor digital temperature data loggers were installed, inside the houses in the room where maximum time was spent by household members. Twelve of these loggers were installed in houses with tin/galvanized sheet roof structure, 7 loggers in houses with cement concrete roofs, and 1 in a tiled roof structure. Each data logger had a unique serial number embedded within its firmware, allowing for tracking of deployed loggers. The data loggers and the automated weather station were set to record temperatures at a 10-min interval, allowing for a maximum monitoring period of summer months.
An automated weather station was also installed in the village for measuring the location-specific outdoor temperature during the summer months.
A structured questionnaire was developed and pretested. Individual interviews were conducted in the month of May 2016, which is the peak summer period in Maharashtra. An adult household member was selected as the respondent who provided information regarding all other members of the family (in the context of exposure to heat and heat-related symptoms).
The types of heat-related symptoms (HRS) included in the survey are as follows: small blisters or pimples, dry mouth, fatigue, leg cramps, heavy sweating, intense thirst, rapid heartbeat, headache, leg swelling, paranoid feeling, swelling of face, fever, diarrhea, vomiting, hallucinations, and fainting. The occurrences of these were recorded with a recall of 2 months (the hottest months – April and May, during the year 2016). Hallucinations and fainting were considered as severe HRS, whereas the rest were considered as mild HRS for analysis. This list was informed from literature and also from the exploratory qualitative study conducted prior to this survey.
The sampled households comprised of 1224 individuals in total. Out of these, there were 671 male members and 553 female members (accounting for 55% and 45% of total individuals, respectively). About 64% of the total household members were in the age groups of 15–30 years and 31–59 years.
Sociodemographic characteristics of the study population
Number of individuals (% of total, n = 1224)
Nomadic and denotified nomadic tribes
Vimukta Jati nomadic tribes
Other backward classes
Graduate and above
Non-income generating activities
Agricultural and nonagricultural labor
Descriptive statistics and cross-tabulations were first used to understand the data. The occurrence of at least one HRS in the individual was the health outcome of interest. This health outcome was cross-tabulated against every other variables (all of which relate to susceptibility, exposure, and coping strategies), through which odds ratios (OR) were calculated on the lines of multinomial logistic regression. Confidence intervals (CI) and p-values for the odds ratios were also reported to help with the interpretation. All the ORs presented are unadjusted.
For analyzing the temperature data generated from each data logger, Hoboware software was used. The software allowed the temperatures to be plotted on a continuous graph covering the monitoring period.
Results and Discussion
Heat-Related Symptoms Among the Households
Occurrence of heat-related symptoms (HRS) at individual level
Number of individuals (N = 1224)
Total individuals experiencing at least one HRS (%)
Average individuals affected in each household
Heat stress categories
No HRS (%)
Mild HRS (%)
Severe HRS (%)
Vulnerability to Heat Stress
Susceptibility factors included age, gender, and pre-existing health conditions. The analysis of wealth status has also been discussed here for convenience, though it relates to all dimensions of vulnerability through various pathways.
Occurrence of HRS in relation to demographic variables (univariate analysis)
Odds ratio (unadjusted)
Pre-existing health conditions
At least one pre-existing health condition
Very poor (ref)
Both men and women reported suffering from HRS. However, the proportion of men reporting HRS (49.5%) was relatively more as compared to women (42%). The unadjusted odds ratio for this comparison was 0.75 (CI 0.6, 0.94). This could be due to a greater proportion of men working outdoors during the day (76% vs. 71%, respectively), performing strenuous work (41% vs. 36%, respectively), and use of protective clothing by women, and not due to physiological susceptibility among men.
Those belonging to middle-class category (OR 0.67; CI 0.48–0.94) and better off families (OR 0.52; CI 0.36–0.77) were less affected as compared to the very poor. Higher proportion of individuals from the “very poor” and “poor” categories reported at least one HRS (about 51% and 53% of total individuals in respective categories) as compared to the individuals in the “better off” category (only 35%). Our finding corroborates previous literature which have indicated that people with low socioeconomic status have been reported to be more affected by heat stress (Harlan et al. 2006; Li et al. 2015). The mechanisms through which poverty might make individuals more susceptible include general health condition and working and living conditions.
Among the 1224 total individuals in the sample households, 157 individuals (about 13% of the sample) reported to be suffering from at least one pre-existing health condition (ranging from asthma to cancer). Those with at least one pre-existing chronic health condition reported relatively high HRS (OR of 6.34, CI 4.16, 9.66) (Table 4). Individuals with pre-existing health conditions have been reported to be more susceptible to heat stress (Li et al. 2015; McGeehin and Mirabelli 2001).
The majority of the sample population in the study area belonged to general and scheduled caste categories. The difference in proportion of individuals reported HRS among the two social categories was not statistically significant.
Exposure can be influenced by hazard factors, amplifying factors, and protective factors (Tran et al. 2013). In this study, the hazard factors are the outdoor and indoor temperatures; the amplifying factors include outdoor work during peak heat hours, type of occupation, and roofing material; and the protective factors include the coping strategies being employed. In this section, the key amplifying factors are discussed.
Exposure due to Livelihood Activities
One of the amplifying factors affecting exposure was the type of occupation an individual is engaged in. Majority of the individuals from the sample households (72%) were engaged in outdoor livelihood activities during summer months such as farming on own land, wage labor (agriculture, non-farm), and in the Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS), a government employment scheme.
Occurrence of HRS in relation to other variables (univariate analysis)
Odds ratio (Unadjusted)
Non-income generating activities (ref)
Agricultural and nonagricultural labor
Minutes spent performing activities outdoors during peak heat hours
Type of roof
Time spent outdoors during peak heat hours
Time spent outdoors during peak heat hours for work or activities
No. of individuals
Total individual responses
Occurrence of HRS was relatively much higher in individuals spending more time outdoors during peak heat hours (Table 5).
Exposure During Other Household Chores
Apart from the livelihood activities, other household activities could also result in outdoor exposure to heat. Over 96% households collect firewood from field and forest. In 43.7% households, only women take the responsibility for collection of firewood. About 84% of households indicated spending more than 4 h each week on this activity. The preferred time for this activity was in the morning, early evening, and evening (these are times with relatively less heat outdoors (Mhaskar et al. 2016)).
On an average, during summer, the time taken for collecting water was 71 min (against 40 min during other seasons). In over 93% households, the women were primarily responsible for fetching water. But during summer, in some households men also support women in fetching water. Similar to the practice of collecting firewood, water too is collected during morning, early evening, and evening hours.
Type of Roofing
Total individuals living in those houses
Total individuals who experienced at least one HRS
Proportion of individuals experiencing at least one HRS
Without adequate rest and recovery time from heat, people become more vulnerable to heat stress (Khan et al. 2014). Poor design of houses with inadequate ventilation (lack of windows) could exacerbate the condition due to high daytime and nighttime temperatures. The elderly were also perceived as vulnerable due to their physiological condition, with several reported cases of fatigue, dehydration, and loss of consciousness, despite majority of them staying back at home (Mhaskar et al. 2016).
Monitoring of Indoor Temperatures
During the day the indoor temperatures recorded in cement-roofed houses were consistently less than the outdoor temperatures, but during the night the temperatures in cement houses were more than the outside temperatures. These houses heated up relatively slowly, but they also cool down slowly. These characteristics of houses and their respective indoor temperatures have important implications for health vulnerability, especially with cooler nighttime temperatures being important for recovering from daytime heat exposure.
Coping Strategies and Adaptation Measures
Individuals, families, and the community took various steps to cope with heat and its impacts. These include changing work timings, resting under trees, resting between working hours, planned reduction in work, using fans indoors, staying hydrated, eating appropriate foods, and using protective clothing. These address the immediate problem and are mostly employed during hot days or following them (Mhaskar et al. 2016).
Indoor and outdoor temperature difference when coping strategies employed by households
Time of the day
Temperature difference (indoor to outdoor) (°C) when different coping strategies are employed
Tin roof+fan+layer of crop residue
Tin roof+cooler+crop residue layer
Finding time to rest was found to be a challenge for women having responsibilities at home and in the fields. Those who work on their own land stated that they rest for an hour or more at home during the afternoons. People prefer to sit outdoors under the shade of trees. It was also observed that some house, especially ones which did not have trees around, have erected a thatched roof propped up by sticks outside the front of the house. Traditional cots were also kept outside the houses in the shade during summer months. Some shared that they rest for a day or two when they are affected by HRS.
A large proportion of households (44%) approached private doctors for HRS. The average distance between villages and their preferred healthcare facilities was 9.5 km. Most people reported that the doctor they consulted was qualified (94.6%) (though this did not adequately corroborate with our earlier qualitative enquiries with local health practitioners). While individuals provided various reasons for inconvenience of visiting healthcare providers, poor transport facilities (reported by 65.7% households) was the most important, followed by distance to health center (41.4%) and cost of utilizing healthcare (31.4%).
Reported sources for information on heat stress
Type of source
Percentage (N = 215)
At least one reliable source of information (TV, radio, newspaper, medical professional)
Didn’t hear any information
In recent years, heat action plans have been prepared at state level (e.g., Uttar Pradesh, Andhra Pradesh, Orissa, and Telengana), city level (e.g., Ahmedabad, Nagpur), and district level (e.g., Hazaribaug in Jharkhand state). Broadly, these action plans aim to build public awareness and community outreach, develop early warning system and institutional mechanism for inter-agency cooperation, build capacity for healthcare professionals, and promote adaptive measures. Their effectiveness on the ground needs to be assessed.
Heat-related symptoms were highly prevalent in the area. The common HRS were found to be headache, heavy sweating, and fatigue, which are typically of mild or moderate nature. It could be useful to use HRS as indicators of heat stress in an area to intervene before they become severe. However, it is important to note that these symptoms are not specific to heat stress, and so there is scope for underreporting and over-reporting. Though heat was considered a problem locally, its priority was relatively low for local people (Mhaskar et al. 2016).
Findings indicate that age, gender, wealth, and pre-existing health conditions were significantly associated with occurrence of HRS. Working men and women (31–59-year category) had the highest proportion of affected individuals compared to all other age groups. Though a greater proportion of men were affected as compared to women, the dimensions of vulnerability and exposure need further study to understand the mechanisms through which more men were found to be affected. Local people, in our qualitative study, attributed the perceived poorer health resilience in the current generation to change in diets over the years (Mhaskar et al. 2016).
The identified exposure factors of working outdoors during midday, roofing material of the households, and indoor ventilation were significantly associated with occurrence of HRS. A smaller proportion of women reported experiencing HRS as compared to men. The type of livelihoods and housing structures influenced exposure to heat stress. It was found that individuals performing physically intensive tasks were more vulnerable to heat stress and so were individuals residing in tin-roofed houses. Indoor temperature in tin-roofed houses was found to be generally high as compared to other roofing types – cement or tiled. During the peak heat hours, temperatures inside tin-roofed houses were more than the outdoor temperatures. This has implications for elderly and young children who may rest inside these houses during those times. The use of coolers reduced indoor temperatures, but the availability of electricity and water as well as the funds to purchase coolers is a challenge in rural areas. A very small proportion of houses (<4%) had these facilities. In addition, relatively high nighttime temperatures inside tin- and cement-roofed houses are of health concern for persons resting indoors.
Further in-depth studies are needed to monitor the indoor temperature of various housing structures (considering not only roofing but also ventilation, location of windows, type of walls, and flooring) and the effect on individuals. This would provide insights for improving the housing designs that can better handle peak heat conditions. There is a need for policy studies as well, as during the time of the study subsidies were being provided for purchase of tin roofs for houses. There is a need for health assessment before the launching of health-sensitive policies.
Existing coping strategies were found to be inadequate to protect people from indoor and outdoor heat-related stresses. Changing the work timing and reducing work on hot days was a challenge for many laborers working in other people’s farms. Those from poor families and woman-headed households also reported having to work without rest and even during periods of illness. Sleeping outdoors at night was also relatively common, despite other reported health risks such as mosquitoes (Mhaskar et al. 2016). A major challenge in rural areas in the context of heat stress is accessibility to well-equipped health centers. Though accessing healthcare was found to be a relatively common coping strategy, poorer families found healthcare to be expensive and avoided accessing it (Mhaskar et al. 2016). A more long-term strategy for competence on HRS, infrastructure, and accessibility to timely medical facilities is needed. For this, investments in upgrading of rural health infrastructure to handle heat stress-related incidences should be considered in all areas with high temperatures. In addition, there is a role for improved awareness on heat stress and associated precautionary measures.
In the future, population exposed to heat waves is projected to increase. Hence, there is a need for pre-emptive strategies to ensure that people in areas where heat waves are not yet a phenomenon are adequately supported to reduce their vulnerability. Improving health systems will benefit not just in the context of heat-related illnesses but for all illnesses, and so it is a no-regret intervention. Heat stress symptoms are easily recognized and can be used for early identification and prevention of more serious impacts such as heat stroke. Such measures will help protect individuals as well as the livelihoods. Effective planning through development of surveillance mechanism to monitor heat-related mortalities and morbidity could help in mitigating and avoiding heat-related stresses and deaths in the future. Housing designs should be improved to facilitate adequate ventilation and reduce the adverse impacts of tin roofs. The government can play an effective role here through existing housing schemes. Our study aims at understanding vulnerability within few villages in a semiarid area. It may be useful to compare our findings to villages in other agroclimatic regions to get a better understanding of relative vulnerability. However, different areas have different temperature-health response relationships, which make it difficult to compare.
At present there are heat action plans for some states (Government of Andhra Pradesh 2016; Odisha State Disaster Management Authority 2018) and for few cities (Ahmedabad Municipal Corporation et al. 2017; District Disaster Management Authority, Hazaribagh 2016). Maharashtra does not have a state-level heat action plan. Therefore, priority should be given to develop a comprehensive state-level heat action plan for Maharashtra, which addresses the needs and contexts of both urban and rural communities to prepare and prevent heat-related illness and deaths.
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