Climate change and adverse health events: Community perceptions from the Tanahu district of Nepal

Abstract

Nepal is a country economically dependent on climate-sensitive industries. It is highly vulnerable to the environmental, social, economic and health impacts of climate change. The objective of this study is to explore community perceptions of climate variability and human health risks. In this letter, we present a cross sectional study conducted between August 2013 and July 2014 in the Tanahu district of Nepal. Our analysis is based on 258 face-to-face interviews with household heads utilizing structured questionnaires. Over half of the respondents (54.7%) had perceived a change in climate, 53.9% had perceived an increase in temperature in the summer and 49.2% had perceived an increase in rainfall during the rainy season. Half of the respondents perceived an increase in the number of diseases during the summer, 46.5% perceived an increase during the rainy season and 48.8% during winter. Only 8.9% of the respondents felt that the government was doing enough to prevent climate change and its impact on their community. Belonging to the Janajati (indigenous) ethnic group, living in a pakki, super-pakki house and belonging to poor or mid-level income were related to higher odds of perceiving climate variability. Illiterates were less likely to perceive climate variability. Respondents living in a pakki house, super-pakki, or those who were poor were more likely to perceive health risks. Illiterates were less likely to perceive health risks.

Full text

Environ. Res. Lett. 10 (2015) 034007 doi:10.1088/1748-9326/10/3/034007
LETTER
Climate change and adverse health events: community perceptions
from the Tanahu district of Nepal
Shiva Raj Mishra
1
, Parash Mani Bhandari
2
, Rita Issa
3
, Dinesh Neupane
4
, Swadesh Gurung
5
and
Vishnu Khanal
1
1
Nepal Development Society, Chitwan, Nepal
2
Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
3
University College London, UK
4
Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark
5
Ipas, Kathmandu, Nepal
E-mail: shivarajmishra@gmail.com,parashmanibhandari@gmail.com,ritaissa88@gmail.com,neupane.dinesh@gmail.com,
grgswadesh@gmail.com and khanal.vishnu@gmail.com
Keywords: climate change, perception, health, Nepal, disease, variability
Abstract
Nepal is a country economically dependent on climate-sensitive industries. It is highly vulnerable to
the environmental, social, economic and health impacts of climate change. The objective of this study
is to explore community perceptions of climate variability and human health risks. In this letter, we
present a cross sectional study conducted between August 2013 and July 2014 in the Tanahu district of
Nepal. Our analysis is based on 258 face-to-face interviews with household heads utilizing structured
questionnaires. Over half of the respondents (54.7%) had perceived a change in climate, 53.9% had
perceived an increase in temperature in the summer and 49.2% had perceived an increase in rainfall
during the rainy season. Half of the respondents perceived an increase in the number of diseases
during the summer, 46.5% perceived an increase during the rainy season and 48.8% during winter.
Only 8.9% of the respondents felt that the government was doing enough to prevent climate change
and its impact on their community. Belonging to the Janajati (indigenous) ethnic group, living in a
pakki, super-pakki house and belonging to poor or mid-level income were related to higher odds of
perceiving climate variability. Illiterates were less likely to perceive climate variability. Respondents
living in a pakki house, super-pakki, or those who were poor were more likely to perceive health risks.
Illiterates were less likely to perceive health risks.
Introduction
Nepal is diverse in its geography, ecosystemand culture.
As a country economically dependent on climate-
sensitive industries such as agriculture, forestry and
ecotourism, it ranks 14th in the world when assessing
for vulnerability to climate change [1]. Since 1975, the
temperature of the country has risen 1.8 °C, with an
average annual increase of 0.06 °C [2]. This may have
detrimental effects [3]. The environmental, social and
economic impacts of climate change are first and most
strongly felt by communities who live in ecologically
fragile areas [4]. Such communities often depend on
local natural resources for survival. Assessing these
communities’perception and response to climate
variability—such as short to medium term fluctuations
in climate state—can identify early coping mechanisms
that are adopted to mitigate the worst of climate change.
Climate change is arguably the biggest current
threat to public health, contributing to the global bur-
den of disease and premature death [5]. Variant cli-
mate patterns and global warming will alter the
pattern and prevalence of infectious and vector-borne
diseases [6]. Disease burden may also increase as a
result of climate change related migration of reservoir
hosts [7]. Additionally, climate variability will lead to a
resurgence and increased endemicity of tropical dis-
eases [6]. Globally, an estimated 166 000 deaths result
from change in climate annually, relative to the aver-
age baseline measurements between 1961–1990 [8].
Diarrhea, the leading cause of under-five deaths in
developing countries, is estimated to increase by 2–5%
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REVISED
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PUBLISHED
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by 2020. Furthermore, annually, 5.5 million disability
adjusted life years (DALYs) can be attributed to cli-
mate change [9]. An earlier study reported five cate-
gories of health outcomes which are most likely to be
affected by climate change: temperature-related mor-
bidity and mortality; health effects of extreme weather
events (storms, tornadoes, hurricanes, and precipita-
tion extremes); air-pollution-related health effects;
water-borne and food-borne diseases; and vector-
borne and rodent-borne diseases [10].
In Southeast Asia, including Nepal, there is a like-
lihood of increased epidemics of malaria, dengue,
other vector-borne diseases and climate-change
attributed diarrhea [11–13]. As a result of rising global
temperatures, rainfall is predicted to increase, thereby
increasing the likelihood of flooding. Droughts and
flooding will result in declining crop yields and sub-
sequent malnutrition in this region [13]. Additionally,
Nepal is vulnerable to flooding, mudslides and glacier
lake outbursts secondary to the melting Himalayan
glaciers, which will lead to fluctuations in the quality
and quantity of water, available land mass and envir-
onmental safety [14]. Few studies have explored the
spatial correlation between climate change and health
outcomes [15–17]. Little is known about perceptions
of climate variability and subsequent health risks in
Nepal, particularly amongst the most at-risk commu-
nities. The following questions are explored in this
study:
(i) What are local perceptions of climate varia-
bility; what form does climate variability take? (ii) does
the local community perceive changes in patterns and
burden of disease?
Our findings are useful to guide climate change
policy for at-risk communities. Utilizing local people’s
perception and coping strategies is essential if inter-
ventions are to be well targeted and well placed. Such
data gathered amongst the most vulnerable commu-
nities are useful for the implementation of wider
national and international policy and strategy.
Materials and methods
We performed a cross sectional study in the Tanahu
district of Nepal. This district is located in the central
hilly region of the country. It covers an area of
1546 km
2
and has a population of 323 228 [18]. The
district is at an elevation of 340–2134 m above sea
level. The climate is tropical and sub-tropical, and the
temperature ranges from 5 °C to 48 °C [19].
This study was conducted in the Bhimad village
which was purposefully selected as a place where the
Terai plain meets the hills. The village is orientated to
commerce and tourism. This Village Development
Committee (VDC; the lowest administrative unit in
Nepal [20]) has a total of 2191 households and is
inhabited by 8414 people [18].
Study samples were drawn using proportionate
stratified random sampling. A comprehensive list of
households was obtained from the office of the VDC
and the existing administrative division of wards was
used to stratify the VDC into 9 strata. Samples were
selected in proportion to the population size of each
strata using systematic random sampling. Heads of
respective households were selected for face-to-face
interviews. If the head of the household was not pre-
sent at the time of the interview, the eldest person from
the same house was selected for the interview. We
selected 258 households, considering a 5 percent
allowable error. This is based on a similar study com-
pleted in Bangladesh, which found that 80% of
respondents perceived increased summer tempera-
tures, a decrease in rainfall and warmer winters (21).
The study questionnaire was prepared in considera-
tion with previous works for reference [21–24]. Earlier
studies on perceptions of climate change have used a
five point Likert scale, with a scale of 1 to 5 to denote
perceptions of climate variability. However, these did
not go so far as to measure what factors were attributed
to variability (22). In our study, we used a similar
approach with additional exposure variables—e.g. per-
ception of climate variability, health risk—measured
dichotomously (‘yes’and ‘no’). By calculating such
variables, a new dimension is added to the existing lit-
erature. Prior to interviewing the 258 household heads,
the questionnaire was pre-tested among 20 household
heads in Nayapati VDC, Kathmandu, Nepal. The study
tool assessed an individual’s: i) socio-demographic fac-
tors (age, sex, ethnicity, educational status, type of
family, type of house, main source of income and area
of cultivable land owned by the family) ii) perception of
climate variability over the past five years, and iii) per-
ception of health risks. Demographic characteristics
were gathered through direct questioning and house-
hold observation. We further used classifications from
the 2008 Household Budget Survey to identify house
types (25). A super-pakki house is defined as the house
in which both the walls and the roof are built in perma-
nent materials, such as cement, concrete and bricks. A
pakki house is a house where either wall or roof is built
in permanent materials and the other is built in tempor-
ary materials. A Kachhi house is one where both walls
and roof are built in temporary materials, such as mud,
straw, bamboo or plastic.
Respondents were asked ‘whether they had experi-
enced, observed or witnessed given climate-change
related indicators’. Three options provided to the
respondent were ‘yes’,‘no’and ‘do not know’. Total
scores for climate variability and health risks were cal-
culated. Perception of climate variability was indicated
if the total score was greater than the median. The fol-
lowing questions were asked to the respondents to
measure the perception of climate variability:
1. Have you perceived a change in the degree of
hotness during the summer?
2
Environ. Res. Lett. 10 (2015) 034007 S R Mishra et al

2. Have you perceived a change in the degree of
coldness during the winter?
3. Have you perceived change in the amount of
rainfall during the rainy season?
We further tested whether respondents had a per-
ception of a change in disease occurrence. The per-
ceived human health risk was indicated if the
perceived health risk score was greater than the med-
ian. The following questions were asked to measure
the perception of health risks:
1. Have you perceived a change in the occurrence of
disease during the summer?
2. Have you perceived a change in the occurrence of
disease during the winter?
3. Have you perceived a change in the occurrence of
disease during the rainy season?
Data was entered into EpiData 3.1 and analyzed
using SPSS Version 17 (SPSS Inc., Chicago). We
considered all variables used in bivariate analysis for
multiple logistic regressions to control for confound-
ing [26].
This study was conducted from August 2013 to
July 2014 and the participants’enrollment was active
from March to May 2014. The study protocol was
approved by the Institutional Review Board (IRB) at
the Institute of Medicine, Tribhuvan University,
Nepal. Permission for conducting the study was also
obtained from the VDC office. We obtained written
informed consent from each household head after
explaining the rationale of the study. We ensured the
confidentiality and anonymity of participants.
Respondents were informed of the right not to answer
any of the asked questions or leave the interview with-
out reason. A few of the respondents could not read or
write and provided verbal consent for interview.
Results
Characteristics of the respondents
Of the 258 participants, 74.4% were female and 86.8%
were aged 24 years or older. When asked about the size
of family, 53.9% reported to be living in nuclear
families. Agriculture was the main source of income
for 33.6% of the households questioned, followed by
foreign remittance at 28.3% of households. In terms of
economic status, 15.5% self-rated as ‘poor’, and 76%
as ‘middle income’. 27.1% percent were illiterate and
43.4% had a basic education (table not shown).
Perception of climate change and health risks
Over half of respondents had perceived a change in
climate (54.7%). A total of 53.9% perceived an
increase in hotness in the summer and 49.2% had
perceived an increase in rainfall during the rainy
season. Similarly, 50.0% had perceived an increase in
the number of diseases during the summer, 46.5%
perceived this increase during the rainy season and
48.8% during the winter (figure 1).
When asked about changes in local climate, 31.4%
noted an increase in wind velocity during the summer,
43.4% said rainfall during the summer was adequate,
though 5.8% had seen a spring dry up over the
preceding five years (table not shown).
Household heads were asked for the necessity and
adequacy of both personal and government efforts in
mitigating climate change and its impact on the com-
munity. 3 in 10 respondents agreed that personal
effort was essential for climate change mitigation.
Only 8.9% felt that the government was doing enough
(figure 2).
Being a female (aOR = 1.780, 95% CI (0.991;
3.200)), belonging to the Janajati (indigenous) ethnic
group (aOR = 2.492, 95% CI (1.293; 4.801)), living in
apakki (aOR = 3.662, 95% CI (1.388–9.663)), super-
pakki house (aOR = 5.862, 95% CI (2.119; 16.218)), or
belonging to poor (aOR = 9.187, 95% CI
(1.808–46.675)) and those with mid-level income
(aOR = 5.193, 95% CI (1.342–20.098)) were related to
higher odds of perceiving climate variability. The illit-
erate were less likely to perceive climate variability
(aOR = 0.410, 95% CI (0.190–0.884)) (table 1).
Respondents living in a pakki house (aOR = 2.907,
95% CI (1.165–7.256)), super-pakki (aOR = 4.833,
95% CI (1.844–12.672)), and being poor (aOR =
5.163, 95% CI (1.138–23.416)) were more likely to
perceive health risks. The illiterate were less likely to
perceive health risks (aOR = 0.320, 95% CI
(0.150–0.684)) (table 2).
Discussion and conclusions
Whilst this is the first study to report community
perception of climate variability and health risks in
Nepal, a number of limitations need to be considered.
Firstly, all respondents’perception of climate varia-
bility and health risks were measured from proxy
indicators. Secondly, this study surveyed a large
number of households in a single village of a mid-hill
district of Nepal. Due to coverage of such a small study
area, extrapolation of the findings to other parts of the
country may be limited. Finally, measuring perception
of climate variability and health risks is difficult. The
responses recorded through indicators may suffer
recall bias, and be subject to personal judgment [21].
Nevertheless, the findings of this study reflect the
communities’view on climate change and health, and
will be important while launching programs to
mitigate future adverse events.
Data confirm that Nepal has experienced a mea-
surable change in climate, particularly in precipitation
patterns and heat stress [15–17]. Our study findings
3
Environ. Res. Lett. 10 (2015) 034007 S R Mishra et al

show these objective findings are reflected in sub-
jective measurements of climate change at a commu-
nity level. A significant proportion of respondents
have a clear perception of climate variability, most
notably through increased summer temperatures,
higher wind velocity and increased rainfall during the
rainy season.
People falling under the Janajati (indigenous)
group were found to have higher odds of perceiving
climate variability. This observed association could be
accounted for their close relationship with and reli-
ance upon environmental resources for survival. An
earlier similar study conducted among indigenous
people in Nigeria [27]reflects these findings, stating
that over a few decades, 73% had experienced rising
temperatures, 83.5% had expressed a decrease in rain-
fall and 75% had said the environment is becoming
drier to the point of affecting human comfort. Our
study found association between economic level and
perception of climate variability and health risks.
Those with lower economic level depend on natural
resources such as forest, grassland and wetland [28],
thus they are supposed to perceive climate variability
and disease occurrence more compared to people of
higher economic level. Education was positively asso-
ciated with perception of climate variability and health
risks. Literacy of the effects of climate change can be
instrumental in achieving better adaptation at com-
munity level. Further research is needed to shed light
on our speculations.
Compared to a similar study in Bangladesh [21], a
smaller percentage of our research community per-
ceived climate variability. Such differences may be an
accurate perception due to floods and heat waves
being more common in Bangladesh than in Nepal. In
an another study in Nepal, 73.2% of people believed
that the weather was getting warmer, 67.2% believed
that the onset of summer and monsoon had advanced
during the last 10 years; furthermore, 46% believed
that there was less snow on mountains than before and
70% felt that water sources were drying up [29]. Again,
variation in results may be due to inherent differences
in the study location.
Table 1. Factors associated with perception of climate variability.
Variables OR (95% CI) aOR (95% CI)
Age 0.674
<20 years 1
20–45 years 1.175 (0.480–2.875)
>45 years 1.439 (0.557–3.718)
Sex 0.054
Male 1
Female 1.780 (0.991–3.200)
Ethnicity 0.000 0.000
Brahmin/
Chhetri
11
Janajati 2.476
a
(1.338–4.580) 2.492
a
(1.293–4.801)
Dalit 0.763 (0.352–1.653) 0.608 (0.261–1.414)
Type of family 0.577
Nuclear 1
Joint 0.817(0.494–1.351)
Extended 1.562(0.337–7.242)
Education 0.197 0.066
Educated 1 1
Literate 0.998 (0.548–1.818) 0.725 (0.370–1.422)
Illiterate 0.601 (0.309–1.170) 0.410
a
(0.190–0.884)
Source of
income
0.063
Agriculture 1
Skilled 1.863
a
(1.084–3.202)
Labor 1.073 (0.383–3.003)
House type 0.019 0.003
Kachha 11
Pakki 2.071 (0.920–4.660) 3.662
a
(1.388–9.663)
Super-pakki 2.950
a
(1.368–6.362) 5.862
a
(2.119–16.218)
Economic level 0.096 0.027
Poor 2.400 (0.581–9.908) 9.187
a
(1.808–46.675)
Mid-level
income
3.589 (0.983–13.100) 5.193
a
(1.342–20.098)
Rich 1 1
a
p < 0.05, statistically significant at 95% CI.
Table 2. Factors associated with perception of health risks.
Variables OR (95% CI) aOR (95% CI)
Age 0.601
<20 years 1
20-45 years 1.336 (0.546–3.266)
>45 years 1.596 (0.618–4.124)
Sex 0.199
Male 1
Female 1.454 (0.822–2.573)
Ethnicity 0.008 0.006
Brahmin/
Chhetri
11
Janajati 1.900
a
(1.042–3.464) 1.805(0.950 –3.430)
Dalit 0.750 (0.357–1.574) 0.596 (0.264–1.346)
Type of family 0.86
Nuclear 1
Joint 0.987 (0.599–1.625)
Extended 1.518 (0.328–7.035)
Educational
status
0.058 0.011
Educated 1 1
Literate 0.880 (0.483–1.604) 0.651(0.335 –1.264)
Illiterate 0.477
a
(0.245–0.928) 0.320
a
(0.150–0.684)
Source of
income
0.116
Agriculture 1
Skilled 1.662 (0.975–2.832)
Labor 0.883 (0.317–2.463)
Type of house 0.038 0.005
Kachha 11
Pakki 1.804 (0.826–3.941) 2.907
a
(1.165–7.256)
Super-pakki 2.560
a
(1.223–5.359) 4.833
a
(1.844–12.672)
Economic level 0.155 0.098
Poor 1.833 (0.496–6.778) 5.163
a
(1.138–23.416)
Mid-level
income
2.723 (0.839–8.835) 3.384 (0.982–11.655)
Rich 1 1
a
p < 0.05, statistically significant at 95% CI.
4
Environ. Res. Lett. 10 (2015) 034007 S R Mishra et al

At present, there are few studies reporting a cor-
relation between climate change and diseases occur-
rence in Nepal. An earlier study reported a 1 °C
increase in minimum and mean temperatures and
increased malaria incidence by 27% [30]. Public per-
ception of climate change is not new to literature
[21–24]; however, further analysis exploring pre-
dictors of climate variability and health risks have not
been reported before. Our study format and findings
can benefit further research in the field to link sub-
jective and objective measures of climate change.
Furthermore, our study pointed out strong evidence
to support climate variability in Nepal. Perception of
climate variability and diseases occurrence were pre-
dicted by a number of factors, including socio-demo-
graphic (ethnicity, education, house type) and
economic level. The literature states that voluntary
mitigation and adaptation is often the result of per-
ception of climate variability [31]. In the light of this
evidence, better awareness activities about climate
variability and associated human health risks can
yield better adaptation and mitigation practices in
Nepal. Our findings can particularly be of higher
importance to the ‘National Adaptation Program of
Actions 2010’(32) and the ‘Local Adaptation Plan of
Action National Framework 2011’launched by the
Ministry of Science, Technology and Environment
[33]. These two frameworks are keys to successfully
adapting to and mitigating climate change in Nepal.
As measures to address and mitigate climate change
receive increasing priority, our data outcomes are
valuable: to assist policy makers in mapping commu-
nity vulnerability to climate change and adverse
health outcomes, and to better direct the design of
community based mitigation and adaptation strate-
gies in Nepal and beyond.
Data accessibility
Data will be made available upon the approval from
Institutional Review Board of Institute of Medicine.
Figure 1. Perception of climate variability and disease occurrence.
Figure 2. Attitude towards climate change.
5
Environ. Res. Lett. 10 (2015) 034007 S R Mishra et al

Acknowledgments
The authors wish to thank the study participants for
contributing their valuable support, time and
responses. We appreciate the help of the Community
Health Diagnosis-Bhimad team. The authors thank
Department of Community Medicine and Public
Health, the Institute of Medicine Nepal, and the
Bhimad Village Development Committee office for
their support during the research.
Competing Interest
The authors declare no competing interests.
Author’s Contribution
SRM conceived the research work. PMB coordi-
nated the field level data collection. SRM and SG car-
ried out the data analysis. SRM wrote the draft of the
manuscript. VK, RI and DN contributed in the litera-
ture review, interpretation of results and manuscript
revision. All the authors contributed in the revision of
the paper and agreed on the final manuscript.
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