Health coping strategies of the people vulnerable to climate change in a resource-poor rural setting in Bangladesh

Background Among the many challenges faced by the people of Bangladesh, the effects of climate change are discernibly threatening, impacting on human settlement, agricultural production, economic development, and human health. Bangladesh is a low-income country with limited resources; its vulnerability to climate change has influenced individuals to seek out health coping strategies. The objectives of the study were to explore the different strategies/measures people employ to cope with climate sensitive diseases and sickness. Methods A cross-sectional study was conducted among 450 households from Rajshahi and Khulna districts of Bangladesh selected through multi-stage sampling techniques, using a semi-structured questionnaire supplemented by 12 focus group discussions and 15 key informant interviews. Results Respondents applied 22 types of primary health coping strategies to prevent climate related diseases and sickness. To cope with health problems, 80.8% used personal treatment experiences and 99.3% sought any treatments available at village level. The percentage of respondents that visited unqualified health providers to cope with climate induced health problems was quite high, namely 92.7% visited village doctors, 75.9% drug stores, and 67.3% self-medicated. Ninety per cent of the respondents took treatment from unqualified providers as their first choice. Public health facilities were the first choice of treatment for only 11.0% of respondents. On average, every household spent Bangladesh Currency Taka 9,323 per year for the treatment of climate sensitive diseases and sickness. Only 46% of health expenditure was managed from their savings. The rest, 54% expenditure, was supported by using 24 different sources, such as social capital and the selling of family assets. The rate of out-of-pocket payment was almost 100%. Conclusion People are concerned about climate induced diseases and sickness and sought preventive as well as curative measures to cope with health problems. The most common and widely used climate health coping strategies among the respondents included self-medicating and seeking the health service of unqualified private health care providers. Per family spending to cope with such health problems is expensive and completely based on out of pocket payment. There is no fund pooling, community funding or health insurance program in rural areas to support the health coping of the people. Policies are needed to reduce out-of-pocket payment, to improve the quality of the unqualified providers and to extend public health services at rural areas and support climate related health coping. Collection of such knowledge on climate related health coping strategies can allow researchers to study any specific issue on health coping, and policy makers to initiate effective climate related health coping strategies for climate vulnerable people.


Background
Bangladesh's vulnerability to climate change has been recognized in global media accounts: it has been referenced in United Nations' reports [1,2], has made headlines in national [3] and international [4,5] reports, and has been the center of concern in many journal articles [6][7][8]. The impending effects of climate change with potentially devastating consequences have drawn the highest attention at the 'global, national and regional level during the decades' [9]. Climate change and its negative effect on human beings is one of the greatest challenges for the global community. The Inter-governmental Panel on Climate Change (IPCC) repeatedly claimed that "climate change currently contributes to the global burden of disease and premature deaths" [10]. The world community has recognized that climate change affects human health negatively both directly and indirectly and can cause long-term effects [11]. It affects individuals, communities and societies as a whole [12].
Climate change has been identified as one of the major threats to human health of this century because of its potential effects on vector or water-borne diseases, cold spells, extreme heat, food and water scarcity and extreme climate variability and population displacement [13]. The majority of such health problems are especially unfavorable for vulnerable populations [14] and may increase global health disparities [15]. The World Health Organization (WHO) anticipates that climate change will cause abrupt and severe storms, floods and heat weaves in the upcoming years, and this will affect the most fundamental determinants of health [16,17]. Globally the frequency, severity and irregularities of natural disasters have tripled since the 1960s [17]. Although climate change poses a severe threat to human health, it has received relatively little attention among scientists and policy makers [13].
Although the impact of climate change on human health will be global, the health consequences will be distributed unequally across regions, occupation, gender, and age [17], and vary depending on community vulnerability level [9,18,19]. People from low and middle income countries are expected to be the most vulnerable to climate change and experience the greatest impact on health [20][21][22]. A WHO estimate projected globally an excess of 150,000 annual deaths due to changes in the world's climate relative to the climate baseline of 1961-1990 [23,24].
In Bangladesh, where a large proportion of the population is vulnerable to climate change, health impacts are expected to take place through a variety of ways, including an increase of water and vector borne diseases and of health problems in general [6,7,[25][26][27]. For example, southern Bangladesh is in a low-lying delta, making it vulnerable to sea level rise, severe storm-surges, floods and salinity intrusion. It is projected that a 1.5 meter rise in the sea level will inundate about 16% land of the southern part of Bangladesh, where about 17 million people live [28]. Almost every household of three districts of southern part of Bangladesh were severely affected by the cyclone "Aila' in 2009 [28]. The average annual death toll in Bangladesh is about 8,241, due to extreme climatic events [29]. Projected extreme climatic events, such as droughts, cyclones, floods, tidal-surges, heat waves, cold spells, directly and indirectly affect major determinants of health and increase the occurrence of different diseases and sickness [28,30]. The Climate Change Cell (CCC) of Bangladesh noted that incidences of major climate sensitive diseases (i.e. diarrhea, skin diseases, malaria, mental disorders, dengue) have increased during last decade in Bangladesh [31]. A number of diseases like normal colds/coughs/fevers, dysentery, headaches, diarrhea, skin diseases, burning sensations, conjunctivitis, jaundice/ hepatitis-B, skin burns/blistering, asthma, psychological disorders, typhoid, pox, weight loss, malnutrition related diseases, rheumatism/aching, pneumonia, measles, heatstroke, malaria, dengue etc., can be influenced by extreme climate events in Bangladesh [6,32]. As an immediate response to this increased health burden, people need to seek different steps and measures to improve the health situation. Policy makers also need to know the extent of health vulnerability and the strategies people use to avert increased sickness and diseases to formulate an effective program of action in the health sector for the climate vulnerable people of the country. Very little attention has been given by the research community in Bangladesh to investigate climate related health vulnerability and the diverse responses to cope with it. Efforts to study these human health risks remain very inadequate in Bangladesh [15]. Given the impending consequences of climate change for the people in Bangladesh, important areas of research are (i) increasing the understanding of community level health systems' capacity to deliver health services, and (ii) individual capacity to cope with climate-related health problems. The objective of this study was to explore what people do to avert climate-induced health problems in resource-poor settings in Bangladesh. Specifically the study explored the various strategies people adopted to cope with increased climate-induced sickness and diseases.

Methods
Health coping strategies of climate vulnerable people were assessed by using a mixed method research design as described in the existing literature [32][33][34]. A concurrent triangulation method was used for the study, in which qualitative and quantitative data were collected simultaneously. The findings were integrated into the results section. Data were collected from two villages, Dhuroil and Sachibunia, between September 2010 and March 2011. The villages were selected randomly. Dhuroil was located in the Rajshahi district in the northern part of Bangladesh, and the other, Sachibunia, in the Khulna district in the south. Based on the national statistics, overall socio-cultural, educational, occupational, and farming practices of the study areas were similar [31, 35,36]. Both villages were well connected with the district headquarters. The administration of Bangladesh is divided into several hierarchal unites. These units include Division, District, Upazila and Union. Each village was serviced by a Union Family and Health Welfare Center (UFHWC) which was the first tier of governmentowned health care system at the village level. This was the only public primary health care facility available to the villagers. The UFHWC was operated by one medical doctor, one paramedic and several nurses. It was open from 9am-5pm. The health center provided primary health care, antenatal care, checkup and consultations.
Two villages were selected randomly to obtain a widerange of health coping strategies for climate-sensitive diseases among household members at community level of the country. Detail of the sample size, sampling strategies and the selection of villages were described elsewhere (Haque, 2012) [19]. Either oral or written consent was obtained from each participant. The study was approved by the Ethical Commission of Heidelberg University, Germany and, the research evaluation committee of the Department of Population Sciences, University of Dhaka, Bangladesh.
Both quantitative and qualitative instruments were used in the collection of data for the study. The validity and reliability of the instruments were insured by following a number of steps. First, a literature review was conducted to identify issues related to health coping strategies, health care providers, and sources of health care costs. Second, the survey questionnaires and interview guides for the focus group discussions (FGDs) and key informant interview (KII) were verified by experts in the field of health economics, public health and climate change. Third, the tools were pre-tested among 11 males and 9 females in the field and modified as needed before producing the final version.
Masters level students (2 males, 3 females) with fieldwork experiences administered the survey questionnaire. They were involved in the development of the data collection instruments which enabled them to understand the research concepts and questions. In addition, they were trained in building rapport, keeping confidentiality and maintaining social and cultural sensitivity at field level. First author (Haque, M. A.) was the team leader and present in the field full time to monitor the quality of the data collected. All surveys and interviews were administered in Bengoli. Translations of the themes to and from English were done by the first author.
The probability proportionate sampling (PPS) was used to maintain the proportionate number of households and respondents (male and female) to interview from each village. There were 1500 households in Dhuroil and 750 households in Sachibunia village (total 2250); from which, 460 households were selected randomly for interview. The response rate of the survey respondents was high (97.82%= 450) and no respondent discontinued the interview. The national male to female sex-ratio (51:49) was used in the calculations for selecting the number of male and female respondents from each village [35]. Either the eldest male or eldest female of the selected households were interviewed for the purpose of extensive information on their health coping strategies for climate induced diseases and sickness, the health care providers available to them and the resources used in covering the cost of health care.
The survey used a semi-structured interview schedule that included the background information of the respondent and their family members at the beginning of the interview. We assessed a detailed section including a total of 52 questions regarding various health coping strategies; self-reported measures or means the respondents used to avert climate-sensitive diseases and sickness. The solicited responses were categorical ("yes", "no", "don't know", "not applicable"). Quantitative data were analyzed using the Statistical Package for the Social Sciences (Version SPSS-12.0 and SPSS-17.0).
Qualitative data were collected through FGDs and KIIs. A total of 12 FGDs and 15 KIIs were completed by the research team using an interview guideline on three broad themes: health coping strategies, choice of treatments/ care, choice of providers and health expenditure as included in the survey. Oral consent was taken from the participants before recording the interview and played back to them. Attending FGD and KII participants were "senior community members, farmers, non-governmental organization officials, village doctors, local political leaders and teachers of a socio-demographic background similar to that of the survey participants from the study areas" [19]. All FGDs and KIIs were transcribed and analyzed according to the broad themes: health coping strategies, choice of treatments/care, choice of providers and sources of the costs for health care.

Socio-economic and demographic characteristics of the respondents
All respondents came from agrarian-based rural areas of Bangladesh considered to be vulnerable to climate variability  [19]. The villages were well connected with the Upazila (second level of administrative unit from bottom) and district headquarters. Each village was serviced by a UFHWC. Both constitute the only public medical facilities accessible to the villagers. Distance to the health center was within 1-2 kilometer from many households of the villages. Health care cost at the public health facilities are at free of cost. Public health facilities are run by government all over the country with qualified doctors, paramedics and nurses. In Dhuroil, the number of unqualified health providers rose from 5 in 1985 to 24 in 2010 while in Sachibunia the number increased from 1 to 7 over the same period ( Figure 1). Unqualified providers are people who do not have a medical degree but who provide health or medical treatment to individuals. They have had a maximum of 3-6 months training in primary health care and locally known as 'palli-chikshok' (village doctor) in Bangladesh. In this study, we called them unqualified private providers. There was no private chamber of qualified providers. Nor were there any doctors in either village with a medical degree and training.

Preventive health coping strategies
The respondents reported 22 types of different primary strategies to prevent themselves and their family members from the effect of climate change on their health ( Table 2). Eleven of these health coping strategies dealt with heat, 6 from precipitation and 5 with cold events. In addition, the respondents approached neighbors, relatives, people who suffered from similar sickness, and NGO workers to discuss the climate-related health problems respondents faced and possible methods for preventing diseases/sickness (Table 2).

Curative health coping strategies options and choices
At the onset of disease and sickness 80.8% of the respondents used their self-knowledge of medication and previous healing experiences to treat themselves and their family members; 99.3% sought treatment available in the rural area (Table 3). In response to the question "what were the choices among the health coping strategies in case of climate sensitive diseases or sickness for your family members," 54.4% of the participants reported that self-knowledge or home-remedies and previous healing experiences were the first strategies they used in treating climate related health problems. Approximately 43.3% of the respondents sought any treatment (which included qualified, unqualified providers) as their first choice. Respondents used multiple means to cope with climate sensitive health problems ( Figure 2).

Health care providers options for health coping
There were 12 types of health providers available in the study areas (

Choices of health provider for coping
Eighty-eight per cent of the respondents choose unqualified health providers as their first choice and 54.2% as their second choice ( Table 5). The use of qualified providers increased from 11% as their first choice to 44.6% as their second choice. Qualified providers were primarily their fourth and fifth choices. A noticeable finding was that public health facilities were never among respondents' first choices for treatment. The percentage of using qualified providers increased to the second and third-choice categories, while the percentage of using unqualified providers decreased to the same choices. About 60% of the respondents had selected qualified providers as their third choice. Gradually, from second choice onward, respondents preferred qualified providers as their health coping strategy ( Figure 3) for their climate sensitive diseases or sickness.

Sources of money for health coping
All the respondents reported that they had to manage health care expenditure to cope with climate related diseases personally. Only 46% of the money which family members spent was from savings. The rest, 56%, had to be acquired from different informal sources outside the family (Table 6). A total of 24 types of different informal sources were reported. The sources included loans taken from mahajans (person who gives loan among villagers informally with high interest/money lender), businessmen, NGOs, banks, neighbors, relatives, or drug stores, as well as the money received from the sale of domestic animals, agricultural crops, ornaments, or from religious funds (known as zakat, fetra). Some families were given donations from neighbors and relatives. The use of "social capital" [37][38][39][40][41], i.e. borrowing money from neighbors, relatives and drug stores were the most common source of money for health expenditure of the respondents. Community-fund pooling, common funding, and health insurance did not factor as sources for the respondents' climate related health care expenditure. Neither public nor private health insurance systems were available to the participants in the study areas.

Discussion
This study's findings provide important insights into what people of a resource-poor setting do when they are affected by climate change exacerbated sicknesses and illnesses. The respondents were from the rural areas which are vulnerable to climate change [42]. Most of the respondents had agricultural occupations and, a low level of formal education and family income. Almost all those surveyed, including focus group discussions and key informants, reported that diseases and sickness had increased due to climate change (changes in heat, cold and precipitation) [19]. The study also informs our understanding about the health coping strategies of the respondents, i.e. preventive health coping options and available and preferred types of health care providers. It also enables us to discern the choices of health care seeking; per family climate related health expenditures (HE) [43]; and the different sources of HEs whose health was negatively affected by climate change [19] in a rural setting. All members used self-medication for their family.
76 types of traditional medicine they used to cope/treat with 12 types of climate sensitive diseases . Figure 2 Health coping strategies used by the respondents to cope with climate-related health problems.
Almost all respondents sought an array of preventive measures to protect their health from the effect of extreme climate change. They choose at least one type of health care service for coping with climate sensitive health problems. As curative health coping strategies, most of the respondents sought treatment from the available unqualified providers in the villages. Only very few could not seek any kind of treatment due to financial inability. The Bangladesh government has decentralized health care facilities up to Union and village levels to introduce quality and trained health care facility officials in villages. It has also tried to ensure accessibility and availability of health care services to people in rural and urban communities [44]. This, however, is not reflected in the findings of the study [45]. Visiting public health facilities were not factored among the first, second or third choice strategies of the villagers in coping with their climate induced health problems. Unqualified providers played a dominant role among the respondents.   The estimated annual health expenditure of all the households (2250) in the two villages in treating the diseases induced by climate change was about BDT 20,977,200 (annual HE × all households), which was spent primarily on unqualified providers. Although respondents were from low income and climate vulnerable groups, they paid high prices for low quality health services from unqualified providers with all the money coming from out-of-pocket (OOP) payment. Strong initiatives from government of the country, international development partners and NGOs are needed to motivate people for the effective use of money they spent individually and to introduce community-based health coping strategies. If community pooling, prepaid health care or insurance system could be introduced at the community level to pool this amount from the households, quality health care services could be provided at the rural level. Such pooling also can help the villagers cope with the additional cost of climate change exuberated health impacts and help achieve funding for universal coverage [46]. The lack of socialized fund-pooling mechanisms exacerbates the situation as high costs might exclude poor people from access to effective health care [47]. Latko B et al. 2011 stated that "taking money from poor people when they are sick is not a good idea" [48], this inequality needs to be addressed by health system reform [49]. Informing the respondents about their high spending could motivate them to develop community fund pooling, health insurance or pre-paid health care with special attention to climate-sensitive health problems. It may also inspire them to enroll for health insurance, thus ensuring adequate and quality health care among rural climate vulnerable people.
Limited income and high prices influence the access to health care of people [50,51]. There was no health insurance or community funding [48] in the community and no NGO initiative to support the high OOP payment and health coping costs of the respondents. There was a great uncertainty in managing climate related health coping costs among the respondents. As a consequence, direct OOP payment spending and the use of "social capital" [52][53][54][55] represented the few options available to purchase health care for coping with climate change exuberated diseases and sickness. Findings show that OOP payment among the respondents is even higher than what was calculated in the national health account (NHA) [46,56]. Collection of such research findings can provide necessary information for health economists to recalculate the direct health expenditures of the people vulnerable to climate change in Bangladesh and NHA [56]. The higher the magnitude of climate change induced diseases, the more socio-economic losses of the households for health coping will accrue. The increase of climate sensitive diseases and almost exclusive out-of-pocket spending for coping with health problems will make the villagers more vulnerable [49].
The study included data from two rural villages among many that actually exist in Bangladesh; as such, the results may not be generalizable to rural communities across the country. The generalization of these health coping strategies to other areas of Bangladesh may require further research. Additionally, there might be recall bias as well as a social desirability bias, as we also had to depend on the subjective judgments of the respondents' experiences on health coping.

Conclusions
People of the 2 rural communities in Bangladesh included in this study are concerned about climate induced diseases and sickness and sought preventive as well as curative measures to cope with health problems. Every respondent used traditional knowledge and known health care practices to cope with climate sensitive health problems. Seeking health care from unqualified private health care providers is the most commonly used most available health coping strategy in treating sicknesses and illnesses brought on by climate change. Public health care facilities at the community level are not used by the respondents to cope with the same health problems. Per family spending to cope with such health problems is very high and health care is solely based on out of pocket payment. Most of them had to depend on their available family assets as well as their "social capital" to cope with climate related health problems. There is no fund pooling, community funding or health insurance program in the study areas to support the overall health coping of the climate vulnerable people. Initiatives and strong advocacies are needed from the government, NGOs and development partners to improve the health coping options for the people vulnerable to climate change in the rural areas. They also need to set measures, to reduce OOP payments and high health care costs and to improve the health services at public and private levels. Such measures are necessary for helping the people vulnerable to climate change in resource poor settings to cope with additional climate induced health problems. Coping with climate related health problems at the village level is mostly an individual's responsibility that is, dependent on unqualified treatments at high prices. There is neither community based mechanism to cope with climate induced health problems nor any additional program or support from the government. The collection of such information on climate related health coping can benefit the government, NGOs and development partners in formulating strategies for effectively coping with the climate induced diseases and sickness.