*Article* **Planning of a Health Emergency Disaster Risk Management Programme for a Chinese Ethnic Minority Community**

### **Greta Tam 1, Emily Ying Yang Chan 2,3,4,\* and Sida Liu <sup>2</sup>**


Received: 30 January 2019; Accepted: 6 March 2019; Published: 22 March 2019

**Abstract:** Rural populations living in poverty are the most vulnerable to disaster. Despite this increased risk of recurrent disaster, previous disaster experience is not a good predictor for disaster preparedness in these populations. This was evidenced on 31 August 2012, when a major flood occurred in Sichuan, China. A health needs assessment carried out in December 2012 showed that residents of Hongyan village, a Yi-minority community in Sichuan lacked disaster preparedness. This indicated that measures were necessary to improve Health Emergency Disaster Risk Management (Health-EDRM) in the community. Nutbeam's planning model for health promotion was used to guide the development of a Health-EDRM programme at Hongyan Village, Liangshan Yi Autonomous Prefecture, Sichuan. Relevant information was obtained from sources such as literature review, household surveys and stakeholder interviews. A team of stakeholders conducted an interactive workshop to train villagers on disaster preparedness in March 2014. Disaster kits and equipment for Oral Rehydration Solution preparation were handed out to villagers.

**Keywords:** ethnic minority; China; Health-EDRM

### **1. Introduction**

### *1.1. Disaster Health Preparedness in the Rural Poor Areas in China*

Globally, 75% of people living below the poverty line of US \$1.07/day live in rural areas. Despite economic growth in developing countries, the resulting benefits are not spread evenly. Poverty is becoming increasingly ruralized in China, Eastern Europe and Central Asia. Rural populations living in poverty are the most vulnerable to disaster. Climate change increasingly exposes rural areas to weather-related shocks and stresses (e.g., drought and repeated flooding) [1]. Meanwhile, poverty causes decreased disaster resilience due to lack of access to services (e.g., health care and education) and infrastructure (e.g., water and sanitation) [2]. Despite the increased risk of recurrent disaster among the rural poor, previous disaster experience is not a good predictor for disaster preparedness in these populations [3–5].

### *1.2. Building Disaster Health Resilient Communities*

In 2015, the UN General Assembly endorsed the Sendai Framework for Disaster Risk Reduction. Priorities for Action included understanding disaster risk and enhancing disaster preparedness [6]. This built upon the previous Hyogo Framework for Action (2005–2015), which included as one of its priorities "use knowledge, innovation and education to build a culture of safety and resilience at all levels" [7].

Resilience is "the ability of a system, community or society exposed to hazards to resist, absorb, accommodate, adapt to, transform and recover from the effects of a hazard in a timely and efficient manner, including through the preservation and restoration of its essential basic structures and functions through risk management" [8]. The United Nations and Red Cross have advocated community-based disaster preparedness programmes to build disaster resilient communities [9,10]. This approach combines integrated programming and cooperation with local communities. Integrated programming ensures a holistic approach: elements from different sectors (e.g., health and hygiene education and disaster preparedness) are combined into one programme. Consulting local villagers ensures that interventions are tailored to specific community needs. Although efforts have been made to implement Health-EDRM programmes globally [9–11], Asia is still disproportionately affected by disasters: China, Indonesia, Philippines and India are among the top five countries most prone to natural disasters and Asia accounts for 90.1% of disaster victims [12].

### *1.3. Local Epidemiological and Demographic Data of Hongyan Village, Liangshan Yi Autonomous Prefecture, China*

In the last decade, China has experienced the most natural disasters in the world [12]. Under the effects of climate change, there has been an increase of weather-related disasters by 69% globally in the last decade, with floods becoming increasingly frequent in China. Many remote villages in China have limited health and hygiene awareness and disaster preparedness, due to the low education level and lack of information. In addition, many lack basic sanitation infrastructures, such as proper latrines and access to basic medical care. Consequently, there is a risk of poor sanitation after a flood, as surface and groundwater are contaminated by effluent from latrines [10].

Hongyan village is one of 169 villages in Xide county, under the jurisdiction of Liangshan Yi Autonomous Prefecture, in the southern area of Sichuan province. Hongyan village is 5 km from the closest township, Lianghekou. Figure 1 shows a location map for the case area. It is composed of 4 sub-groups, with 218 households and 826 residents. The villagers live on the bank of Sunshui River, in a mountainous landscape with poor road conditions. Liangshan has the largest community of Yi ethnic minority group in China. Yi ethnic groups live mostly in rural and mountainous areas in Sichuan, Yunnan, Guizhou and Guangxi. Education levels are low in Yi ethnic groups and they speak their own language [13,14].

A major flood occurred on 31st August 2012 at Xide County, causing great damage: 218,000 residents were affected, 13,300 houses collapsed, and 29,000 houses were seriously damaged, while 1 death and 2 missing people were reported. Flooding also damaged the infrastructure, including roads, water supply, telephone and broadcasting. The county was therefore temporarily isolated from external information and assistance. In 2012, the Collaboration Centre for Oxford University and CUHK for Disaster and Medical Humanitarian Response (CCOUC) was invited by Wu Zhi Qiao Charitable Foundation to perform a health needs assessment and health intervention in Hongyan village.

This study aimed to identify and use relevant data to plan a Health-EDRM programme for Yi-minority community in Sichuan Province, China.

**Figure 1.** Geographical location of Sichuan Province and Liangshan Yi Autonomous Prefecture.

### **2. Materials and Methods**

### *2.1. Planning Framework and Data Collection*

Nutbeam's model for health promotion was employed for planning the health promotion programme (Figure 2). The model was created with the intention to help systematically link relevant research and theory to the practicalities of programme implementation and evaluation. The model was separated into three parts: (i) problem definition; (ii) solution generation; and (iii) capacity building. Problem definition aims to clarify what and who are the targets of the health-EDRM programme. Solution generation aims to determine how and when change could be achieved in the target population. Capacity building aims to create the best conditions for the health-EDRM programme through the assessment of resources (such as financial and human resources) to ensure the programme objectives are a good fit for the available resources. These 3 planning stages require unique information and are summarized in Table 1.

**Figure 2.** Three planning steps within Nutbeam's model for health promotion.


**Table 1.** Summary of information needed and sources for each planning stage.

### *2.2. Information for Health Planning*

### 2.2.1. Literature Review

The literature review identified epidemiological data and relevant past studies. This aided description of the local situation and people, their behaviour, and any predictors for lack of disaster preparedness. In addition, this provided evidence for choosing the most appropriate theory and intervention model to improve Health-EDRM. MEDLINE, Embase and Google were searched for academic and grey literature, and titles were screened for relevance. To review the literature on local epidemiological and demographic data, the keywords "China" and "disaster" were used. Articles and websites were limited to those published between 2011 and 2016. To review the literature on the determinants of disaster preparedness, the keywords "severity", "diarrhoea", "treatment" and "household disaster preparedness" were used. To review the literature for the solution generation stage, the keywords "theory", "disaster preparedness" and "disaster risk communication" were used. Articles were limited to systematic reviews.

### 2.2.2. Household Survey

With limited information published about health status of people in the Liang Shan area, CCOUC conducted a field-based health needs assessment in Hongyan village of Xide county, Liangshan, Sichuan in December 2012. Cross-sectional household surveys were carried out to assess health status, health service availability and utilization of healthcare. A follow-up trip was conducted in March 2014. Cross-sectional household surveys were administered, covering demographics, health and access to health care, as well as knowledge, attitudes and practices of Health-EDRM. The surveys were administered face-to-face. For the 2012 survey, households were recruited using snowball sampling, and the last birthday method was used to recruit a participant within the household. The resulting sample size was 54. 52% were male and 48% female. The mean age of respondents was 43.6 years, with a maximum of 77 years and a minimum of 18 years. All were people of Yi ethnicity except one, who identified as a person of Miao ethnicity. 98% were local farmers and 2% worked as labour workers. 67.9% were illiterate, 11.3% received no formal education while 13.2% and 7.6% received primary and secondary education respectively. For the 2014 survey, all participants of the health-EDRM programme were recruited. The resulting sample size was 100. The respondent profile is reported in another paper [15].

### 2.2.3. Focus Group

One female and one male focus group (each consisting of 6–8 villagers) were studied. Participants were recruited using snowball sampling. Participants were asked what they would do if they felt sick, any barriers they encountered towards seeking healthcare, how they prepared for disasters, and what their response was during the previous flood. Focus groups were semi-structured. Ethics approval

was obtained from the Joint Chinese University of Hong Kong—New Territories East Cluster Clinical Research Ethics Committee (ref no. 2016.334).

### 2.2.4. Discussion with Stakeholders

The sectors and stakeholders involved, and their roles and expertise, are summarized in Table 2.

**Table 2.** Stakeholders and their roles.


<sup>1</sup> A semi-structured interview was conducted with the village head regarding disaster preparedness. His opinion was also sought regarding the feasibility of proposed interventions.

A participatory research approach was used. The only external stakeholders were from the Architecture/housing sector: WZQ and the Department of Architecture, CUHK. The study team was composed of CCOUC staff and students from CUHK. Data analysis was also conducted by the study team.

### *2.3. Data Analysis*

Articles and websites were screened for relevance to the information needed for the literature review. Data synthesis was by exploration of the application of the data to the planned health-EDRM programme in a narrative summary. Survey data were double entered and cleaned by trained staff. Descriptive statistics were generated using SPSS version 21.0. Focus group discussions were taped and transcribed into verbatim. A member of the health needs assessment team and the first author (G.T.) reviewed the transcript and carried out thematic analysis independently. G.T. compared the two sets of thematic analyses. Since the analysis carried out by the team member was for the purpose of writing a trip report, while the author's purpose was to summarize research according to the research framework, the author selected the final themes that were relevant to this study.

Data from the different sources were integrated according to common themes for each category of information needed into narrative summaries.

### **3. Results**

### *3.1. Problem Definition: Community Needs and Perceived Priorities*

Table 3 presents the community needs and perceived priorities in Hongyan village. The results suggest that gastrointestinal problems are common, especially during flood. Poverty and lack of infrastructure result in inadequate health care access, disaster prevention and response systems. Villagers lack empowerment to protect their family's health and safety during a disaster.


**Table 3.** The community needs and perceived priorities in Hongyan village.
