Background: The community awareness, preparedness and response to public health emergencies are essential for successful response to public health emergencies and the study is carried out to determine the community awareness and perception on health sector preparedness and response to Cyclone Nargis which is the worst natural disaster in history of Myanmar.
Methods: Total of 6 focus group discussions are carried out in 3 villages which are severely affected by Cyclone Nargis. Manual thematic content analysis is done to determine the community perception by qualitatively.
Results: Majority of the participants knew the warning for the cyclone but they are unaware on what the intensity and where to make landfall of cyclone. There are some gaps on preparedness due to lack of experience to previous cyclone and weakness in knowledge for how to prepare for cyclone. There is some training and education on public health emergencies management before the cyclone but the application and coverage of the training and education were not enough to make adequate preparedness by community. Almost all of the participants get some kinds of health services and relieve items by health sector with majority of them are positive attitudes towards health services given to them. However, most of the participants mentioned that they are not interested in health education given to them. Except for a few participants, they know how to prepare for future cyclone and the knowledge should be maintained.
Conclusion: Based on the results, there was some weakness in community level awareness on how to prepare and response to cyclone before the Cyclone Nargis. However, community awareness is significantly improved after Cyclone Nargis but health sector should make sure to sustain the awareness for optimal preparedness and response to public health emergencies.
Major emergencies, disasters and crises are approximately 450 to 800 major emergencies per year and are affecting social, economic of the community and public [1, 2]. Cyclone Nargis struck the coast of Myanmar on 2 and 3 May, 2008 and moved inland through Ayeyarwady Delta causing many deaths, destroying infrastructure, affecting on economic and social activities. It was the most devastating natural disaster in history of Myanmar and the most deadly cyclone in Asia since 1991 . Although many emergencies are often unpredictable, but the impact of disaster can prevent and mitigate by strengthening the response capacity of nations and communities at risk . Community level preparedness is also important because people at community level are first responder to emergencies and disaster . It is also recommended that humanitarian action and health services in emergencies and disasters must respect for the culture and health perceptions of the affected communities . Mortality due to the 2004 Indian Ocean tsunami was concentrated in the first few days of the disaster  and community preparedness is essential for prevent unnecessary death. Focus group discussion is useful to assess the perception of disaster preparedness program and their attitude on disasters and emergencies . The study done by Nozawa M also revealed that the awareness and behavior of the community are essential for following with evacuations advice . By focus group discussion, it can also identify the socioeconomic and behaviors factors related to disaster preparedness and response and it is useful for disaster management in the specific area [9, 10]. It is also advisable that obtaining feedback from community about their perception on relief operations is essential for future planning and response to disaster . By finding out the community perception on preparedness and response to Cyclone Nargis, the results will be useful for the future public health emergency preparedness and response in Myanmar.
Materials and Methods
Cross sectional study design with qualitative method (focus group discussion) is used for determination on perception of community awareness on preparedness and response by health sector to Cyclone Nargis.
The study population is selected from Ngapudaw, Labutta, Bogale, Pyapon, Dedaye, Mawlamyinegyun, kungyangon townships which experienced high mortality due to Cyclone Nargis. The study is carried out in 3 villages, namely amar village and kyan-ka-dune village in pyapone township and mangalake village in kynechangone township which is severely affected by Cyclone Nargis. In each village two focus group discussions, one for community members and one for government personnel and community leaders, are carried out. Each focus group of between 6 to 9 women and men are selected according to criteria such as adult men and women with age above 18 years old and at least one third are women; one group compose of government service personnel such as health, education, agriculture, police and community leader and another group compose of ordinary community members.
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The questionnaires such as information, warning, education and training, public health services and curative health services given to the community by health sector prior to and after Cyclone Nargis are prepared for assessment of community perception on preparedness and response to Cyclone Nargis by health sector. The focus group discussions are recorded by tape and notes and the discussion time range from 65 to 95 minutes.
Multistage sampling methods are used for selection of 3 sites for focus group discussion to assess the community awareness about emergency preparedness and response. Two townships are selected by simple random sampling methods among Ngapudaw, Labutta, Bogale, Pyapon, Dedaye, Mawlamyinegyun and Kungyankone townships which suffered the high mortality during Cyclone Nargis. Finally, one or two villages from each township are selected by simple random sampling methods. The participants for community members are choose from different occupations, education levels and different sections of village by purposive sampling.
Data collection and analysis
The ethical approvals from Ministry of Health, Myanmar and Faculty of Tropical Medicine, Mahidol University are already getting prior to carry out the focus group discussion. The focus group discussion is carried out in April 2010. Two facilitators and two note takers are used to carry out the focus group discussion. The data from focus group discussion is coded by two persons to summarize the answers from participants on information, preparedness and response to Cyclone Nargis by health sectors. Agreement between the two coders is determined and if agreement is good, manual thematic content analysis is used to analyze by qualitatively to find out their experiences on information, warning, education and training, public health services and curative health services given to the community by health sector prior to and after Cyclone Nargis.
Characteristics of participants
The total of 22 community members is involved in 3 community members groups. The youngest is 18 years old and the oldest is 58 years old with mean age is 34.4 years in this group. Most of the community members are farmers and others are students, merchants, fishermen, manual labors, and dependents. There are 20 participants in government personnel, community leaders and NGOs member with 7 health personnel, 5 community leaders, 5 NGOs members and 3 from other government departments. The youngest in this group is 24 years old and the oldest participant is 67 years old with mean age is 41.1 years.
Information related to Cyclone Nargis
Most of the participants in community members groups knew the news of warning and there were some of the participants who still didn’t hear the information. Many of the participants who knew the warning said announcement was made in frequent interval from radio and television. However, they noticed the warning only in short time before the storm made land fall on their area. Majority of the participants were not aware of the intensity and where to hit the Cyclone Nargis.
“I knew from the television and warning was announced after every song. However, I didn’t even realize the cyclone was coming to my village and only knew the warning 2-3 hours ahead.” (19 years old student)
Almost all of the participants in the government personnel and community members noticed the information of the storm. But some of them still didn’t notice areas which were hit by Cyclone and they didn’t relay information to the villagers.
“As a village leader, I didn’t relay the warning to villagers. Most of them (villagers) knew and they didn’t expect this intensity.” (42 years old village leader)
For the source of warning, most of the villagers received Nargis warning from mass media such as radio and television.
“Most of the villagers knew from radio and they didn’t do anything. Because of lack of electricity in my village, we relied on radio for information.”(37 years old woman)
Generally, the villagers knew the Cyclone Nargis information from mass media but they lack the knowledge on interpretation of the warning. The villagers noticed the warning in short time which is not enough to make adequate preparedness for the Cyclone.
Perception and preparedness on Cyclone Nargis
Majority of participants mention they didn’t have almost none of preparedness due to lack of previous experience on how to response to cyclone. There were also due to gaps in knowledge on Cyclone Nargis heading to their area. A few mentioned on religious believe (KARMA) for doing nothing.
“Every human being has the birth and death as religious believe and I didn’t prepare anything.” (53 years old woman)
“I didn’t have any preparedness because I have never experienced like this before. The warning didn’t include how to prepare and it didn’t disturb my meal.” (39 years old women)
They left their home after cyclone damaged their home and went to religious and public buildings for shelter.
“My house destroyed by Cyclone at 10pm, my family went to village monastery. Every villager went to monastery because it was situated in high ground and quite strong. Our village was quite fortunate with a few deaths to take shelter in monastery but in Laut-me village some causalities occurred.” (23 years old woman)
One participant from government personnel and community leaders mentioned stimulation exercises in his area after the Indian Ocean tsunami in 2005 but villagers were not interested.
“Tsunami drill was carried out in my village at national level through division and townships after tsunami in 2005. Unfortunately, the villagers were not interested.” (53 years old health staff)
Overall, the villagers didn’t know how to prepare for Cyclone due to lack of interest and weakness in education or training on Cyclone preparedness before Nargis.
Training on disaster preparedness and response before Cyclone Nargis
Majority of the participants pointed that there was some gaps or weakness of training on disaster preparedness and response in their area one year before Cyclone Nargis. One health personnel mentioned the receiving training for disaster management in undergraduate program before Nargis but she wasn’t familiar with how to apply in public health emergency situations.
“In health assistance training program, the topic (disaster management) was included. I didn’t relay the education on the villagers because they were not interested.” (30 years old health staff)
Some participants said the disaster preparedness topic was involved in basic education curriculum for school children but parents were not interested.
Health services after cyclone Nargis
All the villages from which the participants resided received some kinds of health services after Cyclone Nargis and on the other hand, the arriving of medical teams to their villages ranged from 2 days to 2 weeks. They took treatments from medical teams if they had the health problems and there were few complaints of inexperienced medical teams.
“Medical teams included both experienced and inexperienced teams. It is better to come by experienced medical teams.” (35 years old farmer)
Almost all of the participants received some relieve materials such as water and sanitation items, bed nets and medicines from health sector but difference in receiving relieve items among villages were mentioned by some villagers.
“First medical team arrived in 10 days after Cyclone and villagers seek treatment from the team. They distributed water purification tablets but the villagers didn’t know how to use and the smell was quite strong.” (43 years old man)
Most of the villagers mentioned the success in sanitary latrine construction but the others said it was not successful in their villages due to the facts that the poor villagers could not construct sanitary latrine by supplying of only latrine pans.
“—– constructed the sanitary latrines for free and there was almost no sanitary latrine at the villages before Nargis. The villagers constructed them because the organization provide not only latrine pan, but also give construction cost.” (45 years old farmer)
Few villagers mentioned the lack of psychosocial health care and dead bodies’ clearance in their villages. Majority said they only went to health education if they were given some incentives such as relieving items.
“Health education on communicable diseases were present, most of the villagers did not join because they were busy and not settled.” (24 years old woman)
The health personnel also pointed out that the villagers were seeking treatments from medical teams that resulted in success of immunization program and others. However, they mentioned the lack of interest on health education by villagers. Generally, the villagers took health services given by health sectors if required but not interested in health education.
Attitudes towards health care after Cyclone Nargis
Almost all villagers said they were satisfied with health care provided but they preferred those who paid them all expenses including referral expenses. They also preferred the station medical teams to mobile teams due to availability of health services all the times.
“We were satisfied with all medical teams, they gave enough drugs. The diseases were also cured and villagers sought treatment. But, we preferred onsite team for seeking treatment in time of need.” (19 years old woman)
Most of the participants are positive attitudes towards relive items provided by health sector and community leaders also pointed out the villagers were satisfied with receiving relieve items because they are poor.
“We preferred organizations (——–) for giving both treatments and relieve items. Most of the villagers were satisfied if the team gave relieve items.” (42 years old village leader)
Health personnel mentioned coordination between NGOs and township health department was good and some complaint of inappropriate or more than enough supply of items was provided to them.
“Township arranged the coordination meetings and there was no overlapping of medical teams in one area. But, some of items arrived in more than enough quantity such as malaria drugs, B1 tablets and surgical instruments. Our township was not malaria prevalent.” (53 years old health staff)
Majority of villagers mentioned lack of interest in health education because they were busy with their work. The health personnel also mentioned the success of some health programs such as immunization after Cyclone Nargis but stressed on lack of interest on health educations by villagers.
“Villagers came to health education if only given relieve items because they were poor and quite negative attitudes towards health education.” (34 years old health staff)
Generally, villagers had positive attitudes towards the medical teams and relived items given by medical teams. On the other hands, they didn’t want to participate in health education due to several reasons.
Common diseases and illness after cyclone Nargis
The villagers pointed out that pneumonia, ARI, diarrhea diseases, injuries and mental health problems were common health problems in their area immediately and within 6 months after Cyclone Nargis. Health personnel also agreed with the common health problems mentioned by villagers. The health personnel also reported that there was no outbreak of communicable diseases within 6 months after Cyclone.
“The villagers suffered diarrhea, common cold, pneumonia especially in children, abdominal pain. Some suffered the injuries due to Nargis. We got enough drugs with no costs.” (25 years old fisherman)
Generally, the health problems mention by villagers was compatible with common diseases reported by health management information systems/INGOs after Cyclone (11).
How to prepare for future Cyclone
The villagers, community leaders and government personnel stressed the importance of construction of cyclone shelter and disaster resistance building, presence of life jacket, drinking water and food as preparedness for Cyclone. They also desired to store drugs, tents and water and sanitation items in health centers because of roads blockage after Cyclone. They would like to get advanced warning on Cyclone and carry out of drill and training on disasters. There are also a few villagers, who don’t want to make any preparedness due to belief on KARMA (religious belief).
“Life jackets should be distributed to villagers and villagers should prepare for water containers and water because the ponds could not be used after Cyclone because of entrance of seawater.” (47 years old woman)
“As a hospital, we should predisposition of essential drugs, water and sanitation items, and temporary tents for patients because the hospital can be destroy by Cyclone. Drill should be carried out as preparation for disaster.” (53 years old health staff)
Overall, the participants had awareness on how to prepare and response to future Cyclone and this knowledge should be sustained.
Data from the study revealed that some villagers and community members will not be familiar with the weather warnings and there should be strengthening of education programs for community on familiar with weather warnings. Weather warnings should include how to prepare and response for Cyclone. Warnings should also be through village leaders because of unawareness the warning from mass media by some villagers. Education on common disasters term such as intensity of hurricane can increase the community knowledge about hazards risks . It is also recommended that the warning should be advanced for enough time on evacuation and preparedness by community and should include how to prepare and response. The communities are first responder to emergencies and there is also advisable that strengthening of community based training on how to prepare and response to disaster . The villagers will take shelter in public places and religious building in emergency situation and public and religious buildings should be disaster resistant. World Health Organization also recommended that construction of disaster resistant health facilities as safe hospital initiatives [14, 15]. Sometimes, it may take 48 to 72 hours to take outside medical teams to reach the disaster affected area  and community search and rescue team with predispositions of medicines and equipments should be strengthened at township levels based on need assessment for immediate response before the outside medical team arrived . Topics on health sector disaster management should be strengthening in training of basic health staffs because basic health staffs are giving the essential health care at community level. Without proper coordination among different stakeholders, response to public health emergencies/disasters may have negative impact . Good coordination for medical services between stakeholders in response to Cyclone Nargis should be maintained for future public health emergency response. The relief operation should consider the local context affected by disaster and sometime the relief operation fails to consider the local beliefs and contexts . The most of the focus group participants are positive attitudes towards health services given to them but also consider the voices of concern from a few participants especially the vulnerable population in future public health emergency response [13, 18]. It is also recommended that distribution of drugs and medical equipments should be based on requirements at community level. Sustainability of community awareness is also important for public health emergencies management and health sector should also consider how to make attractive for health education given to disaster affected population . In addition, Ricon et al revealed that previous exposure to hurricane may not have affect on better preparedness to future hurricane in United States . Cyclone shelters should be constructed in big villages situated in storm surge area because disaster resistance buildings reduce the risk of disasters . Drill is the best practice for testing of public health emergencies preparedness and drill involving community should be done at least yearly for readiness for preparedness .
There are also limitations about the study. Firstly, study population will not reflect the perception of the whole population due to small sample size. Secondly, information bias may likely to come out because the study is carried out two years after the events.
There is some weakness in community awareness, preparation and response to Cyclone Nargis. Community level planning, awareness, preparedness and response are essential for prevention and response to public health emergency. It is found that community awareness is significantly improved after Cyclone Nargis and health sector must sustain the community level awareness because of the low frequency and high impact nature of major disasters.
The authors declare that there have no competing interests.
NWM, JK, PS were involved in the conceptualization and design of the study. NWM prepared research instruments and other study logistics, collected data in Myanmar. KWT assisted in study management and data support in Myanmar. KC, PS, AKM, PP provided conceptual framework and technical support for the study. NWM and JK performed analyses and drafted the manuscript. All authors read and approved the final manuscript.
We would like to thank Myanmar Ministry of Health for permission to carry out the study. We give special thanks to Pyapone District Health Department and Kungyankone Township Health Department and the participants for focus group discussions to take part in study. Thank you DAAD and SEAMEO-TROMED for their partially support in research grant.
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