Articles – PLOS Currents Disasters Thu, 18 May 2017 18:58:59 +0000 en-US hourly 1 Causal Pathways of Flood Related River Drowning Deaths in Australia Thu, 18 May 2017 01:25:22 +0000 Introduction: Globally, flooding is the most common of all natural disasters and drowning is the leading cause of death during floods. In Australia, rivers are the most common location of drowning and experience flooding on a regular basis.

Methods: A cross-sectional, total population audit of all known unintentional river flood related fatal drownings in Australia between 1-July-2002 and 30-June-2012 was conducted to identify trends and causal factors.

Results: There were 129 (16.8%) deaths involving river flooding, representing a crude drowning rate of 0.06 per 100,000 people per annum. Half (55.8%) were due to slow onset flooding, 27.1% flash flooding and the type of flooding was unknown in 17.1% of cases. Those at an increased risk were males, children, driving (non-aquatic transport) and victims who were swept away (p<0.01). When compared to drownings in major cities, people in remote and very remote locations were 79.6 and 229.1 times respectively more likely to drown in river floods. Common causal factors for falls into flooded rivers included being alone and a blood alcohol content ≥0.05% (for adults). Non-aquatic transport incident victims were commonly the drivers of four wheel drive vehicles and were alone in the car, whilst attempting to reach their own home or a friend's.

Discussion: Flood related river drownings are preventable. Strategies for prevention must target causal factors such as being alone, influence of alcohol, type/size of vehicle, and intended destination. Strategies to be explored and evaluated include effective signage, early warning systems, alternate routes and public awareness for drivers.



Floods are the most common of all natural disasters, and the leading cause of natural disaster deaths worldwide 1.The World Health Organization (WHO) estimates that globally, between 1980 and 2009, floods have claimed the lives of over 500,000 people 2. Drowning is the leading cause of death during flood events 3, accounting for two-thirds of all deaths, followed by trauma 4.

Drowning risk changes during floods due to characteristics 5 such as: water depth, flow velocities and the rate of rising waters 6,7; roadways being covered or cut off by water and debris 8; and an increased amount of water in storm water drains and irrigation channels 9,10. There is a need for prevention strategies to minimise risk of drowning during times of flood. Strategies proposed include: engineering measures to restrict access to floodwaters, particularly by motorists 11 and the use of public awareness and education measures 11; as well as predictive modelling and early warning and evacuation procedures 5.

Australia has experienced significant flood events. One of the most devastating recent events was the Queensland floods of 2010/11 which affected 78% of the state and resulted in the deaths of 33 people, 21 in one flash flood event 12. In Australia, rivers are the leading location for drowning 13 and slow onset floods from inland rivers are the most common, however most deaths occur due to flash flooding, often as a result of thunderstorms 14.

Rivers, with their variable environments 7 and significant contribution to the fatal drowning toll 13, require attention in order to develop effective prevention strategies. Unlike coastal waters, specifically rip currents 15,16,17, which have benefited from much research, flood related deaths (16.8% of all unintentional drowning deaths in rivers) have not benefited from such focus.

Population based research examining risk factors has been identified as a gap in the published literature for river drowning 18. With the likelihood of floods increasing 1,19 there is a need to examine the epidemiology of river flood related drowning deaths in Australia. This paper represents the first total population cross-sectional study of all unintentional fatal river flood related drowning in Australia using coronial data.


This study aims to: Describe the incidence of unintentional fatal drowning during periods of river flooding in Australia between 1 July 2002 and 30 June 2012; discuss risk factors associated with river flood related drowning; and propose potential strategies for prevention.


Ethical approval for this study was provided by the Victorian Department of Justice and Regulation (Department of Justice and Regulation Human Research Ethics Committee – CF/15/13552) and James Cook University (James Cook University Human Research Ethics Committee – H6282). Informed consent has not been obtained as the human subjects involved in this research are deceased.

Unintentional fatal drowning in Australia is considered a ‘reportable death’ and cases of this nature are captured in the Australian National Coronial Information System (NCIS), an internet based data storage and retrieval system for Australian coronial cases. All cases of unintentional fatal river drowning between 1 July 2002 and 30 June 2012 were extracted from the NCIS and collated in a database. This includes populating a range of variables for each victim including sex, age, geographic location of drowning incident, residential location of drowning victim, activity being undertaken prior to drowning, involvement of alcohol and/or drugs, the presence of pre-existing medical conditions and ethnicity of the drowning victim. Cases in the NCIS remain open (i.e. under investigation) until a cause of death has been ruled by the coroner. At time of analysis, 93.4% of cases were closed (i.e. no longer under coronial investigation). For the open cases, data is correct as at 16 July 2016.

All cases within this study are either cases where the primary cause of death (Level 1a) was drowning or where drowning was a contributory cause of death (Level 1b to Level 3). Where an initial non-fatal drowning occurred and the victim subsequently died in hospital from the related effects of the immersion, these cases were included (no such victims in the flood-related cohort). Cases relate to unintentional drowning deaths that occurred in Australian rivers, creeks and streams only. Rivers, creeks and streams were defined as “A natural waterway that may be fed from other rivers or bodies of water draining water away from a ‘catchment area’ to another location…” and “can vary in water flow, length, width and depth…” 13.

Flooding for the purposes of this study was defined as comprising slow onset floods from inland rivers 7 and rapid on-set flash floods as a result of intense rainfall associated with thunderstorms 14. The involvement of flooding was determined through information presented in the cause of death text field or narratives of the police report and/or coronial report (if available). Where available, cases coded to ICD-10 were also identified as being flood related if the external cause code X37.8 (other cataclysmic storms) and X38 (flood, sequela) was provided in the external data tab within the NCIS 20. Data on the ICD10 code for deaths are identified by matching cases within the NCIS to the de-identified data provided through the Australian Bureau of Statistics (ABS) Causes of Death release 21. Cases were identified as being flood-related with a ‘yes’ in the corresponding variable.

Drowning victims were coded into two groups (children or adults) based on their age. Children were defined as those aged 0-17 years and adults were defined as being aged 18 years and over. In Australia, 18 years is the age a child reaches adulthood for the purposes of the criminal law 22.

The remoteness classification of incident postcode was coded according to the Australian Standard Geographical Classification (ASGC) 23. Postcodes are coded into one of five remoteness classifications based on a number of factors including distance from essential services 24.

Visitor status was calculated by determining the distance, in kilometres, between the residential and incident postcodes using Google Maps 25. A distance of 100km or less was classified as ‘Not A Visitor’; those who resided within the same State or Territory with a distance greater than 100km, were classified as an ‘Intrastate Visitor’; those who drowned in a different State or Territory and were greater than 100km from where they resided were classified as ‘Interstate Visitors’; and those with a residential postcode in the NCIS of 7777 (i.e. live overseas) were classified as ‘Overseas Tourists’.

Time of day of drowning incident was coded into four groupings for analysis: morning (6:01am to 12pm), afternoon (12:01pm to 6pm), evening (6:01pm to 12am) and early morning (12:01am to 6am). For the time of incident variable, where time could not be determined a coding of 9999 (Unknown) was used.

Crude drowning rates per 100,000 population were calculated using population demographic data cubes from the Australian Bureau of Statistics (ABS) for the period June 2003 to June 2012 26,27 and excluded international tourists. Drowning rates for people of Aboriginal or Torres Strait Islander descent were calculated using population estimates for 2002-2011 from the ABS 28. Rates for country of birth and remoteness classification of incident location were calculated using a three yearly average from population data available from the three Australian population Census years 2001 29, 2006 30 and 2011 31 and averaged to determine population and yearly drowning rate.

Due to difficulties around interpreting blood alcohol content (BAC) for drowning victims 32, alcohol involvement was deemed where a BAC was available (either in the autopsy or toxicology report) and was ≥0.05% (that is 0.05 grams of alcohol in every 100 millilitres of blood). Cases where alcohol was known to be consumed but no BAC was available were deemed Unknown for alcohol involvement.

Data coding and analysis was conducted in SPSS V20 33. Descriptive statistics were utilised, as well as chi squared analysis. A modified Bonferroni test suggested by Keppel 34 has been applied and statistical significance is deemed p<0.03. Relative risk (RR) was calculated, along with a 95% Confidence Interval (CI). Relative risk and chi squared analyses were conducted without the ‘unknown’ variable as it was assumed that this information was missing and no systematic bias was likely – e.g. presence of alcohol was calculated using the ‘yes’ and ‘no’ variables only. Where variable analysis presents cases of four or less, the term NP (not presented) has been used in the tables. Non-parametric chi squared analysis was also conducted using the proportional basis of the population as the assumed outcome numbers.

Causal factor analysis was conducted for river flood related drowning deaths as a result of the top three activities (falls, non-aquatic transport incidents, swept away; 83.7%). The narrative of the incident was analysed from the coronial finding. If the finding was unavailable, the police report narrative was used. If this was not available the autopsy report was used. The following new variables were added and coded from available data: For all cases – type of flood (flash or slow onset), if the victim was alone or with company and if the victim entered floodwaters intentionally or unintentionally. For drowning deaths due to falls into flooded rivers – what the victim fell from. For drownings as a result of being swept away by river floods – what the victim was swept from. For drowning deaths as a result of non-aquatic transport incidents involving river floods – if the victim was a driver or passenger, if the road was open or closed at the time of the incident, the victim’s intended destination and the type of vehicle the victim was in when they drowned. The data was then visually depicted using flow charts developed with the assistance of a graphic designer. Initial coding was conducted by AEP, and then reviewed by RCF with cross-checking to ensure consistency by PAL.

Rates of non-aquatic transport flood related drowning per 100,000 registered vehicles were calculated using Australian vehicle registration data. Using the ABS Motor Vehicle Census 35, a 10 year average of registrations by vehicle type was calculated using data from 1-March-2003 to 1-March-2012 inclusive. Rates were calculated for passenger vehicles (car, four wheel drives (4WD)), light commercial vehicles (utilities), rigid trucks (heavy vehicles, machinery) and motorcycles (motorbikes, All Terrain Vehicles (ATVs)).


Between 1 July 2002 and 30 June 2012, there were 770 drowning deaths in rivers, of which 129 (16.8%) were river flood related (Table 1). This represents a 10 year average drowning rate of 0.06 per 100,000 people per year (Figure 1). The number of deaths vary from a low of five deaths in 2002/03 to a high of 45 deaths in 2010/11, of which 21 (46.7%) occurred in a single flash flooding incident in the state of Queensland.

Table 1: River drowning deaths and flood related drowning deaths by sex, age group, people of Aboriginal or Torres Strait Islander descent, visitor status, activity immediately prior to drowning, remoteness classification of incident location, presence of alcohol (≥0.05mg/L) and time of day of drowning incident, Chi Squared (p value), Australia, 2002/03 to 2011/12 (N=770)


Unintentional fatal drowning in rivers by flood status and financial year, number and crude rate per 100,000 population, Australia, 2002/03 to 2011/12 (N=770)


Slow onset flooding was involved in half (55.8%) of all river flood drowning deaths, 27.1% were as a result of flash flooding and type of flood was unknown in the remaining 22 cases. Males were significantly more likely to drown in river floods than females (χ2= 9.9; p=0.002), accounting for almost two thirds (63.6%) of all drownings during river flooding (Table 2). Although a larger number of adults (n=99) drowned compared to children (n=30), children were significantly more likely to drown as a result of flooding (χ2= 7.6; p=0.006). (Table 1) The 55-64 years age group recorded the largest number of river flood related drowning victims (n=20), however those aged 75+ years were 2.24 (CI: 0.13-38.24) times more likely to drown when compared to those aged 0-4 years. (Table 2)

Table 2

Table 2: Flood related drowning deaths average per annum and percentage, annual population and crude rate of drowning per annum by sex, age group, people of Aboriginal or Torres Strait Islander descent, state or territory of drowning death, country of birth and remoteness classification of incident location, relative risk (RR) and 95% confidence interval (CI), Chi Squared (p value), Australia, 2002/03 to 2011/12 (n=129).

People of Aboriginal or Torres Strait Islander descent were 5.25 times more likely to drown in floods than non-Indigenous flood victims (χ2 =37.3; p<0.001). (Table 2). The state of New South Wales recorded the highest number of river flood related drowning deaths (n=29) however those who drowned in the Northern Territory and Queensland were 13.16 (p<0.001; CI: 1.57-110.47) times and 3.96 (p<0.001; CI: 1.00-15.60) times more likely to drown in flooded rivers compared to non-flooded rivers. (Table 2)

People born in Australia, were 2.60 (χ2 =10.5; p=0.001) times more likely to drown during river flooding, compared to those born outside of Australia. (Table 2) The majority of victims were not visitors to the drowning location (81.4%). Visitor status of the victim was not found to increase drowning risk. There were no flood related drowning deaths among international tourists to Australia during the study period. (Table 1) There was an increased risk for those who drown in remote areas, with people in remote areas being 79.59 (p<0.001; CI: 6.91-917.33) times and those in very remote areas being 229.05 (p<0.001; CI: 23.82-2202.06) times more likely to drown during times of river flooding than those who drown in major cities. (Table 2)

River flood related drowning deaths most commonly occurred in the summer months (December to February) (55.8%) (χ2= 20.4; p<0.001). Almost half of all flood related drowning deaths occurred in the afternoon (40.3%), with a further fifth (20.9%) occurring in the evening, however time of day was not found to be statistically significant. (Table 1) Alcohol (i.e. a BAC ≥0.05%) was known to be present in a fifth (20.2%) of river flood related drowning deaths, however the involvement of alcohol was not found to be statistically significant (Table 1). Males accounted for 76.9% of cases where alcohol was known to be present.

Non-aquatic transport incidents were the leading activity immediately prior to drowning, accounting for over half (55.0%) of all flood related drowning deaths (χ2= 110.0; p<0.001), followed by being swept away by floodwaters 17.1% (χ2= 73.3; p<0.001). The third leading activity prior to drowning was a fall into water (11.6%), however a fall was found to be significantly less likely to occur during times of flood when compared to drowning deaths in rivers not in flood (χ2= 16.5; p<0.001). (Table 1) Males outnumbered females in all categories of activity immediately prior to drowning with the exception of the category of Swept Away (54.5% female), however sex was not found to be statistically significant by activity prior to drowning.

River flood related deaths as a result of non-aquatic transport incidents were more likely in winter (χ2= 35.8; p<0.001) and more likely to occur on a Friday when compared to drowning as a result of other activities. For flood related drowning deaths in rivers, Monday was the most common day (24.0%) (χ2= 9.1; p=0.002); however these were less likely to be related to non-aquatic transport incidents when compared to Friday (26.8% of all flood related non-aquatic transport incidents).The largest proportion of flood-related non-aquatic transport drowning deaths occurred in afternoon (38.0%), however time of day was not found to be statistically significant. Alcohol was known to be present in just over a fifth (21.1%) of all flood related non-aquatic transport incidents, however alcohol was not found to be statistically significant.

Causal factors

There were three main activities prior to drowning in floods, those who fell into water, those who were swept away and those who drowned as a result of non-aquatic transport incidents. Deaths as a result of these activities represented 83.7% of all river flood related drowning deaths.

Falls into water

There were 15 drowning deaths as a result of falls into water, 60.0% of which were adults, 73.3% were alone, 27.3% were children and alcohol was known to be involved in 26.7% (100.0% of which were adults). Common scenarios were children who either fell into floodwaters from the creek/river bank (33.3%) or whilst wading in the water (50.0%). Interestingly, two children were alone when they drowned, whilst another two were with company, however supervision had lapsed. For adults, common scenarios were being alone (72.7%) and falling from the creek/river bank (36.4%), two cases of which involved alcohol (Figure 2).


Fig. 2: Flood related drowning deaths as a result of falls into water (n=15).

Swept away

Being swept away by floodwaters accounted for 22 drowning deaths between 2002/03 and 2011/12, of which 18 deaths (81.8%) were from one incident (the 2010/11 Queensland floods). In 72.7% of cases the person was unexpectedly swamped by water, commonly in their home (87.5%) and in all cases (100.0%) there was no prior warning of the inundation. For those who intentionally entered floodwaters (27.3%), all (100.0%) entered on foot, with 66.7% of these being swept away by floodwaters whilst crossing a flooded bridge, all of which occurred during periods of slow-onset flooding (100.0%) whilst the victims were trying to get home (100.0%) (Figure 3).


Fig. 3: Flood related drowning deaths as a result of being swept away (n=22).

Non-aquatic transport incidents

There were 71 drowning deaths due to non-aquatic transport incidents, the most common activity being undertaken prior to drowning in river floods. In almost two thirds (60.0%) of cases those who drowned were the drivers and were alone in the car when they drove into floodwaters. Drivers were most commonly in 4WD vehicles and attempting to reach their home or a friend’s home (60.0%). (Figure 4)

Almost two thirds (60.6%) occurred on roads that were known to be open at the time of the incident. Drivers were alone in the vehicle in 58.3% of road open cases, the remaining 41.7% of drivers drove through floodwaters with passengers in the vehicle. Almost a third (30.2%) of non-aquatic transport victims on open roads were intending to travel to their own home or a friend’s home, most commonly in cars (38.5%), utilities (30.8%) and 4WDs (23.1%). Just over a fifth (25.6%) of those who drowned on open roads were intending to travel to work/appointments. All victims driving heavy vehicles or machinery were undertaking paid employment at the time of their drowning. All incidents (100.0%) involving motorbikes/ATVs occurred when the victim was riding for recreation (Figure 4).


Fig. 4: Flood related drowning deaths as a result of non-aquatic transport incidents (n=71).


River flood related unintentional fatal drownings are a regular occurrence in many countries around the world 5,1,36. This study, the first to analyse Australian river flooding deaths using coronial data, found those at an increased risk include: males, children and those residing in states prone to tropical rainfall patterns (Northern Territory and Queensland); and those involved in non-aquatic transport incidents or those swept away. Risk factor identification has been shown to be an important tool for developing successful prevention strategies 11,37,3836.

Understanding causal pathways to inform prevention

This study uses causal pathway analysis to understand common scenarios leading to drowning and depicts these as flow charts. Similar work has been undertaken to understand causal pathways leading to drowning of young children in home swimming pools 39 and among divers 40.

While not the first to use flow charts to depict flood related drowning deaths, this study expands on Fitzgerald’s 41 work using a flow chart to depict circumstances of flood victims before death. Our study differs in that it uses coronial data (rather than newspaper reports or historical accounts) to examine causal factors for the three leading activities prior to drowning. Fitzgerald’s study found almost half (43.8%) of flood fatalities in Australia between 1997-2008 were vehicle related, with crossing a waterway the leading contributor, a finding that is mirrored in this study. Our research reported similar proportions of watercraft related flood drowning (4.4% in Fitzgerald, 4.1% in this study), but a higher proportion of victims being trapped and subsequently swept away by floodwaters (17.1%) with most being trapped in their home (63.6%). Fitzgerald reported zero flood fatalities of this type, with our study reflecting the 2011 mass casualty event in the State of Queensland 42.

Causal factor analysis provides important information about the chain of events leading to river flood related drowning to inform prevention. The development and implementation of prevention strategies must also consider work beyond epidemiological studies, such as behavioural psychology, to determine motivations underpinning behaviour, such as the decision to drive through floodwaters 43.

Challenges around definitions of flooding

A key challenge when conducting analysis of river flood related drowning deaths is the lack of a consistent definition. This has previously been identified as a limitation in the published literature around defining and isolating river drowning statistics 18. This study has classified river floods as slow onset or flash flooding; and while attempts have been made to define different types of flooding in the past 5,44, a lack of consistency in terminology and classifications has made the comparison of different studies difficult. This limits the ability to examine how risk differs between types of floods across a range of studies. A consistent set of definitions allows flood type and flood characteristics to be routinely collected at the time of death investigation (primarily by police). This information may then allow for opportunities to predict the severity 5 of flood events to develop and implement evidence based strategies for prevention.

Consistent terms that are then communicated to, and well understood by, those at increased risk, may increase the effectiveness of prevention strategies. Clearly communicated prevention strategies may increase recall and impact on behaviour 45,46 and therefore the likelihood that such activities will be effective in their aim of reducing flood related drowning.

Falls into water

A fall into water, although statistically more common when rivers are not in flood, was the third leading category of activity prior to drowning in river floods. Causal factor analysis raises questions regarding the protective nature of supervision, with a third of all children drowning due to falls into flooded rivers whilst with company. In order to be effective, supervision must be focused, continuous and proximate 47. Drowning prevention strategies aimed at parents and carers of young children must highlight the key elements of effective supervision, including around floodwaters. Floodwater risks to children must be communicated prior to the traditional risk taking teenage years with the average age of child victims being 8.2 years.

Almost half (44.4%) of all adults who fell into flooded rivers were known to have consumed alcohol prior to drowning. With the contributory role of alcohol having been identified in river drowning deaths in Australia 48, this study highlights the need to ensure flooding is considered in any strategies developed to address alcohol related river drowning deaths.

Swept away

While being swept away was a significant cause of death, 21 people (17.1% of all river flood related drowning deaths) in this study drowned in a single flood event in the state of Queensland in 2011 12. Victims from this event accounted for 81.8% of all deaths as a result of being swept away. Events such as these are worthy of further examination with extreme weather predicted to increase the likelihood of such events in the future 38. It is therefore vital that prevention efforts focus on those most at risk during such events.

Half (50.0%) of those who drowned as a result of being swept away were aged 55 years and over, identifying the vulnerability of older people. Almost all (90.9%) of those aged 55 years and over who were swept away by floodwaters, were swept from their house when it was inundated as a result of flash flooding. The 2011 Queensland floods occurred during the day, when older victims, more likely to be retired from the workforce, were home. This event highlights the impact of age related reductions in mobility and chronic conditions on drowning risk during floods 49. To reduce the risk, including for older people, the implementation and evaluation of prevention strategies such as predictive modelling, early evacuation, the relocation of flood prone communities and improved urban planning to avoid building on floodplains should be considered 12,50,51.

Non-aquatic transport related fatal drownings

Similar to previous studies on drowning deaths in flooded rivers, non-aquatic transport incidents were the most common activities being undertaken prior to drowning 41,52,53,6. Males are consistently at an increased risk, postulated to be due to greater confidence to drive into floodwaters 54. For prevention targeting males with effective education and awareness raising messages will be critical. As over half of all females who drowned as a result of non-aquatic transport incidents were passengers in the vehicle education strategies highlighting risk to life for both driver and passengers may be more effective 43.

While trucks and motorcycles accounted for a small proportion of vehicles driven through floodwaters (13.8%) in this study, rates per 100,000 registrations per annum 35 were 4.33 and 3.67 times that of cars (0.13 / 100,000 and 0.11 / 100,000 respectively). This is partially explained by Coles (2008) research where occupants of bigger vehicles are more likely to try to travel across floodwaters 55. Although registration data is only a proxy for exposure, this highlights the need for education and prevention efforts to be targeted at drivers of such vehicles. Future research should focus on exposure studies 18 to identify those at an increased risk of drowning due to river floods.

Preventing drowning in floodwaters is a challenge and ultimately the most effective strategy is to prevent drivers from crossing flooded roads. In this study only 7% of all deaths were from people traveling on closed roads, as such timely road closures may save lives. Road closures which are automatically based on real time flood water data and are physical in nature (e.g. barriers) 11 are likely to be effective. Providing information about alternative routes and information prior to reaching the flood water to allow for a change of route may also help. Enforcement of closed roads is also important as this helps to reinforce the signage as a means of providing information and may enhance effectiveness.

Prevention may also encompass better urban design, including building infrastructure and bridges to enable safe travel across flood-prone locations. Further research is required to determine effectiveness, and implications for disobeying road closure signage and barriers must be considered. Further work is required to explore other prevention strategies such as enforcing the culpability of those who deliberately drive through floodwaters and put others at risk and the use of regulations to hold driver’s liable for costs incurred during their rescue from floodwaters.


This study has identified a number of risk factors where prevention strategies should be targeted. These include targeting males, those who drive through flooded rivers (particularly truck drivers and motorcycle riders) and those residing in the northern areas of Australia prone to tropical rainfall.

Unlike drowning deaths at coastal locations that commonly involve international tourists 56, all victims who drowned in river floods were Australian residents, the majority of which (83.3%) drowned within 100kms of their residential postcode. It could be postulated that these people were in areas where they are more likely to have “local knowledge” about normal conditions 57, or in the case of non-aquatic transport incidents, on roads they had driven on many times in the past. This mirrors research conducted by Hamilton et al into the key beliefs underpinning people’s decisions to drive through floodwaters, which found that people regularly ignore road closed and flood warning signs if they had previous experience of driving on roads that regularly flooded 58,11. Further qualitative studies that focus on people who reside in flood-prone areas and who have driven through floodwaters may assist in the development of effective prevention strategies for this group that account for the majority of river flood-related drowning victims.

Those who drowned in the Northern Territory and Queensland were at a significantly increased risk for river flood-related drowning, which is related to their tropical climate and wet season. Prevention strategies must consider rainfall patterns and climate differences in order to be better tailored, and therefore relevant, for those at an increased risk. This is evidenced by permanent signage, used in parts of northern Queensland, which shows open and closed roads 50 to 100kms ahead to allow motorists to make decisions about which route to take. This signage is particularly important during the wet season, however the effectiveness of this method has yet to be evaluated.

There is limited evidence regarding the effectiveness of prevention strategies for those who drive through floodwaters. Key prevention strategies currently utilised are low order strategies 59,60, such as signage (road closed and depth markers) and barriers. This study also shows signage appears to be ineffective, with 63.6% of non-aquatic transport incidents in remote and very remote areas known to have occurred on roads that were open at the time of the drowning incident. Signage and detour routes are reactive strategies and hard to enact if authorities do not know if there is water on the road in such isolated locations 61. Further work is needed to explore how to make signage more effective.

In Australia, the use of the “If it’s flooded, forget it” slogan, to discourage people from deliberately entering floodwaters, be it in a car, on foot or for swimming, has been recommended 12. However this campaign has yet to be evaluated. The motivational factors behind people’s decisions to drive through floodwaters must be considered when developing prevention strategies.

There are many challenges associated with effective prevention of river flood drowning deaths. One such challenge is these deaths are reasonably rare in any given location as they are geographically dispersed across the country. Slow onset flooding moves long distances and can affect river systems hundreds and thousands of kilometres from where rainfall occurred, potentially leading those in flood-prone locations to underestimate risk to self and others 62. Gathering evidence that particular stratagems are effective is an ongoing challenge.


There may be limitations associated with this study. Firstly, not all flood related drowning deaths may have been identified. Relying on ICD codes has been found to under report drowning deaths as a result of flooding 18 and boating accidents 63. Just over one fifth (20.3%) of cases in this study recorded an unknown for the involvement of flooding. Where the case remained open (i.e. under investigation within the coronial system) there is limited information available on the circumstances of the drowning. A case that is open will also not be coded to ICD 10 coding. With 6.9% of drowning cases open within the coronial system, this paper may under report the number of drowning deaths as a result of flooding in Australia during this period.

As this study uses data for cases where a coroner must investigate, there is a period of time where there is limited information about the case. Until the case is officially closed by the coroner (i.e. no longer under investigation and a cause of death has been determined) there is minimal data available about the circumstances surrounding the drowning death. The period under analysis has been chosen to minimise incomplete data, however 6.9% of river drowning cases remain open (i.e. under investigation) within the coronial system.

Calculations for crude fatal drowning rates by population of remoteness classifications uses an average from three years 2001, 2006 and 2011 (Population census years in Australia) for population and drowning data from 2002/03 to 2011/12. This may produce rates that are not as accurate as if population data was available for each year of drowning data. These rates were calculated using the yes variable only and therefore some of the unknown cases may be flood related and this may underestimate the rate.

Alcohol involvement was unknown in 27.9% of river flood related drowning deaths. This study may therefore underestimate the involvement of alcohol in incidents of fatal drowning during river flooding. The difficulty with retrieving bodies during times of flood may also artificially inflate BAC readings due to rapid decomposition in water 64.

The chi squared analysis in Table 1 was calculated using the yes and no variables for flooding only. The authors are therefore making the assumption that the unknowns would be evenly distributed between the known categories. Relative risk was calculated on only the yes variable for flooding and as such may be impacted by the unknown cases.

The relative risk calculations based on remoteness of drowning location use census population data by remoteness classification for a victim’s residential location. It is possible that a victim may have drowned in one remoteness classification but resides (and is therefore counted in population data) in a different remoteness classification. This may therefore have an impact on the accuracy of the relative risk calculations.


Although periods of drought and flood may well be inevitable in many countries, including Australia, fatal drowning does not have to be a by-product of such weather events. Prevention strategies are vital to reducing the needless loss of life during flood disasters. This study identifies key risk factors that must be considered when developing prevention strategies such as communicating the risk of floodwaters to children prior to the teenage years, highlighting the dangers of driving through floodwaters, the need to target people in rural and remote areas with prevention messages, drivers of trucks and motorcycles and those in tropical areas prone to periods of seasonal increased rainfall.

By implementing and evaluating a range of prevention strategies based on evidence, it is hoped that the number of drowning deaths occurring in Australia due to flooding, can be minimised, and ultimately prevented.

Corresponding Author

Amy Peden (;

Competing Interests

The authors have declared that no competing interests exist.

Data Availability Statement

With respect to the minimum dataset underlying this research, this data is available on request however as the data is via a third party (coronial data), ethical approval and permission from the data custodians, the Australian National Coronial Information System (NCIS) is required before the authors are able to provide their dataset to the person inquiring. There are strict ethical restrictions around use of this data and it can therefore not be sent to a public repository. Once ethical approval and permission from the NCIS as data custodians has been achieved, researchers can contact to gain access to the data.

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Risk Criteria in Hospital Site Selection: A Systematic Review Mon, 01 May 2017 11:30:31 +0000 Introduction: Hospitals should be safe and remain functional in emergencies and disasters as it is mentioned in the Sendai Framework. Proper selection of a hospital location has a direct effect on survival of affected population in disasters as well as cost and benefit of the hospital in non-emergency situation. Different studies applied different criteria for Hospital Site Selection (HSS). The present study through a systematic review aimed to find out a categorized criteria list that have been used for (HSS) in the literature.

Methods: In accordance with the PRISMA statement, “PubMed”, “ScienceDirect”, “Google Scholar”, and “Scopus” were searched up to end of 2015. All English Articles that were published in peer-reviewed journals and had discussed site selection criteria for hospitals were included. Out of 41 articles, 15 met the inclusion criteria in which 39 general criteria for HSS were applied. These criteria were categorized in six main groups including cost, demand, environmental, administrative, disaster risk, and “other” concerns through a focus group discussion.

Results: Accordingly, the application percentage of cost, demand, environmental, administrative, disaster risk, and “other” concerns in the articles was 100, 93.3, 53.3, 33.3, 20.0, and 13.3 respectively. The least devoted attention was to disaster risk issues.

Discussion: Few researchers applied risk related criteria for HSS. Further consideration of “risk of hazards” and “burden of diseases” in comprehensive studies, is recommended for HSS to guide the decision makers for building more resilient hospitals. Keywords   Hospital, Site selection, Systematic review, Disaster risk



Hospitals are one of the main elements of social services, and a cornerstone of response to disasters in an acute phase, especially in countless mass casualty incidents. Social service delivery has its roots in the time when humans began living together as a community to meet their needs. Accordingly, health-related services were developed particularly in more centralized populations, when diseases and injuries became one of the most challenges besides food and water1.

The percentage of people living in cities is rapidly increasing due to having an easy access to social services. To provide a chance for having equitable access to hospitals a convenient location of establishing the service centers is of great importance1. In the decision-making process to establish a new hospital or renovate an old one proper location plays an important role specifically with regard to guaranteeing the profit return on investment. In other words, determining the location of a hospital is an important factor that can affect the cost and benefits2. In 2006, Younis et al showed that the geographic location influences the profitability of a hospital i.e. financial performance3. Considering the projections related to the increase in urban population to greater than 5 billion by 2025 and its effects on increasing the vulnerability in addition to climate-change related risks, assigning a proper location for medical centers becomes a crucial factor for planners4,5,6, given its long time impacts7. For instance, in a study by Bell (2007) it was indicated that the location of a hospital would have a direct effect on survival in situations such as nuclear attacks8. Also Ochi (2014) stated that inappropriate location may cause damages to a hospital due to external hazards such as earthquakes9.

On the other hand, Sendai framework emphasizes structural disaster risk prevention and reduction measures as well as the promotion of resilience of new and existing critical infrastructures such as hospitals10.

In this regard, there are two main theories used to optimize hospital location. The first is based on the Weberian model, which focuses on a single objective namely the minimum cost or maximum profit. (WU 2007) The second theory has its roots in “behavioral approach” which simultaneously considers several factors to determine the most appropriate location. For instance, Analytic Hierarchy Process (AHP), a Multi-Criteria Decision-Making (MCDM) method, is based on “behavioral approach”11.

The present study through a systematic review aims to retrieve a list of disaster risk related criteria applied in hospital site selection (HSS).


Study design

This study is a descriptive systematic review investigating risk criteria in HSS. The 27-item Preferred Reporting Items for Systematic Review and Meta-analysis statement (PRISMA) 2009 checklist is used as a reference12. The study protocol was approved by the Higher Education Council of School of Public Health at Tehran University of Medical Sciences.

Search methods for identification of studies

In the present study, “hospital “refers to the legal institution that provides 24-h medical services, including accepting, visiting, admission, and treatment of injured and/or sick individuals13,14. “Site selection” refers to an operational problem solving research in which the researchers will find out the best location that meets the assigned preferences15. “Risk” refers to both the probability of an event (hazard) and its impacts on the exposed community (vulnerability)16.

Initially, four electronic databases (MEDLINE through PubMed, Scopus, Science Direct and Google Scholar) were searched up to December 31; 2015.The search strategy was based on the PubMed database model. The key terms were adopted from Medical Subject Heading (MeSH) when possible; otherwise appropriate key words were selected according to the expert idea. The expert team is including the authors’ team and 3 more volunteer PhD students at Health in Emergencies and Disasters from Tehran University of Medical Sciences with previous field experiences in disaster medicine. Titles and abstracts were searched with the following syntax:

  • “Site selection”[tiab]AND hospital[tiab]

Study eligibility

The inclusion criteria were articles that were published in peer-reviewed journals and had site selection criteria for a hospital. Gray literature including conference proceeding papers and thesis were included as well. All non-English articles were excluded.

Data collection and analysis

The key terms were searched in the databases separately and all articles were imported to a bibliographic management program (EndNote X3). Duplications were then omitted. The titles and abstracts were evaluated by two authors (MJM and BR) independently; in the cases that the exclusion criteria could not be applied, the full article was reviewed. If there was disagreement about the eligibility of a particular article between MJM and BR, the third author (AA) was asked to adjudicate. The electronic search was conducted from November 2015 to December 2015.

In the next step, the data were extracted out of the full-text of the included articles. This data included the first author’s name, the year of publication, and the first author’s country, the geographical scope, site selection criteria and the method of study. The references of selected articles was hand searched. Finally, the extracted site selection criteria were categorized through a focus group discussion by the expert team which has been described above already. The final results were sent to the expert team for confirmation through e-mails.

Quality assessment

A 9-question checklist was produced to assess the quality of the retrieved publications by authors (Table 3). The Quality-related questions investigated the following components: number of applied criteria for HSS, categorization of the applied criteria (Yes or No), source of applied criteria (i.e. the authors themselves, experts idea or review of literature) , GIS based method (Yes or No), explanation of why the analysis method was used (Yes or No), description of the candidate regions for HSS (Yes or No), number of candidate regions for HSS (i.e. the number of regions or a countless sites), discussion about the limitation (Yes or No), and discussion about the generalizability of the study (Yes or No).

The checklist was filled out by two assessors independently (MJM and BR) and “AA” adjudicated when there was disagreement.


In the first step 41 studies were retrieved through the bibliographic search. After removing seven irrelevant and nine duplicates, 25 were remained. Sifting process left 15 eligible studies that were published up to the end of December 2015, 2 of them were identified from hand searching of references of included articles. Figure 1 illustrates the related PRISMA flow diagram. The result of quality assessment is summarized in Supporting Information file, S1 Table.

Figure 1

Fig. 1: PRISMA Flow diagram for systematic review of hospital site selection criteria

Table 1 summarizes the main results of the present study. The first article was published in 199517. The maximum number of articles were published in 2013, i.e., 6 articles. The total number of authors of the included articles was 38 (2.7 authors per article, in average). The first/corresponding authors were affiliated with different universities; among these, only K.N.Toosi University of Technology (in Iran) was associated with two publications2,18.

Table 1

Table 1: Main results of the systematic review about disaster risk criteria for hospital site selection

HSS studies performed in China were 2, Iran (5), USA (2), Taiwan (2), Tunisia, South Africa, Israel and Bangladesh (1). Regarding the geographical scope, three studies were performed at the provincial or state level, two at the country level, five at the city level, and five at a district of a city.

With regard to the methodology, 10 articles used Geographical Information System (GIS), 5 studies applied AHP, and one used fuzzy AHP for site selection19. One study combined the AHP with the Ordinary Least Squares (OLS) method18 while another one combined AHP with the Rank Order Method (ROM)20. Other models that were used included mathematical modeling, Belief-Desire-Intention (BDI)2, Technique for Order of Preference by Similarity to Ideal Solution TOPSIS1, goal programming11, fuzzy Analytical Network Process (ANP)7, and travel-time methodology21.

Through a focus group discussion, with the above described expert team, all 39 HSS criteria were classified into six main groups namely cost, demand, environmental, administrative, disaster risk, and other concerns. The application percentage of each of these groups was 100, 93.3, 53.3, 33.3, 20.0, and 13.3 respectively (Figure 2).

Figure 2

Fig. 2: Usage of main groups of Hospital Site Selection Criteria in included articles.

The six mentioned groups were subsequently divided into 16 subgroups (Table 2).

Table 2

Table 2: List of classified criteria for hospital site selection in included articles


This systematic review was conducted to find out the disaster risk related criteria for HSS. According to the results, despite the increasing trend of worldwide disasters, risk related criteria are not taken into consideration to the extent that they should.

It is not mandatory and also not realistic to apply all these factors for HSS. Depending on the strategy for building medical centers, the planners may consider only some of these. For example, Kim et al (2013) conducted HSS in the construction of a hospital for the aging population and considered factors that looked at the real health requirements of the target group; thus, some criteria such as environmental issues (air and sound pollution and sewerage system) were not considered22. Soltani et al (2011) used several criteria such as urban planning, traffic volume, and travel time for site selection of a hospital in district five of Shiraz, Iran; however they did not consider environmental and land specification issues in their study7. As the main goal of Wu et al (2007) was ensuring competitive advantage for HSS, they considered administrative criteria such as regulations, policymaker’s attitude, and even demand for the hospital personnel. They did not consider environmental concerns and accessibility to infrastructures such as main roads, as well23.

Alavi et al. (2013) considered two groups of factors that affect accessibility (roads and social services) and also distance from potential hazards (faults and industrial centers) for one region of the capital city of Tehran, Iran. However they did not use future planning development, real demand for hospital in the region, existing health services, and other land specifications1. Also Jing-Er Chiu and Hang-Hao Tsai (2013) used MCDM to determine the optimal location for expansion of a regional teaching hospital in Yunlin County, Taiwan. They used highly detailed criteria including the demand for medical service, cost, transportation, sector support, and future development. The main theme considered in their study was increasing the competitive advantage for the hospital24.

In 2014, Xiao-Hua Hu et al developed a model to identify the proper location for medical and health services in a large group of islands in Hainan Province in China. This model was based on minimizing the travel distance for clients of these services. In this study, the real demand and environmental issues were not considered25.

To achieve sustainable development, a community should consider important issues in building and utilizing a new hospital. In HSS procedures, environmental considerations are important issues26,27,28. While important, the majority of publications devoted more attention to cost and demand rather than environmental issues such as air and noise pollution as these have sever negative effects on hospital functions. In addition, following the completion of the hospital, these types of pollution would be aggravated.

Regarding the cost concerns, most of the studies devoted attention to accessibility by main roads and arteries. Other cost subgroups were proximity to infrastructures, and land specifications (availability, use, texture of the ground, being vacant, and ownership). However, none of the articles discussed the beneficial aspect of the proximity of the hospital location to airports or seaports.

Concerning the demand category, health service utilization of the community was assessed according to the total number of required beds, the patient transfer rate, and the number of patients rejected by hospitals11,18,22. In this category, epidemiological indices such as “burden of disease” and forecasting demand for health care based on demographic factors, economic growth in the area, and even new technologies in health system could be considered. For example, oil and energy activities are a great source of economic development but require a certain type of health care infrastructure when it comes to emergency medical services including trauma and cardiac patients.

As construction of a hospital is a kind of investment, the investors wait for future profit. Hence, threats to this investment should be taken into account. For more than 25 years, WHO has promoted and supported the efforts to the purpose of safe hospitals to improve the function of hospitals in emergencies and disasters. Besides, in Sendai Framework (2015-2030)10 the application of the principles of universal design and standardization of building materials in critical facilities such as hospitals is considered with the aim of disaster risk prevention and reduction. Unfortunately, few articles discussed hazards such as faults and industrial areas 1,11,27. Other potential hazards, such as floods and man-made disasters, should be considered for at-risk areas. Considering the “risk”, rather than merely hazards, is highly recommended in future permanent and field hospital site selection studies.

The two unclassified criteria, namely unforeseen circumstances and other competitive hospitals were considered in the “Other” category. It is recommended that the safety and security of the candidate locations, rural versus urban areas, local investors, accessibility of communication systems, and availability of competent and qualified staff be considered in this category in further studies.


Despite the critical role of hospitals in health service delivery in disasters and emergencies and the effect of hospital location on the quality of these services, few articles have considered hazards as the criteria for hospital site selection (HSS). Cost and demand are two groups of criteria that have been addressed more frequently in HSS studies. The decision makers should prospectively match the main objectives of hospital building with the HSS criteria according to the strategy of site selection and the availability of data and resources. Undoubtedly, being safe and remaining functional in emergencies and disasters should be one of the main objectives in HSS in line with Sendai Framework. More comprehensive criteria like “risk of hazards” and “burden of diseases” are suggested to be considered in future studies.


Non-English articles were not included in this study.

Supporting Information


S1 Table: Quality assessment results for included publication in HSS systematic review

Corresponding Author

Ali Ardalan, MD, PhD


Tehran University of Medical Sciences, Tehran, Iran

Data Availability

All relevant data are in the article.

Competing Interests

The authors have declared that no competing interests exist.

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Spatiotemporal Identification of Potential Tsunami Vertical Evacuation Sites: A Case Study of Shizuoka City, Japan Mon, 24 Apr 2017 12:00:22 +0000 Introduction: The city of Shizuoka directly faces the Nankai Trough (known for its tsunamigenic history), and is facing a potential tsunami threat. In this setting vertical evacuation can be of great significance in reducing loss of life.

Methods: We apply a GIS based method in order to identify sites that could be utilized for vertical evacuation within the existing building stock of the city, under two tsunami scenarios of 5 and 10 meters of run-up. For each building, we estimate the volume that is expected to be lost per scenario, as well as the number of people inside and how that number fluctuates over different times of the day.

Results: Using the criteria of 25% or less building volume loss and 6 cubic meters of volume per person, resulted in 2,046 potential sites for the 10 meter scenario and 1,643 potential sites for the 5 meter scenario, with the maximum amount of people that can potentially be accepted in these sites in the morning hours being 873,537 in the 10 meter scenario and 304,734 in the 5 meter scenario.

Discussion: Our approach has shown that there is a temporal aspect in tsunami vertical evacuation due to the movement of the local population throughout the day. the proposed method can be used for preliminary identification of potential vertical evacuation sites, however, it must be followed by further vulnerability and engineering assessments of buildings, in combination with accessibility and evacuation routing in order to reach a viable and complete evacuation plan.


1. Introduction

Vertical evacuation is becoming increasingly considered in tsunami preparedness, after the impact of the 2004 Indian Ocean and the 2011 Tohoku tsunamis. Extensive publications from organisations such as FEMA and the Joint Research Centre (JRC) of the EU1,2, describe the concept of vertical evacuation and the characteristics of vertical evacuation sites. According to FEMA1, a vertical evacuation site is any building or high ground that can withstand an incoming tsunami and can accept incoming individuals who seek safety. Shibayama et al.,3 provide a similar description of what evacuation areas should be in Japan, classifying them into three categories of open high ground areas, buildings with more than 7 floors and buildings between 4 and 6 floors.

Despite these extensive guidelines, case studies concerning vertical evacuation have been somewhat limited. In contrast, research concerning tsunami evacuation in general, such as behavioural analyses (eg 5), evacuation simulation studies (eg 4), and research concerning the performance of structures during the Tohoku tsunami (e.g 6,7,8) have been extensive. When it comes to vertical evacuation studies have given insight on some of its aspects. For example, Park et al. 9 , provide a mathematical model of determining optimal locations for vertical evacuation sites in coastal areas with heavy focus on their spatial distribution. Raskin et al,10 performed an evaluation of buildings that could serve as evacuation sites, based on their engineering attributes, focusing mostly on public buildings such as government offices.

While the contribution of the above research is significant, there are still many aspects of vertical evacuation that have not been yet covered. One attribute, and perhaps among the most important ones, is the population that is affected in a potential tsunami flood-zone. To the best of hour knowledge, only Wood et al.11, have provided a spatial analysis of tsunami vertical evacuation shelters that includes local population as a basic attribute of the approach, and under the scope of a vertical evacuation plan. However, given the recent rise of “big data”, population can now be approached not only as a static attribute, but spatiotemporally and on the microscale, in locations where such data is available.

We propose an approach that utilises and combines building inundation and temporal building population estimation, in order to identify existing urban structures as potential vertical evacuation sites. The objectives of our study and our used approaches are:

  • Utilise variable tsunami scenarios
  • Estimate the inundation ratio of structures in the study area
  • Estimate the population of buildings in the study area and how it varies over the course of a day
  • Establish criteria for potential vertical evacuation sites based on available and produced data
  • Identify potential vertical evacuation sites and analyse their capacity to accept evacuees during different hours of a day

2. Study area selection and overview

To reach the objectives of this study, we sought to approach an area that is currently in high risk for tsunamis. The Nankai trough, is a subduction zone where the northern part of the Philippine plate subdues beneath southwest Japan resulting in high magnitude earthquakes 12. The trough has been extensively studied as per its seismicity and tsunami events. In historic times, earthquakes with magnitude of 8.0 or higher and a 120 year occurrence interval ,have happened in the area, with the most recent ones being the M 8.0 Tonankai earthquake of 1944 and the M 8.1 Nankaido earthquake of 1946 13. Tsunami deposits found along the extensive coastline facing the Nankai trough also attest to a tsunami occurrence interval every 100 to 200 years for the last 3000 years 14. The recorded activity of the trough implies further activity with an upcoming earthquake in the near future 15.

In this setting, we aimed to select a city which belongs in one of the 8 prefectures of Japan that directly face the Nankai Trough. Our choice became the city of Shizuoka, Shizuoka prefecture for two main reasons: (a) The city plays a very important role in Japanese geography. Not only it is the capital of the prefecture hosting a range of administrative functions, but it also is a central transportation node connecting north and south Japan. (b) It has excellent data availability compatible with the research objectives of this study. The most attractive data set is the people flow database which describes the population movement of the city over the course of 24 hours of the day.

The city of Shizuoka (Figure 1) directly faces the Nankai trough being in a vulnerable to an upcoming tsunami location. It is the second largest city in the prefecture with a population of 704,340 people 16. While the city boundaries greatly extent into the mountain ranges situated in the northern parts of the prefecture, these areas are uninhabited in their majority, and the populated built-up part of the city is mostly situated along the coastline. Three main highways and a two major train lines intersect the built up area of the city from the southwest to the northeast, dividing the city in two. The Central Business District (CBD) of Shizuoka is located to the northern part further away from the coastline, and a satellite business district is situated in the eastern area of Shimizu in very close proximity to the sea.

Figure 1: Location of the city of Shizuoka, its three wards and its Central Business District (CBD)

Fig. 1: Location of the city of Shizuoka, its three wards and its Central Business District (CBD)

3.Tsunami scenarios and building inundation ratios

3.1 Scenario Selection

Despite the numerous studies that illustrate the seismic and tsunami presence along the Nankai Trough, clear descriptions of the characteristics of past remains remain limited. Sugimoto et al. 17 describe that the 1707 Hoei Earthquake, which originated in the Nankai Trough, was estimated to have had a magnitude of 8.4, while Imai et al. 18 suggest that the tsunami that followed the earthquake reached a maximum run-up of 5 meters.

Beyond that, characteristics of potential tsunamis from earthquakes of such magnitudes have to be inferred indirectly. For example, most tsunami magnitude scales (e.g. 19) suggest that tsunamis from magnitudes in the range of 8 should be expected to have a maximum run-up of 10m. Under these circumstances, it becomes clear that any method of identifying potential vertical evacuation sites should offer flexibility and adaptability to different scenarios originating from different sources.

We used two tsunami scenarios in our approach, the 5m run-up one as described by Imai et al. 18, as well as what the tsunami magnitude scales suggest, a 10m run-up scenario. Using GIS, we were able to visualise both scenarios using a Digital Elevation Model for the city of Shizuoka with a resolution of 5m, as it was provided by the Geospatial Authority of Japan (GSI). Subtracting the elevations from the maximum run-up resulted in water depth maps as can be seen in Figures 2 and 3.

The 5m scenario affects only small areas of the coastline of the city, with most of the flooding occurring in the area of Shimizu to the North. However, the 10m scenario shows greater capacity for flooding, as not only it affects the majority of the city’s coastline, but also, it follows the river system in Shimizu uphill, achieving greater inland penetration.

Figure 2: 10 meter run-up tsunami scenario for the city of Shizuoka

Fig. 2: 10 meter run-up tsunami scenario for the city of Shizuoka

Figure 3: 5 meter run-up tsunami scenario for the city of Shizuoka

Fig. 3: 5 meter run-up tsunami scenario for the city of Shizuoka

3.2 Inundation ratio estimation

Continuing with our GIS approach, we utilised a process of estimating the extent that buildings become inundated under a tsunami. The Inundation Ratio estimation is a widely used approach, usually in studies that investigate the vulnerability of buildings to tsunamis (e.g.20,21). As building heights are necessary for this estimation, we had to obtain a dataset that contains such information for the full building stock of the city. The best choice that offered coverage for the full extent of Shizuoka was the Zenrin Zmap Town II dataset which contains floor number information for each individual building. We had to assume that each floor was 3 meters in height, and as such, we indirectly obtained the necessary building heights. The dataset also contained the information of each building’s footprint geometry, which in combination with the height, allowed us to finally have an estimate of each building’s volume.

As a final step, the building volume and the water depth at the location of each building were used to estimate the percentage of the building’s volume that becomes flooded under both the 5m and the 10m scenarios as follows:

Where VA is the available volume after the tsunami, VB is the volume of the building, EX is the exposure, or water depth at the location of the building and H is the building height.

The results of this estimation can be seen in Figures 4 and 5, where the individual building volume loss to the tsunami is mapped. This process gave two important products for our study. First, the volume that is available in buildings after the tsunami could be utilised by people for evacuation within the flood zone. Moreover, there is a distribution of buildings with such available volumes across the full extent of both the 5m and 10m scenario flood zones.

Figure 4: 10 m run-up scenario building volume loss

Fig. 4: 10 m run-up scenario building volume loss

Figure 5: 5 m run-up scenario building volume loss

Fig. 5: 5 m run-up scenario building volume loss

4. Temporal building population estimation

4.1 Background and Method Selection

For decades now it has been identified that regardless of the detail of a population census, what is often reflected by its statistics is known as nighttime population (e.g.22), meaning that spatially, the census shows where the people will most likely be situated at night when asleep at their homes. However, in reality, the population of a populated area is mobile during the course of a day, and can be distributed in numerous locations at the time when a tsunami occurs. When it comes to the Japanese census, the Statistical Agency of Japan, provides extensive datasets that despite their detail still cannot reflect the mobility of the population. Moreover, even when considering the nighttime population itself, the spatial distribution of the population cannot go lower than 500 m, due to respect of the privacy of Japanese citizens.

The second variable to our potential vertical evacuation site identification would be the number of occupants inside a building and by extension how much volume they occupy. As such, the information provided by the census was somewhat limited and additional estimations were necessary in order to not only achieve a spatial resolution of building level, but also, the temporal distribution due to the mobility of the population. Lwin and Murayama 23 had previously introduced a method of estimating the population of buildings in an area, based on census grids and the volume of buildings. The authors themselves promote this method for its usefulness in natural disaster studies and we previously have been successful in incorporating its results in tsunami vulnerability assessments 24. While this method provides the required spatial distribution, it still lacks the necessary temporal dimension.

Greger 29, used Lwin and Murayama’s method as a base and proposed a spatiotemporal building population estimation method. The way he achieved that was by introducing additional datasets to the process that were available for his study area in Tokyo. The first dataset is the spatial distribution of the workforce, in 50 m resolution as it is described by the census. The second, was a point address dataset that allowed him to determine the use of each building, and the third was the PersonFlow data for Tokyo, as provided by the Center of Spatial Information Science University of Tokyo 25. By using the results described in Axhausen et al.26, Bowman and Ben-Akiva 27 and Jiang et al.,28 he defined six activity types and matching building usages. By combining the movement of people, the census, and the building categories, he was able to estimate the population of people in buildings and how it varies over 24h of a day, using the following equation:

Where BPi,c,t is the building population of building i in category c at time t, APAi,c,t is the total population of category c at time t of the census tract that contains building i, A is the set of all census tracts, BAi is the footprint area of building i, BAi,c is the footprint area of building i in category c, and BFi is the number of floors of building i 29.

Greger’s method has great compatibility with the datasets available for Shizuoka, which led to its selection for our temporal building population estimation process. While the data available for Shizuoka were similar to the ones Greger utilised for Tokyo, there were some differences that led to small adjustments to the application of the method.

4.2 Method application

Figure 6 presents the datasets that we utilised for the 24 h building population in the city of Shizuoka. All of these except one were consistent with the data demands of Greger’s method. The dataset that was inconsistent was the point address dataset of February 2014 that we used could not match the six categories of activities that Greger suggested for Tokyo. The only possible distinction was whether each building was a residence or not. Because of this limitation we had to adjust buildings into two categories, residences and workplaces. Moreover, the movement of the population during the course of a day had to be grouped into two movement types to match the building categories as follows : to home and to work (Figure 7).

Figure 6: Datasets that were used for the purposes of this study

Fig. 6: Datasets that were used for the purposes of this study

Figure 7: People flow movement over the course of the day grouped in three categories. Only the categories of Home and Work were considered. Data source: CSIS


Applying the method resulting in two datasets. One for building footprints of residences and one of workplaces, both of which contain the estimated population of each building in 24 hourly segments. At the end of this step we had obtained the information necessary for our identification of potential vertical evacuation sites: (a) The volume available to be occupied in each building after two tsunami scenarios, and (b) the estimated population of each building at each hour of the day (Figure 8).

Figure 8: Results of the 24 hour building population estimation method for the city of Shizuoka at 12pm

Fig. 8: Results of the 24 hour building population estimation method for the city of Shizuoka at 12pm

4.3 Validation

We opted to validate the building population estimation method with field measured data, not only to verify the method itself, but also its slight adjustment to the datasets for Shizuoka City. We followed the same method as Greger 29, by observing the number of individuals that exit and enter two workplace buildings, one in the centre of Shizuoka and one in the are of Shimizu. Out of respect to the local residents’ privacy, we did not engage in any measurements of residential buildings, and the exact location of the workplaces will selected will also be kept under discretion.

Figures 9 and 10, show the field observed populations for the two buildings and the estimated by the method populations. Building A, an office building has similar estimated and observed values, however, in the late evening hours where the method estimated that people would be returning home, in reality there was a social gathering a number of people as well as some visitors remained in the building till later hours. Given the nature of the data used, we anticipate that it would be of extreme difficulty for this method to anticipate for such irregularities. Building B, was a bank, and similarly to building A the method has similar observed and estimated population values, except for some differences that are due to increased client numbers at different hours. Once again, such variances can be completely random and isolated and would be extremely difficult to be captured by any dataset, and consequently a method.

Excluding the small irregularities that were observed, the majority of measured and estimated populations were of similar values and we were able to verify a close approximation of the population of buildings by the applied methodology.

Figure 9: Observed and estimated populations values for Building A, an office building in the area of Shimizu

Fig. 9: Observed and estimated populations values for Building A, an office building in the area of Shimizu

Figure 10: Observed and estimated populations values for Building B, a Bank in the CBD area of Shizuoka

Fig. 10: Observed and estimated populations values for Building B, a Bank in the CBD area of Shizuoka

5. Potential vertical evacuation site identification

5.1 Evacuation Criteria

In the literature review section it was discussed how vertical evacuation studies in the past have been limited, and how the main focus of the majority of studies has been the physical characteristics of buildings such as their resilience, shape and height. Because of that, there is an absence of established criteria on how populated or unpopulated a building has to be in order to be used for vertical evacuation, and by extent how much volume an evacuee would occupy in that building.

Our concept for this approach is that each building that is more than one floor and is not completely flooded can provide its available volume for vertical evacuation. Moreover, we anticipate, and have demonstrated by our building population estimation, that the volume available for evacuation is expected to be variable during different times of the day as such buildings are expected to be occupied by individuals either for residence or work. In the absence of a previous framework of necessary volume standards we introduced plausible criteria to test our approach. It should be noted that due to the nature of the method these criteria can be adjusted or updated with any other criteria necessary by a complete vertical evacuation plan.

In order to complete the identification of potential vertical evacuation sites we assumed the following: (1) Potential vertical evacuation sites will be buildings with more than one floor, and have an inundation ratio of 25% or less. This ensures that even buildings with two floors are not going to be flooded to extents that might potentially destroy them. (2) Each individual that is either situated in the building already, or is going to evacuate to the building is going to occupy 6 cubic meters of volume. The volume required by those already situated inside is going to be subtracted from the available volume and the rest will be used to determine how many additional individuals can be accommodated for vertical evacuation. Finally, at a given hour of the day X, the number of people that can be accepted in each building that is 25% or less flooded was estimated by the following equation:

Where N is the number of people that can be accepted by the building, VB is the volume of the building, IR is the inundation ratio of the building, PBX is the population of the building at time X, and VE is the volume allocated per person for evacuation.

5.2 Results

Using the above formula for both scenarios produced two kinds of results. The first, is the total number of potential vertical evacuation sites per scenario, and the second, the number of people that can be accepted in each building and in the whole of the flood zone of each scenario.

For the 10m scenario, there were 2,046 buildings that met the criteria, out of which 1,551 were residences and 410 were workplaces. In the case of the 5m scenario, 1,643 buildings were identified, out of which 1,233 were residences and 410 were workplaces. Concerning the population that can be accepted in these buildings, the results showed that the number was variable during different times of the day. Figure 11 summarises the total number of people that can be accepted in these potential sites, for each scenario and for different hours of the day. We found that as the population moves, there are discreet differences in the available volume that buildings can offer to evacuees. The morning hours between 10 and 11 offer the most available volume and show the highest capacity for evacuees. In the case of the 10 m scenario, up to 873,537 individuals could be accepted, while in the 5 m scenario the number was down to 304,734. This translates to more than 100% of the population of the city for the 10m scenario and to 43% of the population for the 5 m scenario. The 5m scenario shows a much lesser capacity to accommodate evacuees, however, given the much limited extend of its respective flood zone, the potential for vertical evacuation is still high. The total capacity for evacuees lessens as the day progresses towards the evenings with the late night hours having the smallest numbers of vertical evacuees that can be accepted.

Figure 11: Temporal variations of additional population that can be accepted for vertical evacuation in buildings 25% or less inundated


5.3 Discussion

The results that were described earlier demonstrate that there is a difference between the two scenarios when it comes to the number of potential sites as well as the number of individuals they can support. This can be attributed to the fact that the severity between the two scenarios is different, and they have flood zones that have variable extents and not only affect different number of buildings but also numbers of populations that are situated in these locations.

In both scenarios the buildings that were identified as potential vertical evacuation sites were residential as well as workplaces, but the residences outnumbered the workplaces 3 to1 and 4 to 1 in the 10 m and 5m scenario respectively. This introduces the temporal dynamic that was verified by the fact that the number of people that can evacuate in the potential sites is increased in the morning hours and decreased in the evening and night hours. Considering that in both scenarios we have many more residences than workplaces as potential vertical evacuation sites, could explain the higher available volumes in the morning, as many locals leave their residences to engage in daily activities, and move to different parts of the city. In contrast, the evening hours have less available volume as the residents return home occupying these previously less populated buildings, while the workplaces that are now scarcely populated or empty are not high enough in numbers to match the morning volumes of residences.

Despite these differences during different hours of the day, the population that can fit in these potential sites was surprisingly high. In fact, within the flood zone of the 10m scenario there is enough volume available in potential sites to accommodate the whole population of the city of Shizuoka in the morning hours. At the same time, in the limited flood zone of the 5 m scenario, there is still enough volume for 43% of the population of the city. This could mean that there is an abundance of volume in the buildings of Shizuoka, with some of them being empty or scarcely populated. Observations from field work in the city pointed towards this direction, but no qualitative methods were used to verify them.

It should be stressed that the buildings identified by our approach are sites that can be potentially used for vertical evacuation. In this case we focused on the inundation and perhaps mainly on the population of those buildings. Due to the extent of the flood zones and the number of buildings in Shizuoka we were unable to incorporate structural attributes into our method. The results produced in this study should be used as part of a greater vertical evacuation plan, which can offer the appropriate resources for a structural evaluation of those buildings. Moreover, access to the potential sites, as well as the general procedures of the evacuation itself remain outside the scope of this study due to similar limitations, and should be the focus of further research or evacuation planning in the future.

6. Conclusions

Our approach has shown that the attributes of building population and tsunami severity affect the way buildings can serve as vertical evacuation sites in a spatiotemporal way. The inundation of buildings differs between the 5 meter and 10 meter scenarios not only number of buildings within their flood zones, but also in the way buildings are extensively flooded or not in overlapping areas of the scenarios, indicating discreet spatial variations.

Using Greger’s29 building population estimation method has revealed a temporal aspect of vertical evacuation due to the mobility of Shizuoka’s population over the course of a day. Residential buildings were shown to be emptier during the daytime while non residential workplace buildings became more populated, with the opposite occurring in the evening, night and early morning hours.

The number of individuals situated in buildings at a different hour dynamically affected the potential of acceptance of additional individuals that are vertically evacuating. By setting criteria of buildings inundated to 25% or less of their volume, and 6 cubic meters of volume per person we showed that for the case of Shizuoka City, its whole population could potentially fit in the available building volume in the case of the 10 m scenario and 43% of the city’s population in the 5 m scenario.

The tsunami inundation scenarios and vertical evacuation criteria used to test our approach can be exchanged for any kind of scenario and criteria that match any goals or research pursuits. Moreover, the method can be applied in other areas of Japan or the rest of the world, where similar datasets are available, or can be obtained by field work. However, the results of our method identify sites that can only potentially be considered. Vulnerability and engineering assessments are necessary in order for the viability of these sites to be concluded. Accessibility and evacuation routing to these sites must also be considered, under the scope of a complete evacuation plan.

Competing Interest Statement

The authors have no competing interests.

Corresponding Author

Gerasimos Voulgaris (

Data Availability Statement

All relevant metadata and resulting data are within the article. Open source datasets used were obtained from the following two institutions: (a) Geospatial authority of Japan (GSI). In their website, free registration is required for open access to GIS data for the whole of Japan. Visit and select the dataset option required. They are divided in basic map information and Digital Terrain Models. Upon selecting the required data, free registration is required before finalising the download. (b) The National Statistics Bureau of Japan. While their website has English support it might be limited. To obtain any kind of spatial statistics, visit , then select the area and type of statistics required and proceed to download. Minimal personal information such as institution and purpose might be required. Non open source datasets were obtained via the Joint Research Assist System (JORAS) of the Center of Spatial Information Science (CSIS), Tokyo University. In order to obtain data, application via form is necessary at CSIS. By visiting , and completing the relevant form, it is possible to obtain the relevant datasets for non commercial use only.

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Constructing the Indicators of Assessing Human Vulnerability to Industrial Chemical Accidents: A Consensus-based Fuzzy Delphi and Fuzzy AHP Approach Mon, 10 Apr 2017 14:00:13 +0000 Introduction: Industrial chemical accidents have been increased in developing countries. Assessing the human vulnerability in the residents of industrial areas is necessary for reducing the injuries and causalities of chemical hazards. The aim of this study was to explore the key indicators for the assessment of human vulnerability in the residents living near chemical installations.

Methods: The indicators were established in the present study based on the Fuzzy Delphi method (FDM) and Fuzzy Analytic Hierarchy Process (FAHP). The reliability of FDM and FAHP was calculated. The indicators of human vulnerability were explored in two sets of social and physical domains. Thirty-five relevant experts participated in this study during March-July 2015.

Results: According to experts, the top three indicators of human vulnerability according to the FDM and FAHP were vulnerable groups, population density, and awareness. Detailed sub-vulnerable groups and awareness were developed based on age, chronic or severe diseases, disability, first responders, and residents, respectively. Each indicator and sub-indicator was weighted and ranked and had an acceptable consistency ratio.

Conclusions: The importance of social vulnerability indicators are about 7 times more than physical vulnerability indicators. Among the extracted indicators, vulnerable groups had the highest weight and the greatest impact on human vulnerability. however, further research is needed to investigate the applicability of established indicators and generalizability of the results to other studies.

Key words: Fuzzy Delphi; Fuzzy AHP; Human vulnerability; Chemical hazards      



Technological advances, and discovery and consumption of thousands of chemicals have met many of the human needs at industrial and economical levels. On the other hand, in some cases, these chemicals have resulted in catastrophic consequences such as explosion, fire, leak, and release of chemicals1. In this situation, there is a high potential for damaging economic, environmental, and human resources and concern is growing about the public health effects, as was the case at Flixbrough, England, Bhopal, India, and Seveso, Italy2,3,4.

The trend of industrialization has been growing quickly on the basis of market demands in Iran and industrial chemical accidents have increased in the recent years5. Therefore, a comprehensive chemical safety program should be a priority of the authorities in the areas that are prone to chemical accidents6. Identifying the human vulnerability can be part of the mentioned program. Human vulnerability can be defined as the factors that make people working in the chemical installation or living in the proximity of such places vulnerable to harms and injuries2. Assessment of human vulnerability to chemical accidents through identifying the relevant indicators could be the first step towards reducing the chemical risk and establishing appropriate mitigation programs7. Most of the available studies have focused on defining the indicators of human vulnerability in natural disasters8. However, a challenging area in this field is whether they can be used in man-made disasters such as chemical releases.

The Delphi method is usually recommended for selecting indicators in many fields based on the mean value of expert opinions9. The Fuzzy theory has been also suggested for the analysis of such studies in order to prevent expert judgment from the influence of extreme values, as Ishikawa did in 199310. Applying the Fuzzy Delphi Method (FDM) has the ability to combine the participants’ opinions more reasonably11. After finalizing the indicators, the Fuzzy Analytic Hierarchy Process (FAHP) approach was used to prioritize the relevant indicators under a hierarchy model12. The combination of FDM and FAHP can calculate weight values and enhance objectivity and accuracy of indicators and their relevant variables13.

The main goal of this study was to construct and prioritize the indicators of human vulnerability in chemical accidents through applying a Fuzzy Delphi-AHP approach. The identification and prioritization indicators of social and physical vulnerability presented in this paper may improve the assessment of human vulnerability in chemical accidents. In addition, they will provide a new insight for the experts of disaster management planning and strategy department of chemical installations.

[DIS-16-0066] Table 1

Table 1: Linguistic variables and relevant trapezoidal fuzzy numbers in this study


This study was conducted in 3 rounds. A total of 42 experts, including Iranian and American experts with different ages and years of experience in disaster, safety, crisis management, and chemical and social sciences were invited to participate in the Delphi study.

The response rates were 76.2%, 90.6% and 96.5% in the 1st, 2nd, and 3rd round of the Delphi study, respectively.


This study used a Fuzzy Delphi-AHP method to identify the potential indicators of human vulnerability in chemical accidents in 2015. This method enables the researchers to reach an expert consensus about the topic during multiple rounds.

In order to simplify the survey process, two primary vulnerability indicators, including social and physical indicators, were proposed considering a review of the literature and focus group discussion2. Based on two primary vulnerability indicators, a questionnaire with a five point Likert scale from ‘‘very low” to ‘‘very important” was designed. Because of having few experts from other countries and also the physical distance among Iranian experts, the online Delphi method was appropriate as it does not require the physical presence of experts14. This study was conducted in 3 sequential rounds of a group of experts, who are anonymous to each other but the selecting the experts was purposeful. The including criteria for Participating the experts to this study were:

  • Having the academic degree (PhD, MSc) in one of the mentioned majors: Health Safety Environment (HSE), Chemistry Engineering in Crisis Management branch, Health in Disasters and Emergencies, Social Sciences and Epidemiology.
  • Working as the faculties (University or Research Institutes), PhD students in one mentioned majors or HSE managers in industries.
  • Having the empirical studies and relevant peer-reviewed articles in relevant subjects to chemical accident modeling, public safety, disasters and emergencies management.

Also, we used anonymous questionnaires for each round and the analyzer was completely blind to the expert who completed the questionnaire. This implementation method of analysis avoided situations in which the analyzer is dominated by the views of a few.

At each round, all experts were contacted via e-mail to define the importance of the indicators. The participants were given 4 weeks to answer. During this period, 3 reminder emails were sent to the experts to complete the survey in each round. If they did not complete the questionnaire after 4 weeks, they were excluded from the study for the next round. The results of each round were analyzed by the Fuzzy method and Fuzzy Trapezoidal Number (Table 1). The threshold value in each round was 0.7 and the cut point for continuing the rounds of Delphi was 0.2. During the 1st and 2nd rounds, the changes were made in the questionnaire based on the group views. After the 3rd round, the mean value of group responses were calculated for each indicator and fed back to the panelists who could reconsider their views based on the reported mean values of indicators. Then the difference between before and after the reconsideration were calculated. Because the difference value was less than 0.2, the study ended up at this round. Ethical approval was obtained from Ethics Committee of Tehran University of Medical Sciences for the whole project as a PhD dissertation. In this part of work, at the beginning of Delphi the oral consents were provided to participate in the study from all experts. The oral consents were not documented but if they rejected, the Delphi questionnaire would not email for them. Also, they were completely free to reply or not to the emails in the next rounds of Delphi study.

Then, we prioritized the extracted indicators of human vulnerability under a hierarchy model identified by the Fuzzy Analytic Hierarchy Process (FAHP) approach. Also, three matrixes were sent to 8 experts to weight. Then, we entered each calculated weight of the criteria into a separate matrix in a software called ‘Super Decision’ for the application of FAHP and computed the weights of relative indicators to human vulnerability.




[DIS-16-0066] Fig 1

Fig. 1: A fuzzy trapezoidal number

[DIS-16-0066] Table 2

Table 2: Descriptive statistics of Delphi participants

First, we extracted 38 indicators of human vulnerability in social and physical domains from a review of the literature. Then, the draft of indicators was emailed for Delphi. Seventeen indicators were deleted and 21 indicators were retained in the first round, including five highest defuzzified values which were population density, public awareness, number of chemical plants and warehouses in the area under study, percentage of equipped health facilities for chemical victim management, and level of safety in chemicals plants. The indicators were screened based on the threshold (The indicators that were greater than 0.7 were retained, and the indicators below 0.7 were deleted. It was found that defuzzified values for the indicators below 0.7 were population growth, minority, migration, dependency, employment and working population in primary, secondary, and tertiary sectors. Also, 11 new indicators were added according the expert views. These indicators were the number of active organizations during disasters and crises in the area, distance between chemical installations and the nearest residential areas, type of communication systems during time of disasters and emergencies, accessibility to location accident, and other supportive systems like fire brigade, health service, ambulance and etc. in factories and companies of the region.

Defuzzified values showed that all 32 indicators were greater than 0.7 and were therefore retained, and no indicator was deleted in the 2nd round. The five greatest values of the indicators belonged to the percentage of chemical plants or warehouses that produced, used, or stored hazardous chemical materials in the area under study, early warning systems, rate of the preparedness of health facilities for chemical accidents, health workers trained in chemical hazards and management of the injuries, and public awareness (0.91, 0.86, 0.84, 0.83, and 0.82, respectively). In the 3rd round, all the mean values of the indicators were greater than 0.7 and retained in the study. The five indicators with the highest averages in the 3rd round were similar to the previous round. Then the calculated mean values of the indicators have been sent to the experts and they were asked to change the importance of the indicators if they wished to. If, after revision, a difuzzified value was more than 0.2, Delphi study was going to continue to the next round. In this study, the calculated revision value was 1.8 and therefore, the study was finished in this round.

Then, we prioritized the 32 factors under a hierarchy model identified by the Fuzzy Analytic Hierarchy Process (FAHP) approach. The analytic hierarchy process model for the assessment of human vulnerability has been demonstrated in Fig. 2.


[DIS-16-0066] Fig 2

Fig. 2: Analytic Hierarchy Process Mode for Assessment of Human Vulnerability

In this study, all calculated consistency ratios from AHP matrixes ranged from 0.00 to 0.09 and fell within the acceptable level of 0.1 as recommended by Satty12, indicating that the study participants assigned their weights consistently after examining the priority of the indicators of human vulnerability to industrial chemical accidents.To determine the prioritization of the social and physical vulnerability with regard to the goal of assessing human vulnerability, the weights of determined indicators were calculated and demonstrated in radiated diagrams (Fig. 3 and Fig. 4).

[DIS-16-0066] Fig 3

Fig. 3: Radiated diagram of weight of social vulnerability

[DIS-16-0066] Fig 4

Fig. 4: Radiated diagram of weight of physical vulnerability

[DIS-16-0066] Table 3

Table 3: Weight of indicators to the human vulnerability in chemical accidents

[DIS-16-0066] Table 4

Table 4: Weight of indicators to the human vulnerability in chemical accidents


The research findings showed that social vulnerability is 2.7 times more than physical vulnerability in assessing the human vulnerability to chemical accidents in the residential areas. The indicators such as vulnerable groups, population density which is defined as the number of people per square meter in the area under study and public awareness of chemical plants, related hazards, type of chemicals and precautionary measures at time of chemical accidents and emergencies, are the top three indicators in the social vulnerability which was also the highest among the overall weight, while the preparedness of region to chemical accidents, accessibility to the accident location and level of safety in chemical plants and warehouses are the three major indicators in the physical vulnerability.

The “vulnerable groups” possessed the highest weight values (0.118) in the human vulnerability indicators to chemical accidents. This indicator had 4 sub-indicators, including households that had children under 7 years old, member(s) above 65 years old, individual(s) with chronic or severe disease(s), and member(s) with mental or physical disability. In the previous studies about social vulnerability, 1 or 2 of the above conditions were considered as one of the indicators of vulnerability15,16,17,18 but four different situations were determined for finding vulnerable households at the same time in this study. Population density can be effective on organizing all facilities required for chemical hazards preparedness and reduction of the relevant vulnerabilities in at risk areas19. Training the first responders who attend at the scene of a chemical accident and also increasing the awareness of residents are essential in the industrial areas20. The people who live in the proximity of the chemical plants and warehouses should have information about chemicals and their relevant hazards in the vicinity and also, the protective measures they can take if a chemical incident occurs. For instance, many lives would have been saved if people stayed indoors with a wet piece of cloth on their face as a simple safety measure in the Bhopal accident7.

Among the indicators of physical vulnerability, “preparedness of the region for chemical hazards” held the highest weight (0.075). This indicator had 7 sub-indicators, including emergency evacuation plan, disaster shelters, percentage of equipped health facilities for chemical hazards management, early warning systems, modern communication instruments, periodic chemical exercises, and providing suitable Personal Protective Equipment (PPE) for residents living near chemical installations. This finding shows that we need to develop required infrastructures for chemical emergency management in the areas which are exposed to chemical hazards. Moreover, the authorities should engage the private sectors which may have resources to contribute to local chemical emergency planning7,21. This result is consistent with the findings of a study by Guizhen22. Accessibility to the accident location was another important factor among physical vulnerability indicators. The sub categories of this factor including the distance between the accident location to the nearest main road and traffic and conditions also had a high weight in another study exploring physical vulnerability against fire hazards in Daka, Bangladesh23. The level of safety in the chemical installations was the third considerable indicator in physical vulnerability with a weight of 0.04. Chemical regulations and relevant standards should be monitored and enforced in order to promote safety to an acceptable level in chemical plants and warehouses24. This strategy has been implemented in the European Union and the countries have succeeded in developing a public health surveillance system for chemical incidents25.


The main contribution of this paper was to identify a draft of effective indicators for assessing human vulnerability to a chemical accident. This study explored the application of the Fuzzy Delphi-AHP Method to quantify the expert views to human vulnerability of the residents living near chemical plants and warehouses. Also, the other possible factors affecting human vulnerability to industrial chemical accidents were considered and two sets of indicators in social and physical domains were constructed. Then, human vulnerability indicators were selected and weighted using the Fuzzy Delphi and Fuzzy AHP method, respectively. The results of the FAHP method indicated that age under 70 or over 65, chronic/severe disease of mental/physical disability (vulnerable groups) was the main risk factor for the human vulnerability of households. In addition, population density and public awareness of chemicals, hazards and precautionary measures in at chemical risk areas were identified as potentially having a greater effect with respect to adverse outcomes of a chemical spill compared to other finalized indicators.

This paper provides implications for both scholars and policy makers to extend their research in man-made disasters with focus on chemical hazards. Previous studies have investigated Social Vulnerability Indicators (SVI) only in natural hazards. However, we added the indicators of physical vulnerability and integrated them with SVI to measure and mapping the human vulnerability in the areas that are prone to chemical accidents. Now, the authorities of region have accessibility to the map of more vulnerable areas in the area under that are more informative for practical purposes such as allocating the needed resources to critical points.

More studies are required to investigate the applicability of the indicators of human vulnerability developed in this paper in different disasters and emergencies. Researchers also need to validate the criteria for generalizability of the results to other studies.


Only English articles were included in the literature review of this article.

Corresponding Author

Ali Ardalan. Department of Disaster Public Health, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. Email:

Authors Contributions

Farin Fatemi, Dr. Ali Ardalan and Prof. Benigno Aguirre have contributed in study design, acquisition of data, data analysis, drafting the article, and development of the final manuscript. DR. Nabiollah Mansouri and Dr. Iraj Mohammadfam have critically evaluated the draft article. All authors reviewed and approved the final version of the manuscript.

Data Availability

All relevant data are within the manuscript and the public repository Figshare. Please view data at the following URL: 10.6084/m9.figshare.4732921. For more information, please contact to the author Farin Fatemi (

Competing Interest

The authors have declared that no competing interests exist.

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The Life Process of Children Who Survived the Manjil Earthquake: A Decaying or Renewing Process Tue, 04 Apr 2017 15:00:25 +0000 Introduction: Among earthquake survivors, children are more vulnerable than other age groups due to their exposure to harrowing scenes of devastation as well as their drastically new living situations that result from an earthquake disaster. The life process of children survivors undergoes many different changes that are affected by a wide range of factors. Understanding the life process of these children may lead to effective outcomes and interventions. In addition, observing children survivors establishes knowledge and understanding of the challenges that correspond with earthquake disasters. Further, observing this group may be further effective in decision-making and establishing types of assistance in similar circumstances.

Objectives: This study was done to explain the life process of children who survived the earthquake of Manjil in northern side of Iran.

Methods: This qualitative study is based on the grounded theory approach. The sampling involved purposive interviews with 12 children who survived the Manjil earthquake and were under 12 years of age at the time of the earthquake. The initial interviews were followed by continuous comparative analysis, and thus the sampling process adopted a theoretical trend. In the end, by the formation of categories and the central variable of the study, interviews were conducted with 16 subjects and sufficient data was provided. Data was collected through face-to-face, in-depth interviews using an interview guide. In order to enrich the categories formed in data analysis, we had also 6 telephone interviews with the same participants in order to complete missed needed information. Data collection began in 2015 and continued up until 2016. Data was analysed using the Strauss-Corbin approach.

Results: The life process of children earthquake survivors consists of ‘unexpected encounter’, ‘transient relief activities’ and ‘long-lasting consequences’. The central variable of this study is ‘the dark shadow of pain and the light shadow of life expectancy’. The life experience of this group of children is immersed in painful memories and varies under different conditions.

Discussion and Conclusion: According to the results of this study, one of the factors affecting the lives of children earthquake survivors which could threaten their health is providing non-specific and transient services. Training relief staff to consider the specific needs of these children at the time of the rescue operation could contribute to improving their health level in various aspects. Considering the effective and comprehensive rehabilitation program in Disaster Management by policymakers can prevent permanent complications caused by earthquakes. Planning and taking action to identify misbehaviours in this group of children as well as raising public awareness, particularly for parents, on how to manage the outcomes of natural disasters are some of the most significant public health priorities. Providing public mental health services for parents and children who survive an earthquake helps to address potential psychological problems in this group of survivors.



The Manjil earthquake1 occurred on June 21, 1990 at 21 GMT near the town of Rudbar, in villages of Gilan Province and the northwest region of Zanjan Province, Tarom Olya located in the north-west of Iran. The Manjil earthquake caused great human and financial losses within a 100-kilometer radius of the epicentre. The earthquake occurred in Rudbar and Manjil was one of the largest and most destructive earthquakes in Iran in recent decades. The earthquake caused nearly 35,000 deaths and 60,000 injuries, and left more than 500,000 people homeless. In addition, 200,000 residential units were demolished, 60,000 of which were completely destroyed. Due to the landslides that occurred during the Manjil earthquake, villages were deeply buried. The initial damage caused by the Manjil earthquake was estimated to amount to more than 800 billion rials, and the disaster caused economic losses equal to 2.5 percent of the gross national product2.


Published statistics of disasters around the world show that in the past two decades, more than 4.3 million people have died, millions of people have been injured and tens of billions of dollars have been spent on financial and life compensations due to natural disasters3. Due to the climatic and geographical situation of Iran, it is one the high-risk countries in terms of natural disasters4. Advances in emergency and injury care systems have caused survivors of natural disasters need wide physical, psychological and social recoveries5.

Among the survivors of the earthquakes, children are more vulnerable than other age groups due to the fact that they are exposed to distressing scenes of devastation. In addition, children survivors are especially vulnerable as their living situations immensely shift following an earthquake disaster. If the special needs of these victims do not receive urgent attention, the evolutionary process of their growth will undoubtedly be interrupted, and they will face serious physical and psychological effects in the near or distant future. Most planning programs emphasise the most immediate needs of disaster victims, including rescue and relief activities and primary care6.

However, it should be noted that in addition to the significant effects and damages associated with natural disasters, the impact of such disasters on victims’ quality of life is much deeper and severe. Therefore, it is crucial to improve the health of victims for prolonged periods after the disaster. Nevertheless, many of the studies conducted in this field have not taken a comprehensive look at this process, and have usually focused on only one aspect such as psychological interventions after disasters, post-disaster stress disorders7,8, physical injuries9, and the role of community participation in physical reconstruction10. Since few studies have specifically explained the lives of children who have survived natural disasters, this study seeks to investigate this particular group. Further, studying children survivors in this context is necessary due to the particular context and culture of Iranian society as it differs from other countries which is based on Islamic beliefs and traditional-local customs. Understanding the life process of these children may lead to effective outcomes and interventions, and explaining the life process of these children according to their experiences could lead to a better understanding of their needs, challenges, issues and problems following their experiences of natural disasters. Furthermore, such a study may reveal the challenges resulting from earthquakes, and may also provide results that are applicable to similar circumstances. Therefore, to address this gap in research, this study aims to explain the life process of children who have survived earthquakes.


This study was conducted using the grounded theory approach, a qualitative research method based on symbolic interactionism. This study examines the social processes in the context of human interactions11.

The sampling involved purposive interviews with 12 children who survived the Manjil earthquake and were under 12 years old at the time of the earthquake. The initial interviews were followed by continuous comparative analysis, and the sampling process therefore took a theoretical trend. Based on the formation of categories and the central variable of the study, interviews were conducted with 16 subjects, and sufficient data for ensuring about the data saturation was provided as a result. Data was collected through face-to-face, in-depth interviews using an interview guide In order to enrich the categories formed in data analysis, we had also 6 telephone interviews with the same participants in order to complete missed needed information. The interviews began with general questions and progressively involved more detailed questions regarding participants’ responsiveness. Questions included, ‘Can you tell me about your experiences after the earthquake?’ and ‘How was your life?’ Interviews were performed in a quiet atmosphere according to participants’ preferences, in locations such as their homes or in a park. According to the tolerance, willingness and environmental factors of participants, 22 interviews were conducted for this study. The duration of face-to-face interviews was 25 to 45 minutes, and telephone interviews lasted 15 to 20 minutes. Data collection started in 2015 and continued up to 2016.

Data Analysis

Data was analysed using the Strauss-Corbin approach11. According to this method, the current study respectively employed concept analysis (immediately after the first interview), context analysis, process analysis, and then combined and integrated the categories and proposed the basic theory (writing analytical stories and reviewing the reminders). The audio-recorded interviews were transcribed, and the typed texts were reviewed several times. Then, the texts were studied line-by-line and word-by-word, and a code was assigned to each key word or sentence. Similar codes were then put together in a category, and the primary classification of 598 codes was obtained. Constant comparison was used to determine the relationship between categories and search the underlying process of data. Then, the researcher integrated the categories using various diagrams to identify the central variable.


The authenticity of the data was examined using the four criteria of Guba and Lincoln12. The data collection took nine months using a combination of face-to-face interviews and telephone interviews. Results were confirmed through peer check and member check. Researchers contributed to the transferability of the data through in-depth descriptions and analysis. The sampling technique with maximum variation (the age at the time of the disaster, gender, losing parents in the disaster, occupation, education level and marital status) was also used, and this improved the suitability or transferability of findings. The researcher precisely recorded and reported on the research process to allow others to investigate the article.

Ethical Consideration

Permission for the study was obtained from the ethics committee of the University Of Medical Sciences Of Babol. Related departments were informed of the study objectives, and their written consent to participate in the study was obtained. The time and place of the interview was determined with the agreement of participants, who were assured of the confidentiality of all personal information and interviews as well as the anonymity of all documents related to the research. The results of the study were made available to the participants upon request. All moral standards relating to the use and publication of texts was observed. Permission to record participants’ voices was obtained. Only one of the researchers listened to the recordings. The recorded interviews did not include any personal identification information. Participants were informed that they could withdraw their information or remove themselves from the study altogether at any time.


In this study, 16 individuals (adults at the time of the study) who were child survivors of the Manjil earthquake were interviewed (Table 1).

M E Table 1

Table 1. Participants’ personal information

Analysis of the data resulted in the obtainment of 598 primary codes. During the process of data analysis, six main categories were extracted.

The life process of children survived earthquakes consists of ‘unexpected encounter’, ‘transient relief activities’ and ‘long-lasting consequences’. The central variable of this study is ‘the dark shadow of pain and the light shadow of life expectancy’. This process is influenced by ‘internal factors’ and ‘modifying factors’ (Table 2).

ME T 2

Table 2. Categories extracted from the data

Unexpected Encounter

Most of these children were sleeping at the time of the earthquake. Therefore, the fact that they did not anticipate the earthquake or its consequences is associated with reactions of panic and feelings of deprivation.

Panic Caused by the Disaster

The first hours after the earthquake were associated with a great deal of fear, apprehension and horror for the majority of these children. These feelings multiplied when they were exposed to the resulting devastation, such as the destruction of shelters and scenes of family members being buried under the rubble, as well as being exposed to wounded and dead victims.

“The ongoing conditions were like the Resurrection. Destroyed and burnt houses, cracked roads, blood, broken bones, dead bodies along the road etc. Everything was a proof of the Resurrection. I was terrified when my uncle was burying his sister, nieces, nephews and other relatives.” (Code 16)


The deep influences of the disaster appeared a few days after the shock and horror of the earthquake. Most children either lost their parents, or their parents were mourning for the loss of their children or other family members. What were previously conceived of as the neighbourhood, kindergarten, school, family and relatives were no longer present. There was no sign of love or loving atmosphere in the family. Most family members were looking for a piece of bread to eat and shelter to live in, and were struggling with many mental pressures. Sometimes the needs of these children were forgotten due to the disastrous situation. Most of these children had no place to sleep and were looking for a clue of memories of good old days in the ruins. Those who had lost their parents and family members wandered around the ruins and cried, and were in search of a safe haven in a world of fear and helplessness. These children were tired, hungry and looking for a way out.

“The earthquake is nothing but the death of love. All my relatives were buried in front of my eyes, the sky of hope was dark and the pain of this separation grew bigger, and as I grew up, it grew up, too.” (Code 14)

Loneliness and the lack of social security in the initial chaos after the earthquake exposed children survivors to mistreatment. This group of survivors trusted people who were available in the tense and cluttered atmosphere, and exposed themselves to mistreatment. On the other hand, these children were neglected or mistreated due to the preoccupation of police, aid workers and family members who were involved in removing corpses and victims from under the rubble. In addition, some children faced threats such as robbery or getting lost in the process of being delivered to the authorities.

“I was crying in a street among the ruins in that confusion, and I saw a man coming towards me. He told me that he came to take me to my mother. As soon as he saw nobody was noticing, he took my bangle by force in such a way that my hand was wounded, he put his hand on my mouth so that I wouldn’t be able to shout and he threatened me.” (Code 13)

Transient Relief Activities

After some time and immediate support efforts, relief activities were provided to enable reconstruction and rehabilitation. However, these steps involved rebuilding houses and buildings, while the important principle of reviving the lives of these children faded out. This category contains the two subcategories of ‘temporary social support’ and ‘ insufficiency of continuity of the care chain’.

Temporary Social Support

What appears in the early hours following a disaster is the influx of government and relief aids to disaster-stricken areas. However, after a short period of time, emotions subside and the amount of aid decreases. This especially diminishes significantly as time goes on. In fact, disaster activities are only vaguely recalled.

“There were lots of people and aids during the first days. But very soon, after one month everything was over. It was [as though] as if the earthquake had involved people only for those days.” (Code 15)

The concept of ‘forgotten’ refers to temporary social support. Although these children require compassionate care, most of them receive humanitarian support for just a few months following a disaster and are gradually deprived of loving attention.

“Children who have survived earthquakes are highly vulnerable and can be emotionally injured by the smallest issues. They need love and a safe shelter more than anything else.” (Code 12)

Insufficiency of Continuity of the Care Chain

A few months after a disaster occurs, continuous care is halted and survivors face serious physical and mental consequences related to the event. The majority of physical and mental health care is limited to emergency and acute care, and rehabilitation services are omitted. The majority of children deal with several complications due to a lack of long-term care services management and planning. ‘Discontinuous follow-ups’ have caused most survivors to suffer from multiple chronic physical and mental problems.

“I was wounded when the earthquake occurred. My leg was stuck under the ruins of the house and was injured. They took me to the hospital and I was taken care of there, but after that they took me home. My parents couldn’t afford to spend money for me. Unfortunately, I limp. If somebody cared about us then and thought [about] what would happen next, I wouldn’t be like this.” (Code 18)

Long-lasting Consequences

Consequences of earthquakes are often delayed and persistent. This category consists of subcategories including ‘persistent anger’, ‘living in the nightmare of the earthquake’, ‘darkness of the sky of hope’ and ‘persistent homelessness’. The consequences of the earthquake proved to be of lower intensity for children who did not lose their parents in the earthquake and could benefit from their physical and mental protection.

Persistent anger

After the earthquake, the games and carelessness of childhood shift toward adult behaviours. ‘The repetitive scenario of the earthquake’ replaces game-playing and living a happy life. Teenagers also experience a shift in perception as they too experience undesirable physical, economic and social conditions. The majority of children survivors cannot enjoy their childhood years as their welfare, physical condition and psychological capacity are lacking in the wake of a disaster. Therefore, this group of survivors refers to their adolescence as ‘unloaded clusters’ The continuous use of wording such as ‘sorrowful dialogues’ or ‘tragedies’ describe the significance of sad memories of the past experienced in their minds and souls. Their spirit is obscured by these dialogues, and these survivors live with the daily repetition of parts of their painful past and memories of the earthquake. Further, these survivors attempt to pay homage to their family members, classmates and friends by keeping their memorabilia. In other words, they consider forgetting the event as a source of guilt and disloyalty.

“At the time I should have been supported by my family, I was taken to an orphanage. As I grew up, I had to leave my friends and move to another place. These changes made me suffer. I didn’t understand how my teenage years passed.” (Code 4)

Living in the Nightmare of the Earthquake

One of the long-lasting and negative consequences for this group is living in the nightmare of the earthquake. The fear of the earthquake’s recurrence along with continuous insecurity and anxiety are always present. Most of these survivors are deprived of a normal life. Participants expressed that they live in fear not just of the earthquake’s recurrence, but also of other disasters occurring. This fear leads them to experience anxiety. Living with prolonged and continuous anxiety leads to conditions such as depression, psychiatric disorders such as drug abuse, and behavioural problems such as delinquency. Living in the nightmare of the earthquake causes ‘excessive sensitivity’ to others, especially family members. Such behaviours of risk aversion cause these people to draw on their memories of the earthquake and, as a result, deter family members from what they perceive to be possible hazards. This problem is associated with fear, and limits the social lives of victims and their family members. In turn, this brings about dysfunction in the relationships between victims and their family members.

“I’ve grown up and aged, but you know, I start shaking even when it’s windy. I go and sit in a corner of the room, hug my baby and get terrified. That fear is still with me.” (Code 11)

The Feeling of Hopelessness

Some of these survivors believe that the feelings of safety and health have disappeared in their lives and have been substituted by fear, uncertainty and loneliness. They reported that after the earthquake, they feel they have lost their direction in life and have lost all hope. They experience a life without financial and emotional support. Their lives have undergone many major changes, and the grief of losing family members and experience of permanent fear have replaced their normal routine of life. Those who have medical problems and severe physical complications caused by the earthquake are exposed to constant medical procedures and treatment recommendations.

“I was young at that time. Our financial situation wasn’t so bad. But suddenly, we lost everything. My father died hopelessly after a few years. I had to work in a factory. It was very hard. I had to work instead of study.” (Code 13)

The ‘guilt’ the respondents feel as the sole survivor, as well as the guilt associated with burying their loved ones, is a significant factor contributing to their feelings of despair. Most of them saw their family members stuck under the rubble and reported that they feel guilty because they could not rescue them.

“I suffered for a long time. I wished it wasn’t me but my parents who were alive. I was little and injured then. I was confused and frightened, and I couldn’t do anything for my family. It hurts me a lot.” (Code 4)

For this group of survivors, disappointment leads to a lack of desire and effort in social activities. Thus, they always feel that they are a ‘social burden’. Lack of adequate physical and academic qualifications for acquiring a job affects this process. Most of these individuals are not married and live with their relatives because they have lost their families. This problem enables the formation of the feeling of being a social burden.

“I went my uncle’s house in another city. That poor man had some children and didn’t have a good financial situation. He was a farmer. I was a burden to their family. I sometimes realised that they couldn’t help doing favours for me, but I also understood that they couldn’t afford to provide for their own children.” (Code 16)

Disappointment causes this group of survivors to refer to their current life situation as ‘bubbles on the water’ (they always think that everything is temporary and is not going to last long like a bubble), and keeps them from envisioning a future for themselves. They feel abandoned because their identity has been buried under the rubble of grief and misery. The missing future is represented in impairment, inability to support family expenses, lack of financial resources for marriage, losing parents and their emotional and financial support. In fact, these individuals believe that they feel they are not in control of their destiny or have failed to fulfill their destinies. The fear of a life without financial resources and family support is always with them.

“A long time ago, I realised that I lost everything in the earthquake. I have neither a good job nor money. I try more and more, but I am always on the first step.” (Code 2)

Persistent Homelessness

A few days after the earthquake, some children who lost their parents and did not have anybody to claim them were taken to children care centres. In their opinion, wandering in these centres and waiting to find a safe haven was the worst experience of their lives. They described the separation from family members, relatives, friends and their hometown in a very bitter manner. Some survivors were given to new families and thus faced many new problems. Orphans who were sent to welfare centres or new families grew up in educational systems that differed from their native culture. Sometimes, this way of life proved contrary to these survivors’ previous beliefs and life experiences, and thus led to behavioural and mood disorders. According to survivors, sympathy was the major factor in their acceptance to these new families or centres. However, over time, many children survivors once again experienced homelessness due to behavioural disorders and adversities.

On the other hand, the lack of necessary physical and mental conditions for adoption led some of these children to stay in care centres for a long time. Further, such conditions at times caused them to wander between different centres as they grew older or their physical or mental complications increased. Children without guardians were taken to welfare centres. There was also a significant difference between genders in child adoption such that most boys were adopted in a short time while girls spent a long time on the waiting list.

“I stayed in the nursery for a long time. Those who were with me were adopted by their relatives or new families. I was sick, I think that’s the reason.” (Code 15)

An important point revealed through data analysis was that some of the parents of children survivors were noted as ‘risky parents’. These parents pose risk factors in the physical, mental, moral and social development of their children due to the loss of their own parents or other children, or due to multiple physical injuries caused by the earthquake. These people cannot provide a safe haven for their children to live. Escape, isolation, and anxiety are just some of the outcomes and emotional experiences of children living with risky parents.

“At first, my father was too nervous because he had lost all his money and two of his brothers in the earthquake. He was usually bad-tempered to me. I remember that he hit me and my mother for small excuses. I grew up in that difficult situation and its result was that I couldn’t study at school. I always started fights at school. Now I am unemployed.” (Code 5)

Internal Factors

The internal factors affecting the life process of children who survived the earthquake are ‘understanding threats’, ‘fatalism’ and ‘dangerous nostalgias’.

Understanding Threats

For children earthquake survivors, facing stressful events, experiencing failures in family and social life, and emotional and educational breakdowns over the course of their lives cause them to feel threatened. The intensity of the feeling of threat shifts according to the context of each individual’s condition. Thus, the intensity and type of stressors influence the intensity of the feeling of being threatened. Feeling threatened affects these survivors’ performance in rebuilding their lives after the earthquake.

“I feel so impatient. Once I was supposed to marry a girl but she left me, I experienced a feeling exactly like which I experienced at the time of earthquake. I reviewed all of my miseries. I felt lonely and threatened very much. I was depressed and devastated for some days.” (Code 15)


Believing in fate and luck are personal factors affecting the life process of these children. According to participants, feeling unlucky suppresses the opportunity to build personal, family and social dimensions of life. It can also cause depression, isolation and social isolation.

“If I was lucky, why should I have been so miserable from childhood? Whatever I do, my bad luck and a part which has been already written in my destiny is with me.” (Code 5)

Dangerous Nostalgias

Internal factors which affect the life process of these survivors include breaks in time and retrieving memories of the earthquake when facing similar scenes or events.

“One day, a motorbike had an accident with a car in the street. The motorbike rider’s leg was stuck under the car’s tire. As I saw this scene, I remembered my mum, her leg was stuck under the rubble of our house. The motorbike rider’s shouts reminded me of stressful scenes and my mum’s shouts. I felt so bad. I cried for many days.” (Code 13)

External Factors

‘Delayed relief activities’ and ‘non-specific care’ are external factors which affect the life process of children who survived the Manjil earthquake.

Delayed Relief Activities

A remarkable finding in the data is that often, treatment measures are delayed due to children’s inability in expressing their immediate needs. This problem is worse in children with injured parents or for those who have lost their parents. Parents help aid groups in considering their children’s needs with the knowledge they have about their psychological characteristics or physical problems. Delayed diagnosis or treatment of different problems of these survivors could have serious and persistent consequences for them.

“I was there when they took a 7-year-old child to the hospital. The child cried and couldn’t answer them when they asked questions. Nurses didn’t even know what medicine the child was allergic to. I remember the doctor gave the child a medicine. The poor child was shocked immediately and died, and it was too painful for me. If they hadn’t given the drug, the child wouldn’t have been dead.” (Code 10)

Non-Specific Care

Health care is not often provided to alleviate the physical and mental needs of children who have survived an earthquake. This reduces the quantity and quality of services. Most attention is focused on mere physical needs, and the mental and emotional needs of these children are neglected. In the area of physical health care, aid workers forget some children, or at times offer them defective or delayed care due to their lack of knowledge of specific care for children.

“They took me to the hospital. I heard two doctors saying that if the aid workers had paid more attention or been trained, they wouldn’t have cut a woman’s leg who was on a bed next to me.” (Code 5)

Modifying Factors

‘Palliative self-care’ and ‘Internal evolution’ are modifying factors in the life process of children who survived the earthquake.

Palliative Self-Care

The lack of long-term social and family services leads to self-action to have a safe and normal social and family life. Children seek different strategies to rebuild various aspects of their lives during different life stages. This category consists of three subcategories including ‘rescue efforts’, ‘religious strategies’ and ‘resilience’.

Rescue Effort

The development of social communications, starting a family, having children and maintaining emotional ties are some of the strategies used by children in rebuilding their lives after earthquake. On the other hand, being optimistic in life, strengthening the ability of forgiveness, being involved in charity works, and public participation have calmed these people. According to participants, empathy is formed in peer groups because of their common pain. By developing social relationships, these people look for those who can be understood easily by them due to the common experience they share. Sharing memories of childhood and using coping strategies proposed in these groups improves their mental relaxation.

“At the moment, I am a stepmother of three orphans. I don’t have money, but this makes me feel good. My sister was six when she died, and I was 7 [at the time of earthquake]. I do it to make her happy.” (Code 6)

Some of the earthquake survivors who are capable of continuing their education attempt to help others by studying. Some even try to make their bereaved or dead parents happy.

“I tried to be a doctor. Any patient who is visited by me to me and doesn’t have money, I don’t charge him. I cooperate with the Red Cross voluntarily. If my family had gotten treatments in time, they would have been alive right now. I became a doctor to help my people if necessary.” (Code 7)

Religious Strategies

One of the strategies for dealing with the persistent crisis of an earthquake is resorting to religious beliefs. Strengthening religious beliefs by reading prayer books and such religious texts as the Quran, participation in religious ceremonies and saying prayers are some of the religious strategies reportedly used by those who survived the earthquake in order to cope with multiple physical, mental and social problems. On the other hand, fatalism and ‘submission to the will of God’ help these children deal with problems after the earthquake.

“As I grew up, I realised that God is the only refuge. Whenever I have problem I say prayers instead of crying and sadness. These beliefs help me out of all pains.” (Code 1)


Resilience is one of the other strategies that children who survived the earthquake use in the process of rebuilding their lives. Resiliency is the result of a shift from being risk-oriented to coping with and modifying stress factors, which leads to the preservation and promotion of health in many aspects. Patience and perseverance, improving self-confidence, seeking familial and social support, and optional forgetfulness are some aspects of resiliency. These earthquake survivors often try to forget what happened in the past through emotional suppression.

“Whenever I give up, I go to my friends and family. My mother understands me very well. She knows how much I was hurt then because I was a kid. I unburden myself [in] this way, and I have withstood many times [through] the help of her.” (Code 8)

Internal Evolution

Internal evolution refers to self-monitoring and positive psychological changes related to the earthquake. Self-monitoring and knowing oneself, others and God are some of the reported positive consequences of the earthquake. These respondents believe that knowing themselves and God gives them the power to deal with the chaos and emotional gaps caused by the earthquake.

“The earthquake was a very bitter memory. But it built me. It made me resistant. It made me appreciate people. It made me more patient. It made me experience things which were productive. When I wonder, I think that it taught me that such moments won’t happen again. I knew my abilities and myself. These made me successful.” (Code 7)


According to the findings of this study, the first step in the lives of children who have survived the Manjil earthquake involves the unexpected encounter with the disaster. King (2006) believed immediately after the incident, the children experienced different reactions of shock and horror. These emotional reactions include a range of physiological, psychological, social and behavioural reactions13. More than other age groups, children are more prone to distress when faced with an earthquake disaster14. The results this study showed that in the early ravages caused by the earthquake, the loss of parents and shelter may have put the children at risk of harm and mistreatment. Therefore proper planning in crisis management, paying attention to the characteristics and needs of vulnerable groups including children, and comprehensive support can reduce the risk of mistreatment15. Based on the results of this study, there is a need for plans to provide long-term services.

It is important to note that threatening factors are persistent due to the long-term and sometimes permanent effects of earthquake disasters, and children are in great need of care at all stages of their lives. Unfortunately, rehabilitation and long-term services are marginal in disaster management planning16. Under these circumstances, there is a significant increase in mortality and a notable decrease in the physical, psychological and social function of these children17. Even if these services exist in society, they do not cover all survivors due to their unavailability and young age. Therefore, providing and sustaining long-term rehabilitation services must be considered as priorities when it comes to children survivors of natural disasters18.

The results this study also indicated that temporary social support and the subsided emotions of people and charities over time cause survivors to be deprived of support services, especially long-term emotional support. According to this group of survivors, after almost 24 years, the disaster has been forgotten and has disappeared from people’s minds. Bolton et al ( 2000) believed this is associated with the lack of understanding by people, especially non-peers19. Concealing the feelings of others and social isolation are some of the strategies that this group of survivors may use to face such reactions20.

Further, this study’s results showed that children whose other relatives are given custody and children who are adopted have the most problems. Since relatives are given priority in adopting a child, in most cases the economic status, emotional situation and social health of these families are not considered before the adoption. The new family members cannot provide a safe haven for these children because they are in crisis and are suffering from many financial, physical and mental problems. These children may experience violence, misbehaviour and secondary displacement in new families21. In such circumstances, these children feel that they are a burden, and experience a lack of opportunity in education, marriage, or suitable occupations22.

Regarding the fact that many of the participants of the present study have lost one or both of their parents in the earthquake, and given that some live with family members in an environment which is not physically, mentally and emotionally stable, most of these survivors face severe emotional issues as their future relationships are threatened. The results of McDermott’s (2005) study showed that distrust of friendly and effective communication with others on one hand and emotional gaps on the other can all cause behavioural and emotional conflicts, and can bring about short-term emotional and social communication issues23.

Failures in communication and constructive attachments cause these child survivors to experience failure in marriage and family life24. Therefore, comprehensive services such as counselling, health care and welfare services are necessary25. This study’s findings also showed that sometimes, parents do not succeed in their parental roles in supporting their children due to the distress they experience as a result of the earthquake. In such cases, these parents in turn can pose a risk to their own children. The results of Gertrud’s (2004) study showed that parents who were themselves severely impacted by disaster reported a reduced ability to assess their children’s reactions, and thereby were unable to provide optimal care2. Interestingly, these parents’ support strategies mirrored the early intervention recommendations put forward in the psychological first-aid guidelines which is a well-accepted and promising practice for helping children after disasters2. In the present study, mental nostalgia is one of the internal factors affecting the lives of those who survived the earthquake as children. These people retrieve memories when they face scenes that they consider as similar to events at the time of the earthquake. Hafstad et al (2004) believed nostalgia of past memories threatens their mental and emotional health during different stages of their lives2.

Believing in bad luck is another internal factor affecting the lives of those who were children earthquake survivors. Similar studies have shown that these beliefs can suppress a person’s effort in coping with stressful atmospheres, and can keep individuals from trying to improve their family and social lives22. Believing in bad luck can also deter this group of people from pursuing their previous dreams and wishes, as well as from social communication26. As the data in this study showed, one of the factors causing threats to the health of these children survivors is non-specific care. It should be noted that ignoring the needs of these survivors, considering the services superficially and providing those services temporarily may threaten their health in various aspects27.

In order to prevent more permanent damages to child survivors, we have to train individuals, aid workers and volunteers to bring up people from under the rubble correctly, identify specific needs of children survivors, and further care provisions28. Participants in this study have tried to resort to strategies such as the development of social communication, spirituality, and psychological strengthening to maintain stability and balance in their individual, family and social lives. In fact, other studies have emphasised religious beliefs as a facilitator of these survivors’ life processes29. Developing social relationships and friendships help improve the quality of survivors’ lives30.


According to the results of the present study, providing non-specific and temporary services is one of the factors affecting the life processes of children who have survived the Manjil earthquake. Training aid workers to consider the specific needs of children at the time of rescue operations could contribute to improving the health of this group in different aspects. Considering effective and comprehensive rehabilitation programs in Disaster Management policymaking can prevent persistent complications caused by earthquakes and other natural disasters. The results of this study also showed that some of the factors threatening the health of children earthquake survivors include homelessness, living in care centres, and living with risky parents. Planning and taking action to identify misbehaviour in this group of children, as well as raising public awareness (particularly for parents) on how to manage a disaster, are public health priorities. Providing public counselling services to children survivors as well as their parents will help to solve the potential psychological problems that threaten the well-being of children survivors.

Further, this study showed that children have tried to use different strategies in the process of their lives to maintain and promote their personal and social life. Strengthening religious beliefs and encouraging children survivors to participate in social groups (especially peer groups) will help them to feel understood, safe and alleviated of many negative feelings resulting from their experience of a natural disaster.

Appendix A: Interview Guide Questions

1- Can you tell me about your experiences after the earthquake?

2- What happened to you at the moment the earthquake happened?

3- Please talk about the harms happened to you.

4- How do you describe the life after the earthquake?

5- What has helped you to deal with the earthquake?

6- What does earthquake mean to you?

7- How was your life?

8- Would you please review a day of your life?

9- Which factors have helped you at the moment of the earthquake or after that?


Among the limitations of this study, restrictions in generalization of the results can be mentioned. As interview method was used for data collection, the veracity of the interviewees might have affected the results. Therefore, conducting more studies focusing on triangulation methods is suggested.

Corresponding Author

Dr Fatemeh Ghaffari. Email:

Data Availability

All relevant data are within the paper.

Competing Interests

The authors have declared that no competing interests exist.

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Towards Providing Solutions to the Air Quality Crisis in the Mexico City Metropolitan Area: Carbon Sequestration by Succulent Species in Green Roofs Fri, 31 Mar 2017 15:00:32 +0000 INTRODUCTION: In the first months of 2016, the Mexico City Metropolitan Area experienced the worst air pollution crisis in the last decade, prompting drastic short-term solutions by the Mexico City Government and neighboring States. In order to help further the search for long-term sustainable solutions, we felt obliged to immediately release the results of our research regarding the monitoring of carbon sequestration by green roofs. Large-scale naturation, such as the implementation of green roofs, provides a way to partially mitigate the increased carbon dioxide output in urban areas.

METHODS: Here, we quantified the carbon sequestration capabilities of two ornamental succulent plant species, Sedum dendroideum and Sedum rubrotinctum, which require low maintenance, and little or no irrigation. To obtain a detailed picture of these plants’ carbon sequestration capabilities, we measured carbon uptake on the Sedum plants by quantifying carbon dioxide exchange and fixation as organic acids, during the day and across the year, on a green roof located in Southern Mexico City.

RESULTS: The species displayed their typical CAM photosynthetic metabolism. Moreover, our quantification allowed us to conservatively estimate that a newly planted green roof of Sedum sequesters approximately 180,000,000 ppm of carbon dioxide per year in a green roof of 100 square meters in the short term.

DISCUSSION: The patterns of CAM and carbon dioxide sequestration were highly robust to the fluctuations of temperature and precipitation between seasons, and therefore we speculate that carbon sequestration would be comparable in any given year of a newly planted green roof. Older green roof would require regular trimming to mantain their carbon sink properties, but their carbon sequestration capabilities remain to be quantified. Nevertheless, we propose that Sedum green roofs can be part of the long-term solutions to mitigate the air pollution crisis in the Mexico City Metropolitan area, and other “megacities” with marked seasonal drought.



INTRODUCCIÓN: En los primeros meses del 2016, la Ciudad de México y su zona metropolitana conurbada ha experimentado una de las peores crisis de contaminación del aire de la última década, urgiendo a las autoridades a tomar medidas drásticas a corto plazo. A fin de proporcionar elementos para investigaciones de sostenibilidad a largo plazo quisimos dar a conocer nuestros resultados de monitoreo de captura de carbono por plantas de azoteas verdes. Estas azoteas son una forma de naturación a gran escala, que constituyen una alternativa para mitigar parcialmente el incremento de dióxido de carbono en las áreas urbanas.

MÉTODOS: Nosotros cuantificamos la capacidad de captura de carbono por dos especies de suculentas ornamentales, Sedum dendroideum y Sedum rubrotinctum, que requieren bajo mantenimiento y nula o poca irrigación. Para tener una idea detallada de la capacidad de captura, medimos el carbono tomado por las plantas durante el día por un año en plantas de Sedum localizadas en una azotea verde en el sur de la Ciudad de México.

RESULTADOS: Estas especies presentan el metabolismo fotosintético CAM. La cuantificación obtenida nos permite estimar que una azotea verde de Sedum de 100 m2 captura aproximadamente 1.8 x 108 ppm de CO2 por año.

DISCUSIÓN: Los patrones de CAM y de captura de CO2 fueron bastante robustos a las fluctuaciones de temperature y precipitación estacionales, por lo cual especulamos que la captura de carbono sería similar en cualquier otro año de una azotea verde de reciente plantación. Azoteas de mayor edad requerirían podas regulares para mantener sus propiedades de captura de carbono, sin embargo, no se sabe qué capacidad pueden tener para capturar carbono. No obstante, proponemos que las azoteas verdes plantadas con Sedum son una parte de la solución a largo plazo para mitigar las crisis de contaminación del aire en la zona metropolitana de la Ciudad de México, y de las megaurbes con una marcada estación de sequía.

Author Contributions

MCO & JRS designed the project; MCO performed experiments; MCO and UR analyzed results; MCO & JRS provided materials and reagents to perform experiments; MCO & UR wrote the manuscript. MCO:; UR:

Corresponding Authors

MCO ( and UR (


Plant physiology, Crassulacean Acid Metabolism, urban biology, megapolis, environmental crisis, plant urban physiology, Sedum dendroideum, Sedum rubrotinctum, air pollution, bioremediation

Competing Interests statement

The authors have declared that no competing interests exist.

Data Availability statement

Raw data available on doi:10.6084/m9.figshare.3395887


Deforestation, urbanization and the intensive use of fossil fuels are some of the main causes of the increase of carbon dioxide (CO2) since the Industrial Revolution in the nineteenth century, contributing to the current changes in climate 1. These CO2 levels have gone from 280 ppm to 380 ppm, and it is estimated that levels could reach 770 ppm by the end of the twenty-first century 2. This dramatic increase in CO2 levels, particularly in urban regions, has caused a change in the global carbon cycles 2,3. Thus, vegetation plays a crucial role in urban ecosystems, by sequestering carbon excess, storing carbon as biomass, and releasing oxygen and water vapor through evapotranspiration. In recent decades urban ecosystems have drastically expanded and increased in complexity due to mass changes in economic activities, the migration of people from rural environments to cities 4, and widespread use of motorized vehicles. Unplanned growth of urban areas sometimes produces “megacities” where space becomes a luxury, and vegetation is often sacrificed to give way to urban infrastructure.

This is the case of Mexico City and its Metropolitan Area, otherwise known as Zona Metropolitana del Valle de México (ZMVM). This is the fourth most populated metropolis of the world and the largest in Latin America 5,6, with more than 20 million inhabitants according to a 2010 census (INEGI, According to the Mexican Fifth National Communication to the United Nations on Climate Change, CO2 emissions increased 23.6 % from 1990 to 2010, coming mainly from fossil fuels, land use changes, and lack of silviculture. In the first third of 2016, the ZMVM is experiencing the worst environmental crisis of air quality of the last decade, demonstrating that short-term solutions implemented since the 1980s when the air quality became extremely critical, have been insufficient. In 2009, the Dirección de Reforestación Urbana, Parques y Ciclovías de la Secretaría de Medio Ambiente del Distrito Federal (today Mexico City), pointed out that poor metropolitan growth planning, deficient management of green areas, lack of legislation on urban vegetation, and poor conservation efforts, have all contributed to the deterioration of the green urban landscape, and their associated environmental and social benefits. In addition to better management of public green spaces, it is necessary to urgently reassess the strategies towards sequestering carbon and other air pollutants. To archive this, the mega-polis inhabitants must play an active role in tackling the challenge.

Besides reducing gas emissions from fossil-fuel combustion, in other cities the promotion of urban vegetation has been adopted as a method to eliminate pollutants and purify the air 7,8. Because of the scarcity of space in large cities, a strategy to increase the vegetation cover is through the implementation of what are known as green roofs, eco-roofs, living roofs, or roof gardens . Green roofs are defined as any rooftop covered by layers of roof coating, plant substrate, and vegetation 9. Green roofs have been associated with multiple environmental, ecological, health, and aesthetic benefits 3,9,10,11,12,13,14,15. Despite the relevance of green roofs as a potential solution to improve air quality in “megacities,” there is scarce experimental data in planta on the capabilities of green roofs to uptake CO2. Therefore, quantifying the green roofs’ capacity to sequester and retain CO2, pollutants, and other greenhouse gases is imperative under the current environmental crisis scenario, particularly in the ZMVM.

Currently there is robust evidence supporting the use of plants to capture air pollutants. However, we still need in planta qualifications on the role of green roofs to capture pollutants 16. NOx, SO2, PM10 and O3 are among the pollutants that have been quantified as sequestered by green roof vegetation 7,17,18,19. Experimentally, CO2 green roof-uptake quantification seems to be rather challenging, and mostly estimated using proxies, such as biomass accumulation 13,20, models of carbon-oxygen balance 21,22, macro-estimations of vegetation cover in large cities 7,13,23 or methods more appropriate for urban forests, rather than herbaceous plants 17.

In their studies measuring carbon uptake on green roofs, Li et al (2010) measured the CO2 uptake in a green roof, placing the IRGA within grass-shrubs and comparing it to a location outside the shrub, obtaining an average of 12.9 mg C m-3 per day 8. Ondoño et al (2016) estimated carbon and nitrogen uptake by quantifying the element composition on a green roof of weedy and grassy plants, obtaining 36.52 g C m-2 at the end of 9 months 24. Regarding Sedum green roofs, Getter et al (2009) quantified carbon storage in green roofs of several Sedum species, by measuring accumulated dry matter in the shoot, root, and soil, obtaining 160 g C m-2 during a two year period 13. More recently, Whittinghill et al (2014) measured carbon content and dry weight, and found that Sedum green roofs captured 1940 g C m-2 in a 14-month period and 3910 g C m-2 in a 12-month period 20. Overall, previous studies support the use of green roofs, and particularly, of highly resilient Sedum species to improve air quality conditions, in particular in overcrowded urban areas. However, we still lack data on the carbon uptake by Sedum plants, measuring CO2 exchange.

During the first months of 2016, the ZMVM has experienced one of the worst air quality crises since the 1980s. This has forced the local governments of Mexico City and surrounding States to implement extreme measures, such as emergency “No Driving Today Program”. However, these are often short-term and unsustainable solutions, because they promote for instance, the acquisition of a second car by the inhabitants of the ZMVM. In light of the current air pollution environmental crisis, we felt compelled to release our monitoring of carbon uptake in a green roof in Southern Mexico City, populated with low-maintenance, low irrigation-requirement, crassulacean species of Sedum. Our results show the potential of the Sedum green roofs as a self-sustainable solution. We hope these results help policy makers of the ZMVM and other urban areas with similar environmental conditions to implement informed long-term solutions towards tackling air quality crises.


Green roof location. The green roof was located on the Southwestern area of Mexico City. This green roof was installed in 2009, comprising a total area of 42 square meters, at the Jardín Botánico, Instituto de Biología, Universidad Nacional Autónoma de México, Delegación Coyoacán, within the Reserva Ecológica del Pedregal de San Ángel (REPSA; (19° 13′ 45” N and 99° 19′ 37” W), 2330 m.a.s.l. (Figure 1A-C), and subtropical highland climate. The highest temperatures are from March to May (16-19° C), and the lowest are from December to February (12-14° C), with a mean annual temperature of 15.6°C. Precipitation follows a seasonal pattern: the rainy season occurs from June to October, while the dry season is from November to May, with an annual mean precipitation of 833 mm 25.


Figure 1. Green roof location within the Jardín Botánico of the Universidad Nacional Autónoma de México; A. Map of Mexico; B. Zona Metropolitana del Valle de México (ZMVM), according to Instituto Nacional de Estadística y Geografía (INEGI, México), x denotes the location of the Jardín Botánico; C. Google maps view of the Jardín Botánico, arrow (<) denotes the location of the green roof; D. Sedum green roof at the start of the experiment (1-month old plant-cuts); E. Sedum green roof towards the end of the experiment (11-month old plants). *Sedum dendroideum, +Sedum rubrotinctum.

Green roof construction. A completely flat roof was leveled up with concrete and bordered with 10 cm-tall edges (cost $7.5 USD per m-2). The roof was then insulated with a waterproof layer ($0.40 USD per m-2), an insulated asphalt layer ($15 USD per m-2), and a root-proof mesh ($16 USD per m-2). On top of these insulating and protecting materials, a 10 cm deep layer of substrate was uniformly placed, composed of tepojal (to facilitate drainage) and compost (for organic nutrients) in a ratio 1:1 ($11 USD per m-2). It is also estimated that initial plant cuttings cost $12.5 per m-2. All costs are expressed in US dollars as of November 2016. Green roofs require trimming of the excess of plants two years after the initial planting, and every 6 months thereafter. Every trimming removes approximately 30% of the old foliage.

Regarding the soil, we measured the soil apparent and actual densities, pH, electrical conductivity, percentage of moisture and texture 26,27. The bulk density was 1.045g cm-3, organic type, 13.12% humidity, pH 6.05, category moderately acidic, conductance 0.127 S m-1, 27.1 % clay, 12.4% lime, and 72.4% sand, which corresponds to a loam soil.

Biological subjects: We used the crassulacean species Sedum dendroideum Moc. Sessé ex DC. and S. rubrotinctum R.T. Clausen. S. dendroideum is a bushy plant of 50-100 cm in height, and up to 100 cm in diameter. In Mexico, its populations are distributed along the Trans-Mexican Volcanic Belt, and surrounding areas on the states of Hidalgo, Puebla, Estado de México, Oaxaca, and Querétaro 28. S. rubrotinctum has a herbaceous lifestyle, of 15-20 cm in height, heavily branched at the base, originally from the East, South, and Center of Mexico, but thought to be a cultivated hybrid of S. stahlii and S. pachyphylum28. The cuts were obtained from 10 year-old parental plants at another green roof, at the Jardín Botánico de la Universidad Nacional Autónoma de México. S. rubrotinctum’s cuts were 10-15 cm tall, and S. dendroideum‘s were 20-30 cm tall. Cuts were disinfected with Terramycin 1 g L-1 for 24h, and TRICON fungicide. Before planting, all cuts were treated at the base with Radix 10000 ppm to promote root formation. 72 cuts of each Sedum species were planted, every 30 cm in S. dendroideum and 10 cm in S. rubrotinctum, giving a density of 3.4 and 10 plants per square meter, respectively. Planting was done in November 2009, and measurements were recorded from November 2009 to November 2010. At end of the experiment the vegetative growth of both Sedum species gave a 100% cover of the studied green roof area.

CO2 uptake. Quantification of CO2 uptake was performed using an Infrared Gas Analyzer (IRGA) (Qubyt Systems, Canada), which is a device designed to study gas exchange on flat leaves. Thus to quantify the CO2 uptake in succulent plant specimens, we evaluated gas exchange using glass jars. We initially used a glass jar of 418 mL connected with plastic tubes to the IRGA, so we could introduce the entire plant into the jar and seal any openings. As plant size increased, we used a larger glass jar of 1200 mL during the months of April to November 2010. After the month of June, we were only able to measure the part of the plant that fitted into the 1200 mL jar. Measurements were taken monthly on three plants per species randomly chosen at 0:00, 0:40, 1:20; 6:00; 6:40; 7:20; 12:00; 12:40; 13:20; 18:00; 18:40 y 19:20h. The IRGA was calibrated 10 mins prior every measurement, and the quantification of CO2 uptake took 15 mins in each case. The baseline of CO2 in the air was subtracted to the readings, and the differential was considered as the net CO2 uptake by any given plant. In addition we quantified the concentration of organic acids, on the same plants quantified for CO2 uptake, by dissecting the tissues and keeping them chilled until they arrived to the lab. The quantification of organic acids was done according to the titration protocol 29,30, which was done as follow: 1) 2g of tissue were dissected from leaves in each sample, tissues were grinded with 20mL of 50% methanol; 2) the ground tissue was filtered, and 10mL more of distilled water were added; 3) titration was done using a potentiometer, by adding sodium hydroxide 0.01N under constant agitation until a pH of 9 was reached. The added base was used to calculate the acidity per gram of fresh tissue. Raw data available on doi:10.6084/m9.figshare.3395887

Statistical analysis. We used a two-way Analysis of Covariance Variance (ANCOVA) to identify significant differences in CO2 uptake (ppm) due to month and species, and time of the day (time) as a covariate, according to the following model: yppm = Ɓmonth + Ɓspecies + Ɓtime + ɛ. The analysis was done in JMP v12 (JMP, SAS, USA).


Succulent plants, particularly Sedum species, have been extensively used in green roofs because of their resistance to prolonged droughts, high temperatures, and strong winds 10,13,31. Here, we studied the Sedum species Sedum dendroideum Mociño & Sessé ex De Candolle, and S. rubrotinctum R. T. Clausen (Family Crassulaceae). These species have xerophytic morphology and physiology that allows them to cope with extremely dry environments. To assess the carbon capture of Sedum species in a green roof located in Southern Mexico City, we evaluated a plantation of 42 square meters, measuring CO2 exchange using an IRGA system, during the day, over a period of 12 months in 2009-2010. The highest carbon capture in both species was recorded during the night, with a peak at 6:00 (Figure 2). Over the periods of time that were measured, the total CO2 uptake was 2472 ppm (±40.35) from 0:00 to 7:20h, and 152 ppm (± 6.82) from 18:40 to 19:20h in S. dendroideum. Over the same intervals, S. rubrotinctum CO2 uptake was 1823 ppm (±40.70) from 0:00 to 7:20h, and 71 (±4.58) from 18:40 to 19:20h. In both species from 12:00 to 18:00 no CO2 uptake was recorded in most months, but the period of highest CO2 uptake was at 6:00h, with 1602 ppm (±11.05) and 1315 ppm (±14.49) on S. dendroideum and S. rubrotinctum correspondingly. The patterns of CO2 uptake on these Sedum species resemble the Crassulacean Acid Metabolism (CAM) carbon fixation patterns.

Figure 2

Figure 2. CO2 uptake in (A) Sedum dendroideum and (B) Sedum rubrotinctum, during the year, and across the day. Error bars: standard error, n = 3. Raw data available on doi:10.6084/m9.figshare.3395887

In order to validate our observations of CO2 uptake, during the experiment we simultaneously collected tissue from the measured plants to quantify the organic acid concentration using the titration method in the lab. The quantification of organic acids (Figure 3) confirmed our CO2 uptake observation regarding the CAM pattern, also indicating that S. dendroideum and S. rubrotinctum are strict CAM because they uptake most of the CO2, and accumulate organic acid during the night, but not during the day 32.

Figure 3


To further investigate the sources of variation on CO2 uptake during our experiment, we performed a 2-way ANCOVA, of carbon uptake (ppm) as a response of months, and species, and time of the day (time) as a covariate, according to the model yppm = Ɓmonth + Ɓspecies + Ɓtime + ɛ. We found no statistical differences between months (F(df 11) = 1.60, p=0.09), or species (F(df 1)= 1.74, p=0.18), but time of the day explained most of the variation in CO2 uptake (F(df 1) = 104.37, p<0.0001). The subtle but not significant differences between Sedum species might be due to their distinctive life forms. S. dendroideum grows erect and bushy, whereas S. rubrontinctum grows herbaceous crawling the floor (Figure 1D-E).

Although it was not statistically significant, February and March were the months with the highest CO2 uptake, coincidentally some of the months with the most chance of high air pollution in the ZMVM. This observation illustrates the physiological plasticity of Sedum species, in which carbon sequestration might be influenced by environmental factors, such as temperature and precipitation (Table 1).

Table 1. Measured net carbon capture of Sedum species in a green roof of Mexico City in a given day per month. Calculated from adding all the 15 mins measured intervals, and averaged from three plants, ± standard error. Tmax: maximum monthly temperature, Tmin: minimum monthly temperature; Tmean: mean monthly temperature; ppt: monthly precipitation. Raw data available on doi:10.6084/m9.figshare.3395887
Month S. dendroideum S. rubrotinctum Tmax Tmin Tmean ppt
November 2009 193 ± 35.76 141 ± 13.89 21.9 8.9 15.4 3.4
December 2009 150 ± 19.67 118 ± 13.71 20.0 7.0 13.0 26.1
January 2010 100 ± 14.89 71 ± 16.29 21.4 7.2 14.0 69.0
February 2010 275 ± 23.05 233 ± 18.09 24.6 9.1 17.2 5.1
March 2010 284 ± 21.13 240 ± 15.12 26.4 10.8 18.5 21.9
April 2010 108 ± 15.33 75 ± 7.03 28.7 13.3 20.7 27.8
May 2010 114 ± 15.24 87 ± 8.69 27.1 14.5 19.7 95.0
June 2010 115 ± 14.58 84 ± 7.05 23.5 14.0 17.9 255.7
August 2010 144 ± 16.09 105 ± 1.06 23.8 14.0 18.8 133.9
September 2010 145 ± 15.90 102 ± 9.69 23.3 13.6 17.7 99.7
October 2010 150 ± 19.05 120 ± 12.21 23.7 9.6 16.2 3.5
November 2010 192 ± 18.39 138 ± 14.43 24.7 7.3 15.2 3.0

The carbon sequestered by Sedum plants can be partitioned into the shoot or root parts of the plant. In order to estimate the biomass partition in the studied species, in a parallel experiment with three plants each, we measured the dry biomass of plants 325 days after planting on a green roof. The largest fraction of the dry biomass was recorded in the shoot (Figure 4). The root:shoot ratio was 0.41 in S. dendroideum, and 0.15 in S. rubrotinctum, which are similar ratios reported for other succulent plants from arid environments 34. This shows that most of the biomass is allocated towards the succulent shoot. However, it is known that roots can produce CO2 because of root respiration and decomposition. The dynamics of carbon sequestration and decomposition in the root and the soil remains to be quantified, however, it is argued that in the short term this ecosystem could be an important sink of carbon 13. Therefore, to mantain a green roof as a carbon sink, we trim about 30% of the old foliage two years after the initial planting, and every six months thereafter. We especulate that trimming practice maintains the plant community as a carbon sink, and reduces carbon emission by decomposition. Nevertheless, carbon sequestration dynamics of older green roofs remain to be quantified.

Figure 4

Figure 4. Dry biomass partition in S. dendroideum and S. rubrotinctum of plants (n=3) measured 325 days after planting on a green roof. The dry biomass of S. dendroideum was 70.3% in the shoot and 29.6% in the root (standard error ±3.1), whereas S. rubrotinctum was 86.8% in the shoot and 13.1% in the root (standard error ±1.1).

It is possible that carbon sequestered by Sedum species is allocated by the plant to the shoot or the root. The shoot adopts a perennial life-style, in which the leaves are succulent, permanently green, and only after several years, they senesce. This is why we believe that shoot senescence would have a small contribution to the re-emission of carbon to the environment. The biomass accumulated in the root, however, has the potential to contribute to the emission of carbon to the atmosphere by decomposition and degradation of the organic matter. Among desert perennial plants, succulents have the lowest root to shoot ratio, ranging from 0.04 to 0.15, which are dramatically smaller than desert shrubs that range from 3.2 to 7.3 33,34. In other words, the root biomass is disproportionately smaller. Moreover, an adaptation of succulent plant roots is to maintain roots, dehydrate them during the drought season and resurrect them during the new rainy season.

Our aim was to estimate the carbon sequestration capacity that green roofs can have. Therefore we used the data that we obtained from measuring individual plants during the day, and across the year to estimate the overall CO2 capture by Sedum plants. To do this we considered the average CO2 uptake from the three measured plants at each time, and month. Assuming that from 3 am to 6 am, Sedum plants have a steady carbon uptake similar to the 6am rate (see Figure 2), averaged the two species and multiplied our estimate of carbon uptake in 15 mins (period of IRGA quantification), by the total number of minutes in 3 hours, and obtained the carbon uptake in a given day per each month. This number was then multiplied by the number of days in any given month. Then we summed the months to estimate the total carbon uptake per plant during a year (July was assumed to have a mean value between June and August, and we averaged the two measurements of November months), giving 524,040 ppm of CO2 per plant per year, or 371.27 g C m-2. Furthermore, assuming that all the plants in the green roof have similar metabolic rates, we can estimate the amount of carbon that was sequestered in the studied green roof, by multiplying the carbon estimate per plant per year, by the total number of plants in our green roof. This gave a total of 75,461,760 ppm of CO2 in the 2009-2010 period of study in a green roof of 42 square meters, with 144 Sedum plants. In other words, a green roof of Sedum in Mexico City of 100 square meters, has the capacity to sequester 179,670,857 ppm of CO2. This estimate is highly conservative given that the number of plants per unit of area increases dramatically over the year as a result of vegetative growth (see Figure 1D-E). Remarkably, our estimation of a Sedum green roof of 100 square meters is equivalent to approximately 46% of the annual CO2 emission of a standard car (up to 7.5 km L-1) 35, driving every day 10km during 365 days, and estimated to produce 388,360,000 ppm CO2.


In this work we evaluated the capacity of two crassulacean Sedum species for capturing CO2, when grown in a green roof, during the day, and across the year. The months of February and March showed the maximum CO2 capture, 75% more than the summer month of June, a response that was possibly influenced by the temperature and precipitation patterns of the ZMVM. Consistent with the CAM, the highest CO2 uptake and accumulation of organic acids occurred early in the morning. We estimated that a green roof of Sedum of 100 square meters is able to sequester approximately 1.8 x 108 ppm of CO2 per year (or 180,000 g C m-2) in the ZMVM. Our quantifications are within the range of previous studies in Sedum species, which range from 160 g m-2 over two years 13, and 1940-3910 g C m-2 over a 12-14 month period 20. It is important to remark that Sedum plants were not irrigated, making these species an ideal candidate, with low irrigation and maintenance requirements, towards promoting naturation efforts in “megacities”.

In our current scenario, carbon concentration in the air is increasing because of the intensive use of fossil fuels. This phenomenon is tightly linked to the growth of human populations and the loss of vegetation in cities, making the design of sustainable urban areas a challenging task. An example of a metropolitan area with poor air quality, linked to decades of deficient urban planning, and short-term solutions to address the air quality issue, is the ZMVM. Particularly, in the early months of 2016, the ZMVM is facing the worst air pollution crisis since the 1980s, which is evidence of the lack of long-term and sustainable environmental policies. Therefore, there is an urgent need to increase the capabilities to fix carbon and other pollutants, in order to improve the air quality in metropolitan areas such as the ZMVM. The widespread installations of green roofs, together with citizen involvement are part of the potential solutions to increase the CO2 sequestration in cities. The green roof system was first developed in Germany in the 1960s 3, and later adopted in several countries such as USA, Canada, and European countries 13,36. Despite their widespread implementation in developed countries and their relevance to tackle air pollution, the understanding of carbon and pollutant dynamics in green roofs is still scarce.

Green roofs are subject to extreme environmental conditions because of the lack of rainfall during certain periods of time, high temperatures, and intense wind. It is because of this that only few species have been used on green roofs, Sedum being the main species worldwide 10,31. As a CAM species, Sedum has fewer capabilities to capture CO2 than C3 or C4 plants; yet, Sedum species are often preferred because of the xerophytic lifeform, and their resilience to extreme conditions.

Carbon sequestration measured in our study is only representative of the environmental conditions of the period 2009-2010. Although we did not measure carbon sequestration in multiple years, we speculate that the pattern should be similar in any given year provided that the variation in temperature and precipitation during 2009-2010 studied period is larger than the corresponding parameters over several years 2005-2015 (CONAGUA, Mexico, 2016; (Figure 5). It is remarkable that, despite the extent of variation in temperature and precipitation, the patterns of CAM and carbon sequestration are highly robust during the period of study (Figure 2-3). Therefore, we believe that the estimated parameter of carbon sequestration can be extrapolated to multiple years with similar environmental conditions in the ZMVM. Moreover, our results further support the use of Sedum in green roofs of the ZMVM, as a highly resilient species to temperature and drought.

Figure 5

Figure 5. Historical climate in the Zona Metropolitana del Valle de México (ZMVM) from 2005 to 2015. Data obtained from Servicio Meteorológico Nacional, Comisión Nacional del Agua, México (CONAGUA, 2016).

In our study we estimated the carbon uptake of Sedum species at interval periods during the day and at chosen days of each month, giving a total CO2 uptake quantification time of 122.4 hours. We acknowledge that our study did not monitor the entire 24h, or every single day in any given month; however, we believe that our sampling strategy and the clear recapitulation of the CAM physiology during the day and across the year, makes our data robust enough to make projections of carbon uptake during the 24h, of the 365 days of the year. We consider that such quantification and projection of the CO2 uptake can be highly valuable information for policy makers, especially those who might be currently planning how to address the air pollution crisis of the ZMVM.

As expected, both S. dendroideum and S. rubrotinctum displayed a strict CAM photosynthesis, because they captured CO2 during the night, and early hours of the morning, including the dry (November to May) and wet (June to October) seasons. Remarkably, the plants only received an initial irrigation, and were later only watered by natural rainfall, which emphasizes their sustainability in “megacities” such as the ZMVM with seasonal droughts (Table 1). Moreover, Sedum is a perennial species, reducing the requirement for replanting year after year. Other perennials have been used on green roofs, for instance trees of up to 3m, which can have higher rates of carbon capture. However, trees often require costly maintenance and frequent irrigation. Trees can sequester more carbon at the global level, but as Getter et al (2009) pointed, “due to building weight restrictions and cost, shallow substrate extensive green roofs are more common than deeper intensive roofs” 13. Therefore we strongly support the use of Sedum species, together with other C3 or C4 plants, towards the widespread implementation of green roofs.

In summary, the high survival, fast growth, low or null-maintenance, low or null irrigation requirement, and capacity to capture CO2 make Sedum an ideal species for green roofs, as an alternative strategy for promoting vegetation in megacities with marked seasonal drought. Particularly, Sedum species would be an ideal solution for the ZMVM, which is in urgent need of long-term solutions towards tackling the air quality crisis of the last decades.

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The Development of a Veterans Health Administration Emergency Management Research Agenda Thu, 23 Mar 2017 15:30:49 +0000 Introduction: The Veterans Health Administration (VHA), the largest integrated healthcare delivery system in the United States, is charged with ensuring timely access to high-quality care for veterans during disasters, and supporting national, state, local, and tribal emergency management and homeland security efforts. In 2008, the VHA Office of Public Health (OPH) sponsored the first VHA Emergency Management Research Agenda-setting conference to develop research priorities that address the needs of veterans and to position VHA as a national leader in emergency management by having VHA serve as a “laboratory” for the development of evidence-based emergency management practices.

Methods: We focused on four steps: #1: Appraising the emergency management research portfolio of VHA-based researchers; #2: Obtaining systematic information on VHA’s role in emergency management and the healthcare needs of veterans during disasters; #3: Based upon gaps between the current research portfolio and the existing evidence base, identifying strategic priorities using a research agenda-setting conference; and #4: Laying the groundwork to foster the conduct of emergency management research within VHA.

Results: Identified research priorities included how to prevent and treat behavioral health problems related to a disaster, the efficacy of training programs, crisis communication strategies, workforce resilience, and evacuating veterans from health care facilities.

Conclusion: VHA is uniquely situated to answer research questions that cannot be readily addressed in other settings. VHA should partner with other governmental and private entities to build on existing work and establish shared research priorities.



In addition to providing healthcare for veterans, the United States Veterans Health Administration (VHA), part of the Department of Veterans Affairs (VA), is charged with improving the Nation’s preparedness for response to war, terrorism, national emergencies, and natural disasters by developing plans and taking actions to ensure continued service to veterans, as well as supporting national, state, and local emergency management, public health, safety and homeland security efforts.1,2,3 Under the National Response Framework of the United States (U.S.), VHA has support responsibility under 7 of the 15 Emergency Support Functions including emergency management, public health, and medical services. Consequently, VHA has directly provided care for veterans—and sometimes non-veterans—during every major national disaster since 1992.

By law, VHA provides health care to enrolled Veterans first, but can provide support to communities when there are local emergency needs or federally declared disasters. In this capacity, VA’s extensive resources as the largest integrated healthcare delivery system in the U.S. (more than 350,000 personnel at more than 1,300 medical sites serving about 9 million Veterans) may be used to support other Federal and state agencies and local communities by providing public health and medical services following emergencies and disasters. For example, VA deployed more than 1,300 personnel and 12 mobile clinics to Louisiana and Mississippi following Hurricane Katrina; the clinics provided care to about 15,000 patients, including 11,000 who were not Veterans. The VA also provide significant amounts of care to individuals impacted by events as diverse as the World Trade Center attacks on September 11, 2001,4 and the earthquake in Haiti that occurred in 2010. VA staff regularly participate in emergency planning for events such as domestic Olympics, Presidential Inaugurations, and Papal visits.

In mid-2008, VHA’s Office of Public Health (OPH, now part of the VHA Office of Patient Care Services) provided funding to researchers at the Health Services Research & Development (HSR&D) Center of Excellence for the Study of Healthcare Provider Behavior to develop a plan to establish a comprehensive, VHA emergency management research and program evaluation agenda. It was hoped that the agenda would provide a basis for fostering the conduct of more VHA-based emergency management research, and, over time, position VHA as a national leader in emergency management research. This paper summarizes the process and outcomes of this effort, and outlines VHA’s research and evaluation priorities.

VHA Emergency Management Research Agenda-Setting Process

Emergency management professionals and researchers with significant funded or published research on emergency preparedness were invited to join a conference wherein attendees would assist in the creation of a research agenda designed to address gaps in research on VHA emergency management. The planning group operated within the framework of a four-step action plan adapted from Yano and colleagues (2006)5 for a VHA Women’s Health Research Agenda-Setting Conference (Table 1).

Table 1. Four step action plan toward a VHA emergency management research agenda
Action Plan Approach
Step #1: Critically appraise the VHA emergency management research portfolio 1. Obtain and review history of emergency management funding to VHA researchers; 2. Analyze data by funding source (e.g., VHA, other federal, private, foundation)
Step #2: Obtain systematic information about VHA emergency management to provide an evidence base for the research agenda Conduct a systematic VHA emergency management literature review, including review of grey literature as well as peer-reviewed literature
Step #3: Based on gaps between the current VHA research portfolio (step #1) and the assessment of the evidence base (step #2), identify priorities for a VHA emergency management research agenda 1. Review and adapt priority-setting strategies by other agencies (e.g., Department of Defense, Centers for Disease Control and Prevention); 2. Review VHA strategic plans3. Conduct gap analysis, priority setting, and consensus development during a VHA emergency-management research agenda setting conference (held July 2009)
Step #4: Foster the conduct of VHA emergency management research 1. Build research capacity through collaboration, networking, and mentoring; 2. Increase awareness and visibility of VHA emergency management research

Appraisal of VHA’s Research Portfolio

To support strategic planning, it was necessary to assess the current state of existing emergency management research within VHA. This historical research portfolio provides a foundation for the reader to understand both the nature and scope of the then current VA emergency management research portfolio upon which the conference planning and subsequent research agenda were based. The following section reviews emergency management research funding secured by VHA researchers through 2008.

Emergency Management Funding

During 2003-2008, VHA researchers based at one of the HSR&D Centers of Excellence were funded by HSR&D and the VHA Office of Mental Health Services, and non-VHA sources, including the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH) (Table 2).

Table 2. VHA and non-VHA funding for emergency management research
Fiscal Year VHA Non-VHA Total
2003 $354,279 $131,500 $485,764
2004 $441,336 $851,859 $1,293,195
2005 $489,235 $466,395 $955,630
2006 $523,910 $958,709 $1,482,619
2007 $385,896 $598,982 $984,878
2008 $0 $1,370,472 $1,370,472
Total Number of Studies: 6 Total Number of Studies: 11

VHA-funded emergency management research increased steadily from 2003 to 2006, then decreased by more than 25% in 2007. No VHA researchers were funded by VHA to conduct emergency management research during 2008. Non-VHA funding increased more than sixfold from 2003 to 2004, then decreased by about half the following year. From 2006 to 2008, non-VHA funding to VHA researchers who study emergency management continued to fluctuate. Some of the fluctuation in funding from year to year during this time period may be due to the cyclical nature of funding related to the occurrence of major disasters. For example, it is likely that the increase in funding for emergency management research in 2005 and 2006 was a response to Hurricanes Katrina and Rita.

It is evident from this review that emergency management is an emerging area of research in terms of VHA funding. As shown in Table 3, emergency management funding has remained relatively constant at under one percent of total funding to VHA researchers based at HSR&D Centers of Excellence. In comparison, former emerging VHA research topics such as women veterans’ health started at approximately 2-3% of total funding to VHA researchers.5 Subsequent to the VHA Women’s Health Research Agenda-Setting Conference in 2004, women’s health was identified as a VHA research priority, leading to an increase in funding for women veterans’ health research.

Table 3. Emergency management research as a percentage of total VHA and non-VHA funding to VHA-based researchers
Emergency management research funding Total research funding % of Total
2005 $955,630 $160,750,113 0.6%
2006 $1,482,619 $156,282,076 0.9%
2007 $984,878 $165,994,469 0.6%
2008 $1,370,472 $170,103,121 0.8%

In summary, the total amount of emergency management research funding secured by VHA researchers stayed relatively constant from FY 2004 to FY 2008, although VHA funding declined to zero in FY 2008. Non-VHA funding decreased in FY 2005, but increased again beginning in FY 2006. VHA funding comprised 34%-73% of the total funding VHA emergency management researchers secured from FY 2003 to FY 2007. NIH was the primary sponsor of this type of research during FY 2007 and FY 2008.

The number of VHA-based researchers funded by VHA sources increased from 9 during FY 2003 to a high of 27 in FY 2007, before declining to zero during FY 2008. In contrast, the number of VHA-based researchers funded by non-VHA sources increased from 1 during FY 2003 to a high of 6 during FY 2007, before dropping to 3 during FY 2008.

The decline in VHA funding in FY 2008 in part reflects the small number of studies in progress during this time period, and suggests a need for more consistent funding in this area in order to attract and grow the emergency management research community within VHA. These trends suggest a clear interest among the VHA community for conducting research in the area of emergency management, but one that is limited by cyclical factors such as variations in funding over time.

Establishing the Evidence Base for Agenda Development

Research Portfolio

A review of HSR&D-funded studies provides a broad overview of emergency management issues confronting VHA. A systematic search within VHA databases identified six HSR&D-funded studies since 2002. One of the six studies focused on surveillance, two on education, and three on the response to bioterrorism or natural disasters (two of which focused on vulnerable populations).

Summary of HSR&D Studies

The six HSR&D-funded studies since 2002 are limited in scale and scope (Table 4). The one surveillance study points to the importance and usefulness of automated monitoring of electronic health information in early illness detection. The two educational studies, involving providers and patients, indicate an existing need to adapt educational interventions to the VHA population. Of the three response studies, two evaluated actual events and one involved scenario-modeling. Collectively, they addressed VHA’s ability to compare responses across locations and time, the ability to study vulnerable populations, and the recognition of VHA as a potential target due its governmental affiliation.

Table 4. Summary of VHA HSR&D Service-funded studies on emergency management
PI Background Objective Methods Findings
S. Delisle(IIR 06-119) Early detection is critical for infectious disease outbreaks of public health importance. Disease surveillance can be potentially enhanced through automated monitoring of electronic medical records compared to manual case reporting systems To automate the use of data from VHA’s computerized patient record system (CPRS) to enhance outbreak detection by including illness progression and severity to reduce “noise” of common syndromes Clinical data was grouped by respiratory disease severity using diagnostic and procedures notes, laboratory results, and free text of clinical notes Automated surveillance for influenza should integrate information from prescriptions and free text clinical notes. Case detection with emergency medical records focusing on influenza-like cases with fever can reduce delay and workload to detect influenza epidemics
C. I. Kiefe(BTI 02-092) The VHA medical system can play an essential role following a biological terrorist attack or infectious outbreak due to its extensive record in disaster preparedness To develop and test web-based teaching modules to increase VHA clinicians’ knowledge about biological warfare agents Web-based educational intervention was tested at 15 VHA facilities via a randomized controlled trial with 332 participants The VHA program demonstrated higher anthrax, but not smallpox, post- training provider knowledge than the information offered on the CDC’s website
M. Sano(BTI 02-233) Limited efforts to prepare general public for a bioterrorism incident have been conducted To develop educational materials for veterans about bioterrorism; to provide coping mechanisms for getting though a bioterrorism incident; to evaluate methods for material delivery A Veterans’ Survey on Bio-Terrorism (VSOB) (the initial and a follow up) was mailed to 2923 veterans VSOB, the first instrument to evaluate veterans’ knowledge, attitudes, beliefs, anxiety and educational needs connected to bioterrorism, was developed
A. Dobalian(RRP 06-134) Existing research within and outside of VHA does not sufficiently address health issues for mentally ill and/or frail veterans during evacuations To understand evacuation and response in VHA nursing homes after Hurricanes Katrina and Rita Data were collected via 13 semi-structured interviews with organizational representatives at 4 VHA medical centers and two representatives at the regional level Administrators primarily relied on local resources, prior experience and local planning rather than on state and federal response systems in their response to the hurricanes. Despite significant difficulties during patient evacuation, VHA response was generally perceived as positive. Retaining staff and a viable organization during and after a disaster presented a difficulty. Respondents reported unaddressed preparedness needs even more than one year post-disaster
F. M. Weaver(RRP 06-135) Individuals with spinal cord injuries and disorders are at particular risk during disasters due to impaired mobility and special needs, such as power wheelchairs and ventilator dependency To use identified lessons learned from natural disasters that impacted veterans with spinal cord injuries and disorders (SCI&D) in developing a toolkit, which focuses on enhancing natural disaster preparedness for facilities caring for veterans with SCI&D Thirty interviews were conducted (16 with providers and 14 with veterans with SCI&D). Most interviewees had experienced at least one weather-related natural disaster Veterans with SCI were usually evacuated to unaffected areas or were admitted to SCI centers. Previous disaster experiences provided lessons to guide providers’ and veterans’ actions. Pre-established response plans served as useful starting points. Family and local agencies’ social support was essential for veterans to attain a sense of personal preparedness. The above information was used to develop tools for disaster preparedness.
B. Schmitt(IIR 02-080) VHA is particularly vulnerable to a postal attack directed at government facilities. Thus, it has an interest in identifying the most advantageous response to small and large-scale bioterrorist events To conduct a cost-effectiveness analysis comparing response strategies to a small and a large-scale anthrax attack A decision analytic model was used to compare 3 basic response strategies to a small scale anthrax attack. The optimal response to a mass inhalation anthrax attack was evaluated. Outcomes included costs, Quality-Adjusted Life Years, and incremental cost-effectiveness For the small-scale anthrax attack, the least costly strategy was administration of antibiotics post-attack; post-attack antibiotic and post-attack vaccination strategy was the most effective. Pre-attack vaccination was the least effective. Pre-attack vaccination was preferable to post-attack antibiotics alone when the probability of anthrax exposure was ≥16%. For the large-scale mass attack scenario, analysis is in progress

Systematic Literature Review

A systematic literature review was conducted to synthesize what is known about VHA emergency management research. Specifically, the review answered the following research questions: 1. What is the role of VHA in emergency management, including mitigation, preparedness, response, and recovery? 2. For each of the identified VHA emergency management activities, what recommendations (“lessons learned”) were made to improve the activity around mitigation, preparedness, response & recovery? 3. What veteran health needs have been identified as important in emergency management? Results of the review are presented elsewhere.6

Achieving Consensus on Research Priorities

The purpose of the VHA Comprehensive Emergency Management Program Evaluation and Research Conference was to bring together researchers and practitioners in a common forum to discuss and make recommendations regarding the direction of future VHA program evaluation and research on emergency management. Participant affiliations included VHA, various universities, CDC, the Department of Defense, NIH, and AHRQ, and other institutions.

After several context-setting presentations about VHA’s role in emergency management, attendees participated in one of five workgroups: Behavioral Health (e.g., mental health; substance use/abuse; psychological first aid; the “worried well”); Workforce (e.g., education/training of personnel; VHA’s Disaster Emergency Medical Personnel System (DEMPS); competing family concerns); Communication and Information Flow (e.g., decision-making; inter-organizational collaboration; risk communication); Sustainability and Resilience (e.g., quality improvement; community resilience); and Systems Capabilities (e.g., broad health systems issues such as evacuation, pandemic influenza; methodological considerations when conducting research in this field; inter-organizational collaboration).

VHA’s Emergency Management Research Agenda

Behavioral Health

The Behavioral Health workgroup (e.g., mental health; substance use/abuse; psychological first aid; the “worried well”) was tasked with identifying and prioritizing VHA emergency management research issues related to the mental health needs of individuals impacted by a disaster or mass casualty event. While the conversation did include some discussion of VHA workforce needs (e.g., training and psychological support) as well as the mental health impacts of disasters on VHA and VHA’s role in providing care for the larger community, most of the workgroup’s discussion focused on preventing and treating post-disaster development or exacerbation of behavioral health problems in the veteran population. Because VHA provides ongoing medical and support services for many veterans with psychological and substance use disorders, addressing the impact of large scale emergencies and disasters on behavioral health needs was considered to be of particular significance to VHA.


  1. Preventing and treating post-disaster development or exacerbation of behavioral health problems among veterans7,8
  2. Identification and evaluation of existing post-disaster mental health interventions among veterans
  3. Examining the impact of large-scale emergencies and disasters on behavioral health needs of veterans

Key Questions/Research Topics

  1. How can VA mitigate the impact of a disaster or mass casualty event on the physical, psychological, and social functioning of veterans with pre-existing or emergency behavioral health issues?
  2. How does VA assure adequate and appropriate post-disaster access to quality emergency behavioral health services, both for veterans receiving services from VA and for veterans seeking VA health services for the first time? Examples of specific questions within this broad area of inquiry included:
    1. What systems are in place to assure access and continuity of care for current VA health care users who are displaced or impacted by an event?
    2. What administrative processes are necessary for a veteran who is new to VA to receive services and is there a need to expedite or modify these processes to provide emergency behavioral health services?
    3. What type of behavioral health services will be most needed post-disaster?
    4. Who is likely to seek post-disaster behavioral health services through VA?
    5. How can VA identify veterans who may need post-disaster behavioral health services, but are not likely to seek out or access the services?
  3. What post-disaster mental health interventions are currently used by VA? Who provides the interventions and how are the providers trained? How, if at all, are the interventions evaluated? What is the association between these early intervention strategies and long-term mental health outcomes?
  4. Assess the psychosocial consequences of disasters and emergencies for the “worried well,” and develop evidence-based strategies to minimize those consequences.
  5. How, once identified, do we build “best practices” for addressing the behavioral health impacts of disasters into VA’s emergency management system?


The Workforce workgroup (e.g., education/training of personnel; Disaster Emergency Medical Personnel System (DEMPS)9; competing family concerns) focused on issues regarding: designing and evaluating effective education and training strategies for health care personnel, establishing competency guidelines, effectively engaging health care providers in decision making related to emergencies, DEMPS teams, and how to address employees’ competing concerns for the safety of their own family members. There was a general consensus that a fair amount of funding has been dedicated to training and education, but that rigorous research about the effectiveness of training and education programs is lacking. Furthermore, future effectiveness research should differentiate demonstrating competencies of individuals from system capacity, which is dependent on infrastructure. The workgroup recognized the importance of VHA’s work with various federal partners, and that the manner in which it interacts with other federal agencies is a critical area of research regarding workforce issues.


  1. Rigorous research about the effectiveness of training and education programs is lacking
  2. Research should differentiate between demonstrating competencies of individuals from systems capacity, which is dependent on infrastructure

Key Questions/Research Topics

  1. Evaluation
    1. What evaluation methods are currently being used to assess workforce training outcomes?
    2. How are exercises being used to assess workforce competency?
    3. Develop recommendations for optimizing the learning potential for attendees who participate in emergency management exercises.
    4. How does prior training of staff affect performance?
    5. Develop recommendations for the most effective methods of learning their roles and responsibilities before, during and after disasters for each of the various job groups within VHA’s emergency management competency framework (all employees; health system leaders; patient care providers; clinical support; facilities and engineering; law enforcement; and, emergency program managers).
  2. Leadership Skill Development
    1. To what extent is the leadership at VA facilities able to apply FEMA 100-800 standardized training to its facility?
    2. Is further training necessary and in what areas?
    3. How do VA facility leaders’ expectations for preparedness differ across staff?
    4. What questions does VA leadership have about workforce and emergency management and preparedness (needs assessment)?
  3. Optimally Utilizing Existing Data
    1. How can the Comprehensive Emergency Management Program (CEMP) hospital readiness data that was collected by VA in 2008-10 be used to answer questions about workforce and emergency preparedness?10,11
    2. What are the mutable and immutable characteristics of high-performing systems identified by VA hospital readiness evaluations in 2008-10?
  4. Relationship between Local and National Preparedness
    1. What locally-provided training predisposes individuals to be more effective during national deployments?

Communication & Information Flow

The Communication and Information Flow workgroup (e.g., decision-making; inter-organizational collaboration; risk communication) focused on a wide array of topics related to emergency management planning issues within VHA, specifically crisis communication, risk communication, communication tools, and community collaboration applicable to the overall healthcare system, veterans, staff, and the community. The group expressed the potential concern that VHA’s organizational culture may be overly driven by protocols and standards, and questioned whether communication could effectively be structured to make and disseminate clinical and strategic decisions to veterans, staff, and local communities in an effective and time-efficient manner given these concerns. The group indicated that it would be valuable to identify triggers that lead to the effective dissemination of information from VHA to the public, and wondered how those mechanisms would be altered by a public health emergency. In this regard, the workgroup noted that VHA could also draw on the expertise of its federal and other partners.


  1. Decision-making process
  2. Communication with external audience
  3. Crisis communication strategies and management
  4. Internal communication, decision-making and information management
  5. Communication tools and techniques
  6. Media
  7. Culture and culture change

Key Questions/Research Topics

  1. How effective is decentralized decision-making for the veteran population and VA community?
  2. How well does VA communicate with veterans (particularly for certain groups of veterans such as the homeless, veterans in the community) and the public?
  3. Determine the most effective strategies for communicating with at-risk veterans before, during, and after impacts from hazards, and provide recommendations on how these strategies may change based on the nature of the hazard or the particular group of at-risk veterans.
  4. How well integrated is crisis communication integrated in VA preparedness and response activities? How effective is it?
  5. Is communication flow from decision-making to clinicians and staff adequate?
  6. Determine the most effective strategies for communicating with employees after major disasters.
  7. How does VA effectively monitor social media and respond?
  8. How effectively is VA partnering and working with the media around emergency management?
  9. How well does VA’s general employee culture adapt to the disaster and response culture?

Sustainability and Resilience

The Sustainability and Resilience workgroup (e.g., dual-use systems that may improve the quality of care delivered outside of a disaster situation as well as in the event of an emergency; community resilience) met to discuss the sustainability of resources for emergency preparedness and response, and was asked to consider areas in which to invest scarce resources; quality and cost; how to leverage existing systems or to establish “dual-use systems” that provide benefits both under non-emergent and emergent situations; challenges related to the ebb and flow of funding related to the recency and size of a domestic disaster; and the resilience of veterans and VHA, as well as community resilience in general. The workgroup stressed the importance of disaster research funding and recommended that such funding be increased as a prerequisite for a successful emergency management research agenda and its ongoing implementation.


  1. Emergency management visibility and capability building
  2. Community integration
  3. Supply chain limitations (especially pharmaceutical caches and hospital bed capacity)
  4. Staff resilience and other resilience issues9,12
  5. Special needs patients13,14,15,16,17

Key Questions/Research Topics

  1. Who and what organizations constitute and are possible and probable partners of VA, especially during an event?
  2. What tools must be developed to map out networking, communications, and cooperation opportunities with community’s healthcare providers and public health departments?
  3. How can VA gauge the awareness of supply chain limitations?
  4. What tools must be developed to identify the locations of national and VA suppliers?
  5. How can VA compare actual versus theoretical hospital bed capacity?
  6. What training should VA staff receive to lower mental health stress (especially during an event), maintain proficiency, and be adequately and appropriately cross-trained?
  7. What role can VA play in leading community resilience efforts?
  8. How can VA examine and test community resilience?
  9. How to assess needed support systems to assure access to services and continuity of care for veterans who are displaced or otherwise impacted by a disaster or emergency?
  10. What strategies and tactics should VA treatment facilities incorporate into their emergency management programs to be ready for the effects of convergence during and after community disasters?
  11. How can VA coordinate emergency preparedness/management efforts within a broader community?
  12. Identify the targets, frequency and nature of collaborations necessary for VA treatment facilities can use to establish effective mutual-aid relationships with community health care partners and public safety agencies.
  13. How can VA map out networks/cooperation between VA and local healthcare providers?
  14. Who is considered a special needs patient?
  15. What are the most vulnerable populations of veterans?
  16. Ascertain the percentage(s) and locations of veterans who fall into one or more socioeconomic or demographic categories for those who are considered at higher risk from the effects of hazards.
  17. Develop recommendations to address the special needs of veterans in general, and specific vulnerable populations of veterans including veterans with cognitive or functional impairments (e.g., those with traumatic brain injuries or spinal cord injuries), homeless veterans, veterans living with HIV/AIDS, frail veterans in the community (e.g., those needing oxygen), and veterans with posttraumatic stress disorder (PTSD).
  18. What is the backup plan to assist veterans with special needs during an event?

Systems Capabilities

The Systems Capabilities workgroup (e.g., broad health systems issues such as evacuation, pandemic influenza; methods; inter-organizational collaboration) discussed the broader healthcare system and population issues applicable to all healthcare systems, although it focused primarily on VHA-specific issues while considering both internal and external concerns. Using both experience with current practices, including a discussion of actual operational decisions made during the response by VHA and others to Hurricane Katrina, as well as an assessment of current gaps in the field’s understanding, this workgroup identified various research priorities. Much of the workgroup’s discussion concerned the potential for VHA to become a leader in developing evidence-based standards for emergency management. The workgroup noted that VHA’s facilities and other resources provide an invaluable “laboratory” to strengthen national emergency management research capabilities. Resources noted by the workgroup included the recognition that VHA facilities that provide care for the most complex inpatient cases are required to have academic resource centers in their facilities. In addition, VHA staff with a military background often have experience either training for or actually having responded to a disaster. Furthermore, VHA currently makes resources available to the local community, including pamphlets that describe how to respond to a local emergency, and plays an extensive role in national emergency response. Finally, in rural areas, VHA may be the sole federal presence in the community and is often relied upon as the primary source of federal distribution, care and support. Members of the workgroup who had been part of the Katrina response also discussed issues surrounding surge capabilities where healthcare workers from neighboring institutions were farmed out to distant facilities because their hospitals were closed.


  1. Evacuation and sheltering in place18,19,20,21
  2. Develop “off-the-shelf” evaluation protocols and surveys for use in the immediate aftermath of an event
  3. Developing common standards of practice, looking both nationally across VAs as well as within local community settings
  4. Staffing variables to consider when responding to a multi-casualty incident since VAMCs are typically not acute trauma centers
  5. Breakdown of communication within a community, in particular when regular communication lines are down
  6. Assessing actual volunteer capabilities

Key Questions/Research Topics

  1. Develop decision support tools that healthcare providers and officials would need in the event of various disasters and emergencies.
  2. The development of criteria and algorithms for evacuating patients, to be determined pre-incident and to guide the process of how to make decisions effectively.
    1. Assess current hospital and nursing home evacuation procedures and develop recommendations to improve their effectiveness.
  3. When is it safer for an institution to not evacuate, but rather focus on facility hardening, sufficient supply, and shelter/protection (i.e. shelter in place)?
  4. Determine the level of investment necessary to retrofit VHA’s current building inventory (business occupancies) to the effects of wind, water, fire and ground-shaking.
  5. Define, measure, and evaluate surge capacity within VHA.
    1. How to address surge capabilities, such as when personnel are sent to distant facilities because local facilities are closed.
  6. How to best build interest in the importance of emergency management at all delivery levels (e.g., the CMOs).
  7. How can the six major capabilities of the VHA hospital readiness data collected in 2008-10 be used to establish a framework for evaluation?
  8. Review the current VHA Capabilities Assessment Program and recommend strategies for enhancing future evaluation strategies and methods.
  9. Assess the current effectiveness and develop improvement strategies related to VHA’s health information technology in detecting, tracking, and providing real-time decision support to clinicians.
  10. What lessons may be learned from the use of Federal Medical Stations (FMS) as a lab for post-incident patient care?
    1. The types of equipment used to support these facilities, such as having sufficient equipment to support obese patients.
    2. The FMS can also be used to examine the effects of altered standards of care in post-incident situations on healthcare professionals themselves.
  11. Compare currently available methods for assessing risk, probability and vulnerability for VHA treatment facilities and develop recommendations for the most effective approach.
  12. How to evaluate the effectiveness of current competencies required of VA employees? How effective are they in actual emergency responsiveness?
  13. Develop evaluation strategies to support exercises and drills.
  14. What equipment does a VA treatment facility need to effectively protect its employees and patients from the effects of an influenza pandemic?

Building an Infrastructure for Fostering the Conduct of VHA Emergency Management Research

Based on the first three steps, the research team recommended a variety of measures to assure that there is adequate infrastructure within VHA to support the implementation of the research agenda. We recommended that a VHA agenda-setting process be reconvened within five years to assess progress on implementing the agenda and to establish new directions for subsequent years. The current research agenda was developed based on the best available data at the time. We anticipate that VHA’s investments in emergency management program evaluation and research will continue to yield rapid advances. This translates into a rapidly changing landscape, and a new set of knowledge and investigators who should be brought together to reappraise, re-energize, and recommit to the next phase of VHA emergency management evaluation and research. Although an updated agenda-setting conference has not been reconvened as of 2016, the initial conference was followed in subsequent years by annual meetings (Advancing and Redefining Communities for Emergency Management) that continue to bring together VA and non-VA researchers, practitioners, and policy-makers to share evidence-based practices and discuss the current state of emergency management research.

Some key differences exist between the VHA and other hospitals and healthcare facilities. For example, VHA has a well-integrated electronic medical system. Private facilities have begun to expand these capabilities in recent years. Electronic medical systems have advantages, but do require power to operate, and thus may require paper backups or other options during some disasters. In addition, VHA has a wide array of facilities that serve various populations, including residential facilities that serve Veterans with substance use disorders and various residential facilities for homeless Veterans.

In addition, it was recommended that efforts be made to increase the visibility of VHA’s emergency management research and its potential to serve as a laboratory for emergency management research for the Nation. Hospital systems often focus on healthcare-related issues at the expense of applying findings from the broader disaster-related literature.22,23,24 It was hoped that issues such as this could be explored within VHA for the benefit of both VHA and the nation. In particular, VHA should maintain and expand a searchable database of published articles and unpublished reports related to VHA emergency management program evaluation and research that would provide support to VHA researchers interested in VHA emergency management research opportunities and collaborations. This effort could lead to the establishment of a multi-component, web-based emergency management evaluation resource clearinghouse that would make emergency management research and evaluation resources more readily available and accessible to researchers and practitioners. Similarly, the establishment of a VHA Comprehensive Emergency Management Program Evaluation Center would enhance VHA’s mitigation, preparedness, response, and recovery activities in the event of emergencies and disasters. The Center’s goal should be to develop an evidence base by which VHA contributes to the development, evaluation and improvement of healthcare services and programs that (1) strengthen VHA’s CEMP, and (2) position VHA as a national leader in emergency preparedness and response. As a result of these recommendations, VHA established the Veterans Emergency Management Evaluation Center (VEMEC) in July 2010. VEMEC continues to this day.


Using a systematic evidence base and consensus development process among stakeholders within and outside VA, we report on the first national VA comprehensive emergency management program evaluation and research agenda. VA provides a unique national laboratory for the conduct of high quality research that will improve VA’s and our Nation’s emergency medical and public health preparedness and the role of health delivery systems in that endeavor. To effectively foster the conduct and expansion of emergency management evaluation and research within VA, the consensus was that VA needs to build program evaluation capacity, increase the awareness and visibility of VA’s emergency management research, and build bridges to research partners at agencies and organizations with longstanding commitments to advancing emergency management research.

Corresponding Author

Aram Dobalian:

Competing Interests

The authors have no financial relationships or conflicts of interest to disclose.

Data Availability

All relevant data are available from the figshare repository:

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The Demand for Disaster Microinsurance for Small Businesses in Urban Slums: The Results of Surveys in Three Indian Cities Wed, 01 Mar 2017 09:47:43 +0000 Background: Small informal businesses make up the core markets for many poor urban communities, providing essential goods, services, and livelihoods. Many of these communities and businesses exist in hazardous locations. In most cases, these business owners do not have access to proper coping mechanisms including risk transfer and lack resilience to shocks. Access to risk-transfer in the form of insurance for these small businesses is extremely limited. This demand survey is the first phase of an intervention to test disaster microinsurance for these businesses. Previous research has examined the demand for and value of microinsurance to protect poor households but not micro- and medium-sized informal urban businesses.

Objective: This study investigates knowledge about and demand for microinsurance among small informal business owners in three different cities of India.

Methods: Survey of all informal business owners (n=4919) identified through purposive sampling of the most vulnerable in three proposed study sites: Guwahati in Assam (n=1622), Puri in Odisha (n=1551) and Cuddalore in Tamil Nadu (n=1746).

Results: Our findings reflect that while small business owners largely did not know about disaster microinsurance, after describing it, a vast majority wanted to subscribe to such a program. Without it, they often rely on personal savings, forgo basic necessities, or take out costly loans that trap them in debt to cope with disasters.

Discussion: This research supports the need for more experiments on actual adoption patterns, feasibility studies, and innovative trial programs by governments, non-governmental organizations, and insurance providers.



The 2015-2016 Slum Almanac published by UN-Habitat showed the dramatic extent of urban poverty: over one billion people currently live in slums.1 To combat this problem, the UN’s newly agreed Sustainable Development Goals (SDGs) include a focus on cities — a call for improving slums and creating more sustainable communities. SDG Number 11 calls for making cities safe, inclusive, resilient, and sustainable.2 However, natural and man-made disasters hinder progress made toward these goals.

Furthermore, humanitarian efforts tend to focus on the response to crisis rather than the long-term goal of improving resilience. The most recent World Humanitarian Summit highlighted the need to place humanitarian response within a broader development and resilience framework.3 By embracing a focus on resilience, development and humanitarian efforts can work together in complementary ways. Working towards resilience involves not just making infrastructure more robust, but also instituting risk mitigation techniques designed to promote appropriate investment and safeguard progress in the wake of disasters. These incremental steps improve the stability of a community and often do more good than reactive measures following catastrophes.4 However, while more groups are looking at how humanitarian aid can better adapt to urban crises — specifically those affecting informal settlements — few effective tools exist.5

In many cases, small and informal businesses provide livelihoods and offer goods and services to urban communities. Because of this, small-scale and decentralized market enterprise may be one of the best ways to identify and address needs in urban settings. People living in slums rely on small and informal businesses for inexpensive, reliable goods that satisfy their immediate needs and make other commerce possible. As a result, failure of these businesses represents failure of local markets in these communities.

Since local markets fulfill such a necessary role, humanitarian efforts have looked to salvage businesses directly after disasters. Cash programming previously showed promise; supporters hoped to spur demand in local markets and provide capital for businesses to operate.6,7 Unfortunately, small businesses feel the effects of disasters too, preventing or limiting recovery after a shock. And even when businesses can operate, introducing cash into a disaster-affected community can inflate demand without increasing supply. With limited supply, and little outside competition, merchants can simply raise their prices, adding to local inequality and risking high inflation.8 Even in open-market communities, cash assistance alone is not a complete answer; it fails to support local markets and businesses that are equally affected by the crisis.

Disaster microinsurance may be part of the answer. Several previous studies have proven the efficacy and reliability of microinsurance.9 Disaster microinsurance, which uses smaller premiums to cover smaller losses, has specifically been tested in endangered low-income households.10 The concept of microinsurance is simple: When businesses are doing well, they pay insurance companies a relatively small amount against the risk of natural disasters or significant environmental pressures. Should calamity strike, insurers compensate the business owners — potentially saving their businesses, their livelihoods, and their families. In doing so, the insurance industry transfers risk away from small businesses, which play an important role in local economies. Through this process, microinsurance provides an important link between humanitarian and development assistance.

Yet research into the impacts of disaster microinsurance has been limited. Some studies have shown that microinsurance has helped people recover from disasters faster than other coping strategies.11 And insurance companies have voiced their willingness to create programs. In 2005, insurance providers in Bangladesh, India, Pakistan, and Malawi all expressed interest in marketing their products to the poor. On a global scale, creative alliances between NGOs, insurance companies, governments, and donor organizations could enable microinsurance programs to be successful.12 But assumptions that informal business owners are uninterested, questions about financial feasibility, logistical challenges, and insufficient knowledge of the actual impacts understandably contribute to a lack of microinsurance programs in urban markets.

Additionally, questions about the merits of microinsurance in these settings remain. Some argue that microinsurance may create a form of moral hazard, actually promoting unsustainable or dangerous endeavors.13 Furthermore, since microinsurance has not been rolled out on a large scale, adoption rates — and, subsequently, financial viability — cannot yet be determined. The premiums may be too high to afford, business owners may lack understanding of microinsurance, or business owners without extensive financial experience may be wary of financial programs — a recurring issue due in part to prior scams.

Indian cities are an ideal setting to test microinsurance as a tool for addressing urban poverty and increasing community resilience. In the fastest-growing urban areas, over half of the population lives in slums. In the financial hub of Mumbai, for example, slums house roughly 54% of urban residents.14 Many dense urban slums struggle with natural disasters, including storms and floods — exactly the kind of unpredictable but expected hazards that microinsurance programs are designed to protect against.

Specifically, Southeast India is disproportionately affected. Due to its location in one of the seven major cyclone basins, the region frequently struggles with severe storms. Since 2010, for example, Cyclones Laila, Jal, Thane, Phailin, Hudhud, and Nada, and Vardah have all hit the southeast coast of India.15 And floods — the most common natural disaster in India — endanger the entire coast of India.16 All of the study sites — Puri in Odisha, Guwahati in Assam, and Cuddalore in Tamil Nadu — are located in this volatile region.

Between 1990 and 2016, the total loss from natural disasters in India has been assessed at over 48 billion US dollars.17 The insurance sector compensated just 11-12% of that amount, revealing an enormous gap in coverage and an opportunity for microinsurance.18 Additionally, informal employment contributes 48% of India’s urban GDP and 53.9% of its jobs; although informal businesses benefit urban populations immensely, insurance companies typically do not cover them.19

This initial survey study is a part of a larger randomized controlled trial of small business disaster microinsurance funded by the Humanitarian Innovation Fund. This study investigates the concerns noted above and looks at the potential for microinsurance in poor urban areas. In each surveyed region, we gauged knowledge of microinsurance and small business owners’ desire for programs. This initial study report contextualizes those findings and assesses the potential success of microinsurance programs.


The study was conducted in partnership between the All India Disaster Mitigation Institute (AIDMI), an NGO based in Gujarat, India and Stanford University in California, USA supported by the Humanitarian Innovation Fund. The study sites include urban slums in three disaster-prone cities of India: Puri in Odisha, Guwahati in Assam and Cuddalore in Tamil Nadu. The demand survey instrument was designed collaboratively between the two organizations with feedback from local community-based organizations (CBOs) in the study cities. After teams at AIDMI and Stanford had finalized the survey template, it was sent to CBO staff in the field.

To understand the effects of recent disasters on small business owners, local teams surveyed 1622 people in Guwahati, 1551 people in Puri, and 1746 people in Cuddalore from urban slum communities served by a local CBO in each region. These three pilot sites were selected because they met two important criteria: each lies in a high-risk zone for cyclones or flooding, and each had a community-based organization with the capacity and motivation to participate in this program. Purposive sampling was employed to identify small informal business owners to include and survey in the study. Since no comprehensive database of small business owners in slums exists, random sampling could not be conducted. Additionally, a purposive design enabled focus on the vulnerable vendors most in need of microinsurance programs. After obtaining consent, staff from each local CBO collected survey data from informal business owners at their shop on mobile platforms using the KoBo toolbox software, Cambridge, Massachusetts. The survey instrument included questions about demographics and household information. It also included questions regarding previous experience with disasters and gauged knowledge of and interest in disaster microinsurance. The data was compiled by AIDMI and analyzed at Stanford using Microsoft Excel, Seattle, Washington.

Ethical approval for this study was granted by the Human Subjects and Research Institutional Review Board at Stanford University, Protocol # IRB-33474.


Demographics from the three study sites are displayed in Table 1. In all three locations, males compose the majority of business owners. Most house owners had ownership documents, but many lived in kutcha houses — buildings made out of weak or flimsy materials — which would not fare as well in a natural disaster. Many also owned shops made out of temporary materials, defined as fragile due to their risk in the face of natural disasters. In Guwahati and Puri, around half of the small businesses were mobile, though many still set up and kept their business materials in hazardous areas.

Many vendors sold food and other goods; 12% to 31% sold fruits and vegetables. Others offered bread or other groceries. And a few offered sundry items or more specialized products. Notably, 26% of Puri’s vendors sold handicrafts (owing to Puri’s beach tourism), and 20% of Guwahati’s merchants sold pan, but few sold either in the other study sites.

Though income varied, on average, small business owners made between Rs. 7,000 and Rs. 9,000 each month.

Screenshot 2017-02-08 at 3.58.02 PM

Table 1: Demographic Information

Experience with previous disasters is summarized in Table 2. Nearly everyone in all three sites had been affected by disasters at some point, and a considerable number had had their businesses or goods damaged. However, each community struggled with slightly different challenges. In Guwahati, 67% of people who reported being affected by disasters listed floods as being particularly damaging. And in both Puri and Cuddalore, everyone impacted by disasters referred to cyclones. People in Puri specifically complained about the Odisha Super Cyclone (1999), Cyclone Phailin (2013), and Cyclone Hudhud (2014).

Respondents reported varying levels of destruction. In Cuddalore, for example, 61% of those who had damaged businesses said they suffered major damage, and 34% had lost their businesses completely. In Guwahati, 23% of those with damaged businesses described major damage.

Screenshot 2017-02-08 at 4.08.48 PM

Table 2: Effects of Disasters

Prior to explaining microinsurance, surveyors asked vendors how they would respond to a natural disaster; the results are shown in Table 3. In Guwahati, 53% of respondents said that they would use savings to cope. Most people in Puri and Cuddalore — 72% and 100%, respectively — said they would take out a loan. Others noted they would sell their assets or rely on aid. However, all of these options can be detrimental to business owners and their families.

Screenshot 2017-02-08 at 4.11.06 PM

Table 3: Current Coping Mechanisms

To learn more about the potential for future programs in the region, surveyors specifically asked about knowledge of and demand for microinsurance, displayed in Table 4. While the numbers within each site varied, most business owners responded very favorably to the idea of microinsurance.

We found that, in general, wealthier households wanted to buy more expensive microinsurance plans, but the least expensive model (between 100 and 200 Rupees) suited most respondents. This held true across all three study sites.

The survey asked the respondents who did not want microinsurance to explain their aversion. By and large, of those who did not want insurance coverage in Guwahati and Puri — 44% and 71%, respectively — said they simply would not be able to afford the price. Because everyone interviewed in Cuddalore wanted disaster microinsurance, reasons for lack of demand cannot be reported. Some feared chit scams, a form of financial fraud that has taken advantage of people across India in recent years. Others did not believe that they faced enough risk to justify the purchase. Another group had purchased some form of insurance previously, but did not think that they needed it currently. However, the percentage of business owners not interested in microinsurance made up a small minority in all three study sites.

Screenshot 2017-02-08 at 4.14.13 PM

Table 4: Insurance and Microinsurance

Screenshot 2017-02-08 at 4.19.25 PM

Table 5: Preferred Premium

Screenshot 2017-02-08 at 4.20.06 PM

Table 6: Preferred Renewal Period

Screenshot 2017-02-08 at 4.34.55 PM

Table 7: Current Response to Disaster

Screenshot 2017-02-08 at 4.35.43 PM

Table 8: Current Amount Spent on Recovery

Screenshot 2017-02-08 at 4.36.27 PM

Table 9: Reasons for Rejection of Microinsurance


The comprehensive data from this initial survey of almost 5000 business owners shows that small informal business owners largely do not know about disaster microinsurance for businesses. The survey demonstrates that this lack of awareness pervades multiple regions of India — including high-risk zones.

The study also corroborates the hypothesis that small informal business owners have low awareness of microinsurance for businesses. The survey demonstrates that this lack of awareness exists across multiple regions of India, even in high-risk zones prone to frequent disasters.

But it also highlights the opportunity to create demand by raising awareness. The first operational goal for microinsurance providers entering this space should be to explain how risk-transfer programs function and benefit business owners; based on the high demand indicated by respondents following an explanation, this strategy seems viable. As a risk-pooling mechanism, the success of microinsurance programs depend on a robust and diverse user base. The data above clearly show that the majority of small business owners would purchase an affordable plan. Often, witnessing payouts makes microinsurance more attractive, meaning the subscriber base will likely grow after a disaster (furthering the financial viability of the program).

Beyond generating demand, insurance providers will have to design products and delivery methods that function and scale easily. Insurance requires an implicit level of trust. Unfortunately, many of these communities have been the victims of fraud, often in the form of chit schemes, where many individuals put money into a pot and a randomly selected winner receives the money. Chit schemes and other financial scams can easily be confounded with legitimate insurance. To combat this confusion, community-based organizations can institute partner-agent models, in which staff serve as insurance agents by signing up subscribers and remaining a point of contact in the community. This model overcomes the logistical challenges of serving urban slum populations that have been largely neglected by financial institutions. In addition, community-based organizations already have the social capital and history in the community through previous development projects, allowing them to work effectively. Finally, the cost of insurance and the price of covering high-risk areas can hinder adoption rates and scalability. However, this survey shows that even small business owners have the ability and inclination to afford a product that is priced right.

Our study indicates that small informal business owners have suffered extreme loss in recent disasters. They currently resort to various coping mechanisms in lieu of formal risk reduction and risk transfer options. Unfortunately, many business owners rely on unsuccessful or even counterproductive coping strategies that trap families in poverty. These alternative coping strategies, including taking out loans and selling assets, would be obviated or limited by a microinsurance product. Insurance companies should be excited by this opportunity; the findings of this study support the possibility of price discrimination in real-world programs. Most small business owners wanted to purchase the most comprehensive insurance product they could afford, suggesting an opportunity for a range of insurance coverage and pricing.

This paper looked specifically at knowledge of and demand for small business disaster microinsurance across three different regions in India. To create a more complete picture of the impacts, more research — as planned in a randomized controlled trial of disaster microinsurance for this population — is required. It is important to note that intent does not necessarily equal action; people will vote with their wallets. Feasibility studies remain pertinent, especially since cost was the main reason stated for not participating. Future surveys and trials will be needed to test actual demand for microinsurance and actual impact on post-disaster recovery.

Governments and nonprofit organizations are actively exploring ways to help small and informal business owners to facilitate economic development. Humanitarian efforts are also looking to leverage markets found in urban areas to speed recovery after crises. Yet despite years of existence, disaster insurance for businesses remains underdeveloped and underused as a means to protect the poor and vulnerable. However, it has the potential to fill the gaps in financial inclusion seen in various products and services. While further operational research is needed, this study demonstrates that risk transfer for small informal business in urban slums shows promise as a revolutionary product for populations at risk.

Data Availability Statement

The data used to produce the tables above is freely available at Figshare via the following DOIs:;;

Competing Interests Statement

The authors have declared that no competing interests exist.

Corresponding Author

Ronak B. Patel who may be contacted at

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Current State and Problems of Radiation Risk Communication: Based on the Results of a 2012 Whole Village Survey Fri, 24 Feb 2017 09:00:44 +0000 Purpose: The entire village of Iitate was contaminated by radioactive material from the Fukushima Daiichi Nuclear Power Plant; even today, the residents remain evacuated. For the villagers, risk communication is an important element of recovery and maintaining health. This analysis focuses on the problem of radiation, presents results from a questionnaire of villagers, and examines methods for future risk communication activities.

Subjects and Methods: In May 2012, anonymous surveys were sent to 2914 heads of households whose addresses were registered in Iitate. Their understanding of radiation and information needs were extracted from the answers.

Results and Discussion: There were 1755 valid responses (61.4%). In relation to understanding, the most frequent answer was “There are numerous opinions and I do not know which one is true” (72.2%), followed by “I definitely want opportunities to learn more about how radiation is created” (41.6%). Residents felt that they could not determine which of the available information was reliable. The 60s+ age group responded more than younger age groups that “I do not have much information and do not know much about it,” “I do not know much about it, so I want to learn more,” and “I definitely want opportunities to learn more about how radiation is created.” Among information needs, “publications” (50.2%) and “community associations” (45.9%) received many responses; residents want study groups to be held at places and through media that give them regular opportunities to connect with each other. Residents in their 20s and 30s preferred “publications,” while those in their 40s, 50s, and 60s+ were more likely to request “community associations” and “resident meetings.” In addition, we found gender differences in both understanding and information needs. These results indicate that radiation and health risk communication should be addressed in a way that aligns with residents’ needs by age and gender.



After the 11 March 2011 Great East Japan Earthquake and nuclear disaster, residents living in affected areas experienced great physical and psychological changes. Five years later, the number of “disaster-related deaths”, such as from health deterioration and overwork, had risen to 3472 people in 10 prefectures, including 2038 from Fukushima Prefecture as of 31 March 2016, and more than 1607 deaths directly caused by the tsunami or earthquake1. The consequences of the accident have been reported both at home and abroad2,3,4.

Iitate village that is subject to this study is located 30-50km northwest of the crippled nuclear power plant, and had a pre-disaster population around 6000. Some parts of the village received a heavier dose of radiation than other towns far closer to the nuclear power plant5. However, they were not immediately evacuated because many residents felt safe following a medical expert’s lecture on radiation exposure at the end of March and the government’s announcement that “levels of radiation would not immediately affect the human body”6. Yet there was also a great sense of mistrust toward statements from experts, as well as toward the disclosure of information and the response from government and the public administration7.

Mistrust inhibits risk communication8,9,10. Risk communication has been deemed a pillar of recovery measures in Iitate11. Since the earthquake, the term has been used in a variety of settings. In this paper, it is defined as “promoting the sharing and discussion of information regarding radioactive contamination in order to support informed decision making”11. Mothers, village representatives, doctors and experts in radiation protection, and public officials in Iitate established the Health Risk Communication Promotion Committee in October 2012. The committee conducts study groups with radiation protection experts and village public health nurses in temporary housing locations and elementary and middle schools. It also publishes a quarterly magazine about health and radiation12, and disseminates information about radiation, such as to the villagers who remain evacuated outside the prefecture.

Individual differences influence perceptions of anxiety and risk; these differences may depend on the way risk is conveyed13,14. Slovic identifies the perception of dread and knowledge of risks as elements of risk perception15. Sandman adds outrage16. Radiation cannot be seen or felt, and education in Japanese schools has neglected radiation. Thus, radiation risk communication in Japan faces two major problems:

(1) Laypeople have difficulty understanding radiation itself17,18.

(2) With different standpoints, people understand “radiation” differently19.

This study analyzed data from a questionnaire sent to all Iitate residents after the evacuation to determine what residents wanted in risk communication.


1. Survey Method

An anonymous self-response survey was sent out by the Iitate local government by mail from 22 May to 1 June 2012 to 2914 heads of households (or main income earners) with addresses registered in Iitate. This study used some of the results of that survey.

2. Survey Items

The survey comprised 30 items on opinions regarding life after evacuation, contamination in the village, and returning to the village. This report focused on 2 items relevant to radiation. The analysis for this study targeted items relating to radiation risk communication and basic attributes (age group, gender, occupation).

Iitate’s risk communication committee identified two items relevant to radiation risk communication. The first concerned the self-evaluated level of understanding. In answer to the question “When we think of the village residents’ health and future, we believe that radiation study groups (on risk communication) are necessary. What is your level of understanding about radiation and radioactive materials?”, respondents could choose from the following:

  • I do not have much information and do not know much about it(Q1-1).

  • I do not know much about it, so I want to learn more(Q1-2).

  • There are numerous opinions and I do not know which one is true(Q1-3).

  • I definitely want opportunities to learn more about how radiation is created(Q1-4).

  • I know about it, so I do not need a study group(Q1-5).

  • Other.

The second item concerned the format of study groups. In answer to the question “In implementing radiation study groups, what type of location would make them easy to attend?”, respondents could choose from the following:

  • I would like them to take place in schools, in preschools, and at daycare parent–teacher association events(Q2-1).

  • I would like them to be implemented through community associations of administrative districts and at temporary housing locations(Q2-2).

  • I would like them to happen together with health lessons(Q2-3).

  • I would like them to happen together with resident meetings(Q2-4).

  • I would like them to be given in lecture halls by experts(Q2-5).

  • I am extremely concerned about radiation and would like the study group to happen as an individual consultation(Q2-6).

  • I would like information to be published in the form of special features and announced in public newsletters, flyers, and newspapers(Q2-7).

3. Analysis

Responses to answers by gender (male and female) and by age group (20s–30s, 40s–50s, and 60s+) were compared by chi-squared test in SPSS v. 19.0 software.

4. Ethical considerations

This survey was conducted by the Iitate village government. Data was provided to author to analyze and has no personal information. The Ethics Committee of Fukushima Medical University granted its consent (Examination No. 2609).


1. Subjects’ backgrounds

There were 1788 responses (60.2% of 2914). Excluding answers from teenagers left 1755 for final analysis, of which 15.5% were in their 20s–30s, 37.5% in their 40s–50s, and 47.0% 60 or older (Table 1). Males comprised 70.5% of the total and females comprised 29.5%. The most common occupation before evacuation was agriculture (31.9%), followed by working at a company (29.8%).


Table 1. Characteristics of subjects (n = 1755).

2. Differences in level of understanding by age group and gender (Table 2)

In relation to level of understanding, the answer “There are numerous opinions and I do not know which one is true” was chosen the most (72.2%), and “I know about it, so I do not need a study group” was chosen the least (4.4%; Table 2). Males were significantly more likely than females to respond “I do not know much about it, so I want to learn more” (χ2 = 12.89, P < 0.01), “I definitely want opportunities to learn more about how radiation is created” (χ2 = 13.25, P < 0.01), and “I know about it, so I do not need a study group” (χ2 = 6.09, P = 0.012). Older people more frequently responded with “I do not have much information and do not know much about it” (χ2 = 98.82, P < 0.01), “I do not know much about it, so I want to learn more” (χ2 = 64.72, P < 0.01), and “I definitely want opportunities to learn more about how radiation is created” (χ2 = 45.21, P < 0.01). People in their 40-50s gave the highest response to “There are numerous opinions and I do not know which one is true” (χ2 = 13.77, P < 0.01).


Table 2. Level of understanding about radiation: age group and gender distribution.


Figure 1-1. Level of understanding about radiation by age group (n=1755)


Figure 1-2. Level of understanding about radiation by gender (n=1733)

3. Differences in study group requests age group and gender (Table 3)

“Publications” received the highest response (50.2%) and individual consultations the lowest (13.4%; Table 3). Significantly more males than females requested “community associations” (χ2 = 20.21, P < 0.01), “resident meetings” (χ2 = 4.89, P = 0.02), and “lectures by experts” (χ2 = 9.65, P < 0.01). An age frequency bias (toward younger or older people) was found in “schools and preschools” (χ2 = 17.01, P < 0.01), “community associations” (χ2 = 125.46, P < 0.01), “health lessons” (χ2 = 22.16, P < 0.01), “resident meetings” (χ2 = 33.59, P < 0.01), “individual consultations” (χ2 = 19.25, P < 0.01), and “publications” (χ2 = 25.11, P < 0.01).


Table 3. Requests for study groups on radiation: age group and gender distribution.


Figure 2-1. Requests for study groups on radiation by age groups (n=1755)


Figure 2-2. Requests for study groups on radiation by gender (n=1733)


The fact that a great number of residents chose “There are numerous opinions and I do not know which one is true” suggests that many of them feel overwhelmed by too much information on radiation. In addition, the fact that 40% chose “I do not have much information and I do not know much about it” and “I would definitely like opportunities to learn more about how radiation is created” indicates that residents did not receive information from authorities (such as the local village) that they trusted, and that it is necessary for both national and local government to reconsider the volume and quality of knowledge about radiation. The fact that over 50% of residents chose “publications” and over 45% chose “community associations” reveals a strong desire for media or places that allow people to connect regularly with each other, as well as a need to create mechanisms for risk communication that meet residents’ needs.

Current state and problems of risk communication: analysis by age group

Differences by age group were found in both the level of understanding about radiation and requests for study groups. The response “I do not have much information and I do not know much about it” was greater among those aged 60 and older than among those in their 20s–30s and 40s–50s. Responses indicating initiative—“I do not know much about it, so I want to learn more” and “I would definitely like opportunities to learn more about radiation how is created”—were also more common.

Although the village has been holding study groups on radiation for older villagers who live in temporary residences, it is possible that these villagers do not have enough opportunities and that they are not receiving information they want. So in addition to this current approach, it will be necessary to engage in dialogue with older villagers to learn which specialists and public health professionals can best meet their needs.

Unlike the older villagers, the younger villagers seem to strongly distrust the discourse on radiation. Figueroa suggests that immediately after a natural disaster, disseminating uncertain information hinders residents’ ability to make decisions, especially in young adults, and instead reinforces the sense of mistrust20. Covello and Sandman report that the two-way approach (in which “expert” and “lay” perspectives should inform each other) allays fears even among young people who are suspicious21. Furthermore, because losing the sense of control after an accident exacerbates mistrust22,23, a resident-participation approach that is an approach in which residents participate in shaping the decisions about that information to provide, how frequently to provide it, and the optimal medium for conveying the information might help residents regain that sense24.

While respondents in their 20s–30s showed a strong desire to implement study groups in schools or via publications, those in their 40s–50s and 60s+ preferred for them happen through community associations and resident meetings. In addition, the 60s+ group tended to want “health lessons”. These results show that many people want study groups to be held in places or via media that bring them into regular contact with others. In addition, 15.7% of the 20s–30s group and 16.6% of the 60s+ group were extremely worried about radiation and wanted individual consultations. This indicates the need for an individual approach that uses radiation experts or trained nurses in a medical setting.

The evacuation divided the community, and the residents’ lives changed completely. Although many people were living together in three-generation households, homes in which the young and the old lived separately increased. The number of senior citizens living alone also grew, and the total amount of households doubled from what it was before the evacuation25. As the community changes, we can see that the younger generation wants to obtain information at school events and through publications. Moreover, most senior citizens live in groups in temporary housing as opposed to rental housing provided by Fukushima prefectural government, and various events and study groups happen at group meeting centers. Since the need for study groups changes according to age, it is desirable to implement them in settings and in ways that make it easy for residents to participate.

Current state and problems of risk communication: analysis by gender

Gender differences were found in the level of understanding and in requests for study groups. There was no gender difference in the response “I do not have much information and I do not know much about it”; however, significantly more males than females chose the answers “I do not know much about it, so I want to learn more” and “I definitely want opportunities to learn more about how radiation is created.”

On the other hand, it is possible that the level of understanding is polarized, since a considerably larger proportion of males chose “I know about it, so I do not need a study group.” It has also been shown that men and women hold different concerns about what is considered a risk26,27: specifically, women have more concerns about life (e.g., effects on children, pregnant women, future generations), and men have greater economic concerns. An analysis of societal gender roles can improve understanding of these findings28 .

Men favored interpersonal approaches to study groups, such as through community associations and at resident meetings, while women tended to prefer the more indirect approach of publications. This, too, is related to societal gender roles: elderly men usually attend meetings at “places” such as community associations and resident meetings while elderly women prefer a more informal setting. In addition, 8.6% to 16.6% reported being “extremely concerned” about radiation. Detailed implementation system that allows a small number of residents to have two-way communication with experts, with whom they can share their health concerns about radiation24,29.

Limitations and prospects

This study used a survey targeting all residents of Iitate village, and presents valuable data on residents’ understanding of radiation and the methods of risk communication that they wanted. However, it has several limitations. Since the validity and reliability of the survey items have not been confirmed, it is necessary to take care in interpreting and generalizing the results. In addition, the survey could not examine the kind of risk communication content needed. The survey targeted the entire population of the village, not a sample, and was conducted as village policy; the question of how to interpret a failure to respond remains.

For future consideration, it is necessary to clarify the content that residents need, and to measure results on a scale whose reliability and validity have been verified. Since a failure to respond could be viewed as criticism of village policy, the potential engagement of a third party (such as a university or non-profit organization) needs to be examined. Furthermore, since the survey results were reported a year after the evacuation, it is possible that residents’ perceptions of radiation have now shifted. Beside conducting the survey again, it will be necessary to explore timely ways of communicating risk.

Corresponding Author

Yujiro Kuroda, PhD (

Data Availability Statement

Data is available upon request from the author Yujiro Kuroda (

Competing Interest Statement

The authors have declared that no competing interests exist.

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The Most Effective Methods for Delivering Severe Weather Early Warnings to Fishermen on Lake Victoria Wed, 22 Feb 2017 17:00:10 +0000 Introduction: It is estimated that five thousand people die on Lake Victoria every year by drowning which is triggered by severe weather hazards like lightning.

Objectives:  In order to improve predictability of severe weather conditions on Lake Victoria, there is need to deliver timely and effective Severe Weather Early Warning Systems (SWEWS) to those at risk. On Lake Victoria, previous SWEW service trials ceased with the end of the funding grants. This study therefore assessed the possibility of sustaining the SWEW service by assessing willingness to pay.  

Methods: An assessment was conducted between March and May 2015 to determine the SWEW service improvements desired by the population. A convenience sample of respondents was gathered and interviewed during impromptu visits to landing sites on Lake Victoria. The respondents were also among community members that had earlier participated in a pilot assessing the feasibility of mobile phones is delivering SWEW alerts.  Semi-structured questionnaires were administered to fishermen and fisher folks at the landing site to gather suggestions/strategies for (i) better design and implementation of SWEW service, (ii) use of smart phones, and (iii) their ability and willingness to pay for a SWEW service. Results were presented as frequencies.

Results: Two hundred fifteen respondents from fourteen landing sites (communities) were interviewed. Over 50% of the respondents (113/215) were aware about at least one community member who had been injured due to lightening on the lake in the past year. Ninety two percent (198/215) of the respondents reported using mobile phones as their main tool of communication but only 4% had smart phones that could receive early warning weather alerts through internet connectivity. Seventy five percent of respondents said they would welcome a system that could deliver commercial weather alerts and 65% were willing to pay for such a service.  

Conclusions: A SWEW service is feasible in this community but must be accompanied with public education on risk, a design that can fit the basic phone functionality and a system that the community majority will be willing to pay for on a continuing basis as a sustainability plan/strategy for an early warning system. This will enable timely dissemination of severe weather alerts and reduce risk of drowning on lakes among fishing communities. 



According to the recent study, an estimated 5,000 people per year die from severe weather on Lake Victoria.1 The northern part of Lake Victoria experiences the maximum number of thunderstorms which average to 242 days per year compared to any other country in the world. Fishermen are at special risk of drowning, not only from high winds, waves and lightning but from poorly maintained boats, lack of life saving equipment and navigational aids. In addition, gale size winds can move inland to destroy vegetation, property and human settlements including schools and health centers.2

The loss of life impacts more than fishermen by affecting their families and communities both economically and socially. Persons who feel they have little control over their lives may become resigned to their fate. They may be less likely to listen to warnings of other risks such as HIV and more likely to choose life’s pleasures rather than pursue education for their children and other self-improvement activities that require time, energy, money, and sufficient hope that delays gratification becomes a viable behavior. The communities surrounding Lake Victoria are among those with the highest levels of HIV infection, poverty, disease, gender-based marginalization, lack of education, and violence.3

By providing weather information and warnings to fishermen, they are able to make informed decisions about when and where to fish, whether to go out onto the lake or seek shelter in safe areas. This not only helps save many lives, but also enhances the livelihoods of the communities around the lake, as many fishermen are the sole providers for large families.

In order to decrease the loss of lives, we propose to design a Severe Weather Early Warning System (SWEWS) utilizing lightning detection and other weather data in cooperation with the Uganda National Meteorological Administration, Earth Networks, and other agencies to deliver SWEWS by smart phone technology to fishermen and others who work around the Lake.

Previous SWEWS have been piloted in the communities living on Lake Victoria by the World Meteorological Organization (WMO) and Grameen Foundation in 2011-2012 but tended to fail when grant funds and personnel left. Most of these projects are no longer operating for a number of reasons, including problems with delivery to the end users, timeliness of information, and lack of sustainability given that the community was not paying a fee for this service. Other projects utilizing different segments of this idea have been implemented in the region including one for farmers to search for advice on managing crops and livestock, for weather data and market prices4 for fishermen

In summary, we propose a SWEWS with accurate and timely weather reports delivered to mobile phones in languages appropriate to the user. Many components are involved:1)Accurate weather data collection; 2) Skilled interpretation to provide reliable forecasts and timely warning; 3) Delivery of warnings in a timely and effective manner to the end-user; 4) Education on how to interpret the information delivered; 5) Implementation of alternative livelihood 6) Assurance that the SWEWS is economically sustainable

Before any of these can be effective, it is essential to determine what the end-users, particularly the fishermen and those living around the Lake, identify as important to its effectiveness as well as their willingness to support the system with subscriptions once it is implemented as part of the community sustainability strategy.


This study focused on the fishing community of Lake Victoria in Kalangala District, a major group at risk from severe weather effects. Kalangala District is located on the northern shore of Bugala Island, the largest of the Ssese Islands in Lake Victoria. Kalangala is made up of 84 widely scattered islands. It is approximately 60 kilometers across water, southwest of Entebbe, the largest and nearest mainland town. In 2011, the Uganda Bureau of Statistics (UBOS) estimated the mid-year population of Kalangala district at 5,200. People settle mostly in villages made of temporary structures with each village having approximately 200 households. The principal economic activity on the Island is fishing. Nile Perch is the species primarily fished with most of the catch processed on the mainland for export. Other economic activities include agriculture, crop and animal husbandry, logging and tourism.

Twenty four villages spread across five islands of Bubeke, Bukasa, Kachanga, Misozi and Bulagain in Kalangala District provided a convenience sample gathered during impromptu visits to interview those found on site. A total of 215respondents were sampled from the 1000 participants who had participated in the earlier pilot of Mobile Weather Alerts supported by World Meteorological Organization that ended in early 2011. They were specifically solicited, when possible, because their experiences were deemed valuable in planning an improved approach and in enhancing use by the target population.

The information collected was aimed at determining the elements of a people-centered EWS, i.e.

1) risk knowledge , 2) monitoring and warning service , 3) dissemination and communication and 4) response capability.

Written informed consent was sought from each individual before the questionnaire was administered. The study approval was sought from the Uganda National Meteorological Authority because this assessment was part of a follow up of the work done by the World Meteorological Organization to inform adjustments in the intervention. We did not obtain approval from an Institutional Review Board but rather approval from the Uganda national Meteorological Authority. The assessment was conducted under supervision of Makerere University School of Public Health

Respondents were assessed for; socio-demographic characteristics, experience with the Mobile Weather Alert pilot, extent of use of the mobile phone as an information source, knowledge and perceptions about lightning and severe weather including the features they desired to be part of a mobile weather alert system. Quantitative data was collected using a pretested semi-structured questionnaire which was developed based on the information gathered from previous pilots and included questions on; personal history, exposure to the Lake, perceptions about SWEWS, as well as, willingness and ability to pay for such a system or service.

The questionnaire was administered to the adults with the aid of a local language (Luganda) translator by trained research assistants utilizing iPads/tablet computers for data entry. Data was summarized using Microsoft Excel spreadsheets to obtain frequencies in each category of questions and data was presented by appropriate tables, figures and text.


A total of 215 respondents from twenty four landing site communities/ villages were interviewed as summarized in Table 1. The table also highlights their socio- demographic characteristics. Most of the respondents were men (84%) and from Bulaga village. Over a half (52%) had attained primary education and 48% reported that their main occupation was fishing in the lake.

Table 1 - Demographics of Study Population

Table 1 – Demographics of Study Population

Community exposure to the Lake

In the study population, 27.9% (60/ 215) of the respondents reported that they owned their own boats. Boats were nearly equally split between those with motors versus those without (48.1 vs 51.9%). Over half of the respondents reported that they traveled by boat on Lake Victoria on a daily basis. (Fig 1),

Fig. 1 - Frequency of travel by boat on the Lake

Fig. 1 – Frequency of travel by boat on the Lake

When asked about the community’s perception of severe weather effects, the majority of respondents (91.7%) cited a combination of different hazards, mainly high winds and thunderstorms. The same group noted that high winds come with high waves, while thunderstorms come with lightning, making it difficult to quantify each of these hazards separately (Table 2). Lightning injury alone was cited by only 6.5% as a major hazard. However, up to 54% of respondents could recall lightning strikes on a regular basis (24% everyday; 17% every week; and 13% every month).

Table 2 - Perceptions of the community in relation to severe weather

Table 2 – Perceptions of the community in relation to severe weather

Over 50% of the respondents (113/215) were aware about at least one community member who had been injured due to lightning on the lake in the past year. It was also noted that 32.6% (70/215) of the respondents knew at least one community member who had died on the lake due to lightning (Table 3). When asked specifically what they believed was responsible for these deaths, multiple responses were given including high winds (88%; 62/70) and 30% (21/70) cited poorly maintained boats.

Table 3 - Knowledge about Injuries and Fatalities from Lightning on the Lake in the past year

Table 3 – Knowledge about Injuries and Fatalities from Lightning on the Lake in the past year

Level and extent of mobile phone use in the fishing community

All respondents reported using mobile phones. Ninety-two percent (198/215) mentioned the mobile phone as their most useful tool for obtaining information, while 8 % mentioned the radio. The majority of the respondents 85.1% (183/215) paid for their own mobile usage fees. On average, the respondents reported that they spend USD 8 per month for mobile phone services. In the study population, 96% of the respondents (206/215) had mobile phones with basic functionality and only 4% (9/215) had advanced features.

Use of mobile alert systems

It was reported that 30.7% (66/215) of the respondents were currently receiving mobile phone weather alerts. When these respondents were asked how the mobile phone alerts were helping them, 80.3% (53/66) said that the alerts were helping them in planning while 2.8% (6/66) said that the alerts informed them about the weather conditions. However 70.2% (151/215) of the respondents were not receiving any mobile phone weather alerts. Seventy-five percent of respondents said they would welcome a system that could deliver commercial weather alerts, while 65% were willing to pay for such a service. Table 4 also illustrates how respondents thought that alerts on mobile phones could be made more effective.

Table 4 – Preferred Characteristics of Severe Early Weather Warnings

Table 4 – Preferred Characteristics of Severe Early Weather Warnings


The populations that depend on fishing for their livelihoods is of high economic importance in Uganda’s economy since the fishing industry contributes 2.48% to the Uganda’s GDP.5 The fact that so many respondents could recall more than two incidences with three or more deaths within the past year speaks to the loss of life and to the many productive years. Such loss to the economy and family support due to premature death alludes to the need for risk reduction through early warning.6 In addition, the fact that over half of those studied travel on boats every day points out the risk are exposed to.

The aim of this study was to gather information that would be used to improve the delivery of potentially life-saving weather warnings. These warnings would enable fishermen and others in the community to make informed decisions about their work and exposure to severe weather. For that reason, it was good news to note that most of the respondents in the sampled villages were natives, making it easier to build a trusted and sustainable business model for the early warning delivery. It is much more difficult to build a sustainable enterprise with migrant workers and their dependent populations.7 In order to assure sustainability in building EWS where community members pay for the system or service through subscriptions, it is important to choose a warning communication technology that is acceptable to the recipients. Among other considerations is the; recipient location, their activity, the systems they rely on to receive local news and information, any special needs they may have and how they understand and respond to warnings.8

In this study, all respondents owned mobile phones, relied on them as their most common source of information, and spent 8 USD per month on average for airtime credit. This presents the opportunity to harness the mobile phone alerts to their willingness and ability to pay for severe weather alerts in order to support a sustainable EWS. However, for this particular project to succeed, it will be necessary to consider the functionality of the phone and to either fit the EWS to basic phones or to make smart phones available at a low cost.

The study revealed some parts of the population at risk during all hours of the day and night as they routinely traveled and worked on the Lake. This support the need for an effective EWS that incorporates; risk knowledge, appropriate monitoring of the warning service, timely dissemination to the populations at risk and enhanced response capacity of the community.8,9 As far as risk knowledge, the majority of respondents were aware of severe weather related hazards on the lake and believed a scientific explanation for lightning, rather than a superstitious or supernatural explanation for its source. This implied that they will see scientific methods as reliable for giving them warning and improving their control over lightning risk. The proposed severe weather casting early warning system aims to use lightning as a proxy measure of severe weather, a sound and scientific basis for early warning on the lake that regularly provides hazards like heavy winds, waves and thunderstorms.10

Concerning dissemination and communication, respondents reported that they rely heavily on mobile phones for information. The few people who had experience with mobile phone weather alerts in earlier projects had found the alerts useful especially in planning, showing that warnings reached the intended users, were understood and usable.

Most respondents preferred an alarm as a warning system over color codes or text. This may be due to the low literacy levels among the fisher folk which could impede reading text warnings to ensure timely response. They also agreed that timeliness was the most important factor and thus preferred the use of local language for EWS.

In this study, the community noted their trust in the SWEWS that had been piloted earlier which speaks to the perceived validity of the warning messages. In addition, authorities like the police were perceived as the responsible body that should issue the alerts. This is in agreement with the incident command operations that call for a clear chain of information flow.

The most common response action to a severe weather alert reported in this community was moving to a nearby island for safety and anchoring the boat. Although validation of this response was not tested as part of this study. The use of such indigenous/ local knowledge, if effective, may improve the effectiveness of response to an early warning system. As part of the warning dissemination, such information should be widely available so that there is organized response capacity in the community

There are some limitations to this study worth mentioning. Given that a convenience sample of individuals was taken, the results may be biased in a way that they don’t represent the views of the general population. In addition, some communities had few respondents compared to others. Nevertheless, we believe that the information can aid in the design of an acceptable tool for early warning with the best delivery mechanisms, given that we interviewed the population that is aware of the hazards and risks associated with the Lake and severe weather effects.

The study sample was not chosen randomly and this may have caused reporting bias. In addition, a portion of the population targeted had participated in the pilot study of testing a mobile phone weather alert service. However, since the pilot interventions had ended over a year ago, we believe that the experience of the respondents and their responses may actually enhance the next system and that the results of this assessment are valid enough to guide an improved approach. This will enable timely dissemination of severe weather alerts against hazards like lightning and thunderstorms hence giving lead time to those exposed to take actions to prevent, mitigate or prepare for such risks. The severe weather early warning system will hence reduce risk of drowning on lakes among fishing communities.


Exposure to the lake was common with fishing in the lake being a major occupation in the study population. Over half of the respondents were aware of at least one community member who had been injured due to lightning and a significant number of respondents were willing to pay for a smart phone based commercial severe weather early warning system service. This will enable timely dissemination of sever weather alerts against hazards like lightning and thunderstorms hence giving lead time to those exposed to take actions to prevent, mitigate, or prepare for such risks. The sever weather early warning system will therefore reduce risk of drowning on lakes among fishing communities.

Corresponding Author

Doreen Tuhebwe (;

Competing Interests

The authors have declared that no competing interests exist.

Data Availability Statement


Ethics Statement

Approval for the study was received from the Uganda National Meteorological Authority. The assessment was conducted under supervision of Makerere University School of Public Health.

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